Original Study| Volume 22, ISSUE 9, P1927-1932.e1, September 2021

Download started.


Making the Most of Mealtimes (M3): Association Between Relationship-Centered Care Practices, and Number of Staff and Residents at Mealtimes in Canadian Long-Term Care Homes

Published:December 15, 2020DOI:



      To determine if (1) number of staff or residents, when considering home-level factors and presence of family/volunteers, are associated with relationship-centered care practices at mealtimes in general and dementia care units in long-term care (LTC); and (2) the association between number of staff and relationship-centered care is moderated by number of residents and family/volunteers, profit status or chain affiliation.


      Secondary analysis of the Making the Most of Mealtimes (M3) cross-sectional multisite study.

      Setting and Participants

      Thirty-two Canadian LTC homes (Alberta, Manitoba, Ontario, and New Brunswick) and 639 residents were recruited. Eighty-two units were included, with 58 being general and 24 being dementia care units.


      Trained research coordinators completed the Mealtime Scan (MTS) for LTC at 4 to 6 mealtimes in each unit to determine number of staff, residents, and family or volunteers present. Relationship-centered care was assessed using the Mealtime Relational Care Checklist. The director of care or food services manager completed a home survey describing home sector and chain affiliation. Multivariable analyses were stratified by type of unit.


      In general care units, the number of residents was negatively (P = .009), and number of staff positively (P < .001) associated with relationship-centered care (F9,48 = 5.48, P < .001). For dementia care units, the associations were nonsignificant (F5,18 = 2.74, P = .05). The association between staffing and relationship-centered care was not moderated by any variables in either general or dementia care units.

      Conclusion and Implications

      Number of staff in general care units may increase relationship-centered care at mealtimes in LTC. Number of residents or staff did not significantly affect relationship-centered care in dementia care units, suggesting that other factors such as additional training may better explain relationship-centered care in these units. Mandating minimum staffing and additional training at the federal level should be considered to ensure that staff have the capacity to deliver relationship-centered care at mealtimes, which is considered a best practice.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Registered Nurses Association of Ontario
        Transforming long-term care to keep residents healthy and safe. 2018.
        (Available at:)
        • Lowndes R.
        • Daly T.
        • Armstrong P.
        “Leisurely Dining”: Exploring how work organization, informal care, and dining spaces shape residents’ experiences of eating in long-term residential care.
        Qual Health Res. 2018; 28: 126-144
        • Barken R.
        • Armstrong P.
        Skills of workers in long-term residential care: Exploring complexities, challenges, and opportunities.
        Ageing Int. 2018; 43: 110-122
        • Hung L.
        • Chaudhury H.
        Exploring personhood in dining experiences of residents with dementia in long-term care facilities.
        J Aging Stud. 2011; 25: 1-12
        • Watkins R.
        • Goodwin V.A.
        • Abbott R.A.
        • Tarrant M.
        Eating well in care homes: Testing the feasibility of a staff training programme aimed at improving social interaction and choice at mealtimes.
        Int J Older People Nurs. 2019; 14: e12247
        • Shune S.E.
        • Linville D.
        Understanding the dining experience of individuals with dysphagia living in care facilities: A grounded theory analysis.
        Int J Nurs Stud. 2019; 92: 144-153
        • McGilton K.S.
        • O’Brien-Pallas L.L.
        • Darlington G.
        • et al.
        Effects of a relationship-enhancing program of care on outcomes.
        J Nurs Scholarsh. 2003; 35: 151-156
        • Carrier N.
        • West G.E.
        • Ouellet D.
        Dining experience, foodservices and staffing are associated with quality of life in elderly nursing home residents.
        J Nutr Health Aging. 2009; 13: 565-570
        • Harnett T.
        • Jönson H.
        Shaping nursing home mealtimes.
        Ageing Soc. 2017; 37: 823-844
        • Dunn H.
        • Moore T.
        “You can’t be forcing food down ‘em’: Nursing home carers” perceptions of residents’ dining needs.
        J Health Psychol. 2016; 21: 619-627
        • Ågotnes G.
        • Jacobsen F.F.
        • Barken R.
        A Norwegian view on Canadian long-term residential care.
        J Can Stud. 2016; 50: 491-498
        • Barnes S.
        • Wasielewska A.
        • Raiswell C.
        • Drummond B.
        Exploring the mealtime experience in residential care settings for older people: An observational study.
        Health Soc Care Community. 2013; 21: 442-450
        • Wu S.
        • Morrison J.M.
        • Dunn-Ridgeway H.
        • et al.
        Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care.
        BMC Geriatr. 2018; 18: 277
        • Hung L.
        • Chaudhury H.
        • Rust T.
        The effect of dining room physical environmental renovations on person-centered care practice and residents’ dining experiences in long-term care facilities.
        J Appl Gerontol. 2016; 35: 1279-1301
        • Philpin S.
        • Merrell J.
        • Warring J.
        • et al.
        Memories, identity and homeliness: The social construction of mealtimes in residential care homes in South Wales.
        Ageing Soc. 2014; 34: 753-789
        • Palacios-Ceña D.
        • Losa-Iglesias M.E.
        • Cachón-Pérez J.M.
        • et al.
        Is the mealtime experience in nursing homes understood? A qualitative study.
        Geriatr Gerontol Int. 2013; 13: 482-489
        • Chaudhury H.
        • Hung L.
        • Badger M.
        The role of physical environment in supporting person-centered dining in long-term care: a review of the literature.
        Am J Alzheimer Dis Other Dementias. 2013; 28: 491-500
        • Watkins R.
        • Goodwin V.A.
        • Abbott R.A.
        • et al.
        Attitudes, perceptions and experiences of mealtimes among residents and staff in care homes for older adults: A systematic review of the qualitative literature.
        Geriatr Nurs. 2017; 38: 325-333
        • Keller H.
        • Carrier N.
        • Duizer L.
        • et al.
        Making the Most of Mealtimes (M3): Grounding mealtime interventions with a conceptual model.
        J Am Med Dir Assoc. 2014; 15: 158-161
        • Ducak K.
        • Keller H.
        • Sweatman G.
        Dining culture change in long-term care.
        Ann Long-Term Care. 2015; 23: 28-36
        • Sjögren K.
        • Lindkvist M.
        • Sandman P.-O.
        • et al.
        Organisational and environmental characteristics of residential aged care units providing highly person-centred care: A cross sectional study.
        BMC Nurs. 2017; 66: 44
        • Heggestad A.K.
        • Nortvedt P.
        • Slettebø S.
        Dignity and care for people with dementia living in nursing homes.
        Dementia. 2015; 14: 825-841
        • McGilton K.S.
        • Heath H.
        • Chu C.H.
        • et al.
        Moving the agenda forward: A person-centred framework in long-term care.
        Int J Older People Nurs. 2012; 7: 303-309
        • Doyle P.J.
        • Rubinstein R.L.
        Person-centered dementia care and the cultural matrix of othering.
        Gerontologist. 2013; 54: 952-993
        • Lood Q.
        • Kirkevold M.
        • Sjögren K.
        • et al.
        Associations between person-centred climate and perceived quality of care in nursing homes: A cross-sectional study of relatives’ experiences.
        J Adv Nurs. 2019; 75: 2526-2534
        • Nolan M.R.
        • Davies S.
        • Brown J.
        • et al.
        Beyond “person-centred” care: a new vision for gerontological nursing.
        J Clin Nurs. 2004; 13: 45-53
        • Low L.F.
        • Venkatesh S.
        • Clemson L.
        • et al.
        Feasibility of LifeFul, a relationship and reablement-focused culture change program in residential aged care.
        BMC Geriatr. 2018; 18: 129
        • Edvardsson D.
        • Sjögren K.
        • Lood Q.
        • et al.
        A person-centred and thriving-promoting intervention in nursing homes—Study protocol for the U-Age nursing home multi-centre, non-equivalent controlled group before-after trial.
        BMC Geriatr. 2017; 17: 22
        • Røen I.
        • Kirkevold Ø.
        • Testad I.
        • et al.
        Person-centered care in Norwegian nursing homes and its relation to organizational factors and staff characteristics: a cross-sectional survey.
        Int Psychogeriatr. 2018; 30: 1279-1290
        • Abdelhadi N.
        • Drach-Zahavy A.
        Promoting patient care: Work engagement as a mediator between ward service climate and patient-centred care.
        J Adv Nurs. 2012; 68: 1276-1287
        • Canadian Institue of Health Information
        Dementia in home and community care. n.d.
        (Available at:)
        • Perivolaris A.
        • LeClerc C.M.
        • Wilkinson K.
        • Buchanan S.
        An enhanced dining program for persons with dementia.
        Alzheimers Care Q. 2006; 7: 258-267
        • Keller H.H.
        • Carrier N.
        • Slaughter S.
        • et al.
        Making the Most of Mealtimes (M3): Protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes.
        BMC Geriatr. 2017; 17: 1-15
        • Reimer H.D.
        • Keller H.H.
        Mealtimes in nursing homes: Striving for person-centered care.
        J Nutr Elder. 2009; 28: 327-347
        • Viau-Guay A.
        • Bellemare M.
        • Feillou I.
        • et al.
        Person-centered care training in long-term care settings: Usefulness and facility of transfer into practice.
        Can J Aging. 2013; 32: 57-72
        • Kieft R.A.M.M.
        • De Brouwer B.B.J.M.
        • Francke A.L.
        • Delnoij D.M.J.
        How nurses and their work environment affect patient experiences of the quality of care: A qualitative study.
        BMC Health Serv Res. 2014; 14: 249
        • Ontario Long Term Care Association
        This is long-term care 2018.
        (Available at:)
        • Harrington C.
        • Jacobsen F.F.
        • Panos J.
        • et al.
        Marketization in long-term care: A cross-country comparison of large for-profit nursing home chains.
        Health Serv Insights. 2017; 10: 1-23
        • Comondore V.R.
        • Devereaux P.J.
        • Zhou Q.
        • et al.
        Quality of care in for-profit and not-for-profit nursing homes: Systematic review and meta-analysis.
        BMJ. 2009; 339: 381-384
        • Hsu A.T.
        • Berta W.
        • Coyte P.C.
        • Laporte A.
        Staffing in Ontario’s long-term care homes: Differences by profit status and chain ownership.
        Can J Aging. 2016; 35: 175-189
        • Harrington C.
        • Olney B.
        • Carrillo H.
        • Kang T.
        Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies.
        Health Serv Res. 2012; 47: 106-128
        • Slaughter S.E.
        • Morrison-Koechl J.M.
        • Chaudhury H.
        • et al.
        The association of eating challenges with energy intake is moderated by the mealtime environment in residential care homes.
        Int Psychoger. 2020; 32: 863-873
        • Keller H.H.
        • Chaudhury H.
        • Pfisterer K.J.
        • Slaughter S.E.
        Development and inter-rater reliability of the Mealtime Scan for Long-Term Care.
        Gerontol Soc Am. 2018; 58: e160-e167
        • Iuglio S.
        • Keller H.
        • Chaudhury H.
        • et al.
        Construct validity of the Mealtime Scan: A Secondary data analysis of the Making Most of Mealtimes (M3) Study.
        J Nutr Gerontol Geriatr. 2018; 37: 82-104
        • Iuglio S.
        • Keller H.
        • Chaudhury H.
        • et al.
        Construct validity of the Dining Environment Audit Protocol: A secondary data analysis of the Making Most of Mealtimes (M3) study.
        BMC Geriatr. 2018; 18: 20
        • Hartmaier S.L.
        • Sloane P.D.
        • Guess H.A.
        • et al.
        Validation of the Minimum Data Set Cognitive Performance Scale: Agreement with the Mini-Mental State Examination.
        J Gerontol A Biol Sci Med Sci. 1995; 50: M128-M133
        • Stockdell R.
        • Amella E.J.
        The Edinburgh Feeding Evaluation in Dementia Scale: Determining how much help people with dementia need at mealtime.
        Am J Nurs. 2008; 108: 46-54
        • Canadian Health Coalition
        Ensuring quality care for all seniors 2018.
        (Available at:)
        • Alzheimer’s Society
        Person centred langugae guidelines 2017.
        (Available at:)
        • Kok J.S.
        • Berg I.J.
        • Scherder E.J.A.
        Special care units and traditional care in dementia: Relationship with behavior, cognition, functional status and quality of life - A Review.
        Dement Geriatr Cogn Dis Extra. 2013; 3: 360-375
        • Trinca V.
        • Morrison J.
        • Slaughter S.
        • Keller H.
        Making the Most of Mealtimes (M3): effect of eating occasions and other covariates on energy and protein intake among Canadian older adult residents in long-term care.
        J Hum Nutr Diet. 2020; 33: 3-11
        • Keller H.
        • Awwad S.
        • Morrison J.
        • Chaudhury H.
        Inter-rater reliability of the Mealtime Scan+.
        J Nutr Heal Aging. 2019; 23: 623-627