Journal of Nutrition in Gerontology and Geriatrics, 33:160–178, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 2155-1197 print=2155-1200 online DOI: 10.1080/21551197.2014.927303

Keeping Consumers Safe: Food Providers’ Perspectives on Pureed Food HEATHER H. KELLER, RD, PhD Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada

LISA M. DUIZER, PhD Department of Food Science, University of Guelph, Guelph, Ontario, Canada

Twelve focus groups were conducted in five sites with 80 allied health providers to identify their perspectives on providing pureed food to consumers. Thematic care analysis was completed to summarize and interpret these data. Providers’ greatest concern was keeping consumers safe, and the right texture was prioritized over sensory appeal and acceptance. Providers recognized that these foods impacted the quality of life of consumers and worked to rationalize these diets with residents=patients and their families. In addition, offering foods they knew to be poorly accepted affected their self-concept as providers. As a result of these challenges, they did whatever they could in the kitchen and tableside to promote intake of pureed foods. Those in the ‘‘food chain’’ of pureed food provision suggested several ways to further improve these products. Greater communication between those who assist consumers with eating and those who produce the pureed food they consume is needed to promote acceptable pureed products. KEYWORDS foodservice providers, modified texture, pureed, qualitative

INTRODUCTION Older adults who require a modified food texture, and specifically pureed food, often require eating assistance from nursing staff, family, and volunteers as the diseases and syndromes that can result in dysphagia can

Address correspondence to Heather H. Keller, RD, PhD, Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, Canada N2L 3G1. E-mail: [email protected] 160

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also affect the capacity to feed oneself (1, 2). As a result, part of the eating experience with modified texture foods involves those providers who assist older adults to consume these products. Additionally, providers can be considered part of this ‘‘food chain’’ if they prescribe, plan, prepare, or deliver these foods to consumers. Although it is acknowledged that the sensory quality of pureed foods is important to consumption and quality of life (3–8), relatively little research has described consumer perspectives and their ‘‘liking’’ and experience with eating this texture (9, 10). These reports suggest a less than desirable experience (3, 7, 9–11), but also an acceptance of this texture when it is necessitated (10). Although it has been alluded to in prior studies as being important to consumption and acceptance, perspectives of providers in the ‘‘food chain’’ within institutional environments has been neglected. A single report on six providers suggests staff perceptions that are consistent with consumers (9). However, it is also known that perceptions of nutritional and sensory quality of pureed food do influence nutrition managers purchasing of commercial products (12). Previous research where pureed foods have been improved in appearance and texture suggest that providers of food, especially those that assist older adults with eating, notice these changes in the sensory quality (7, 13, 14). Some of these reports suggest that those assisting with food consumption have a significant impact on what is provided (7) and the amount of food delivered to consumers (14); the way that assistance occurs potentially leads to the refusal of food at mealtimes by persons with dementia (15). Consequently, commercial molded food products with an improved appearance are offered in some institutions for special occasions to promote quality of life for those requiring these foods (12). As low intake of pureed foods may be one of the mechanisms by which malnutrition occurs in consumers (16), efforts to improve on food intake, including understanding and improving perceptions of providers, is needed. The purpose of this qualitative study was to describe the perceptions and perspectives of providers who prescribe, plan, make, deliver, and=or assist consumers with eating pureed food. Specifically, their thoughts on the sensory quality of these foods; how they specifically have modified these foods to promote appeal and intake; as well as their suggestions for further improvements were elicited.

METHODS Between October 2010 and July 2011, five sites were recruited in southern Ontario, Canada (one rehabilitation=complex-care facility, one long-term facility, and three mixed long-term care=complex=rehabilitation care facilities, two of which had two sites each). Site selection was driven by the ability

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to access consumers of pureed food that could participate in an interview for a companion study. Staff focus groups were conducted to determine their perceptions of the modified food and how they addressed challenges in sensory quality. In all but one site, more than one focus group was conducted (Table 1), often segregated by staff type (e.g., dietary, nursing) to promote homogenous groups and increased disclosure (17). One site (#5) did not have any nursing representation in the focus groups, but did provide participants from two locations with different food delivery systems. Site management or research staff assisted with setting up the focus groups, disseminating information letters, and recruiting participants. Focus groups were typically conducted over the lunch hour for staff and food was provided; discussions were 30 minutes to one hour in length. All participants spoke English and received a $10 gift certificate at the point of signing the consent form at the beginning of the focus group. To ensure consistency and quality of data, all discussions were led by the first author who has expertise in focus group conduct. Discussion questions focused on perception of the sensory appeal of pureed foods; how they felt about providing this food to their residents=patients; their perception on what sensory attribute (e.g., taste, look) was most important for appeal; what they currently do to increase the sensory appeal; and what could be further done to improve the sensory qualities. The technique of asking each participant in a TABLE 1 Focus Group Participant Characteristics Site

Focus group # participants

1

1

9

2

2 3 4

7 5 4

3

5

5

6

4

7 8 9

7 4 8

10

12

11 12

3 12 80

4

5 Total

Staff type 4 registered practical nurses; 3 dietary staff; 1 nursing management; 1 administrative dietitian 2 dietitians; 2 cooks; 3 dietary aids 4 personal support works; 1 volunteer 2 speech language pathologists; 1 physiotherapist; 1 administrative dietitian 2 speech language pathologists; 1 dietitian; 1 diet technician; 1 dietary staff 1 diet technician; 1 dietary staff; 1 dietitian; 1 administrative dietitian 2 registered nurses; 5 registered practical nurses 4 registered practical nurses 4 registered nurses; 1 nursing student; 2 dietitians; 1 dietary staff 3 registered practical nurses; 8 personal care assistants; 1 nursing student 1 dietitian; 1 dietetic intern; 1 administrative dietitian 9 dietitians; 3 dietetic interns Nursing ¼ 37 Dietary=nutrition ¼ 37 Allied health ¼ 5 Volunteer ¼ 1

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‘‘round robin’’ fashion, at the beginning of the discussion their views on pureed food, and at the end of the discussion how it could be improved, was used to elicit comments from all participants. In addition, participants were provided with cue cards on which they could anonymously write comments and hand into the focus group leader at the end of the discussion. Focus groups were digitally recorded and transcribed verbatim for analysis by an experienced transcriptionist; they were then checked for accuracy by a different research assistant. Ethics clearance was provided by the University of Guelph Human Research Ethics Board as well as the research boards in three of the institutions that participated. Thematic analysis was completed using the steps of Braun and Clark (18). Transcripts were reviewed several times in a stepwise process to develop themes; analysis was completed on printed copies with hand coding. The first reading of the transcript was used to develop initial ideas and potential codes for categorizing the data, written in the margins of the transcript. The second review was used to identify core ideas that would evolve into themes, amalgamating all codes pertinent to a potential theme in summary tables or lists. Initial labels and ideas for theme description were also outlined in these summary lists tables. Review of these amalgamated codes and re-reading of transcripts resulted in further expansion of and labeling of a theme that was confirmed by returning to the data to fill out label descriptions and identify exemplar quotes. A member-check was completed by providing a summary report to each site that participated for their review and comment.

RESULTS Twelve focus groups were conducted in the five recruited sites; the 80 participants were mostly nursing (n ¼ 37) or dietary=nutrition (n ¼ 37) staff, although some allied health (n ¼ 5) were also recruited (Table 1). Groups ranged in size from 3 to 12. Pureed food products provided in these sites varied, including totally commercially prepared and individually packaged (two sites #3 and #5b), to a mix of bulk commercially prepared, with or without individual portioning, with some in-house production of key items (Site #1, #4, #5a), to almost total in-house production, with use of bulk commercial only for key foods that were challenging to puree (Site #2). Staff used a range of terms to describe the pureed food provided in their setting. Although many had a generally negative view of these foods, described as ‘‘bland,’’ ‘‘colorless,’’ ‘‘baby food,’’ ‘‘tasteless,’’ ’’ boring,’’ ‘‘not appealing,’’ ‘‘unnatural,’’ and ‘‘mush,’’ others used terms such as ‘‘tasty,’’ ‘‘aromatic,’’ ‘‘safe,’’ and ‘‘easy to eat’’; these more positive comments typically came from allied health professionals and dietary=nutrition staff. It was noted by nursing participants that how the food looked often impacted if the food

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was offered to the resident and if staff manipulated the texture to achieve what they considered to be required for the resident. One site (#4) had recently gone through a change to improve presentation, and staff noted that this did make the food more appealing. Another site (#2) had worked on developing good tasting products and promoting variety, and this was also appreciated by staff and seen as an improvement. Five themes evolved from the analysis of these data: rationalizing the use of pureed foods; providing the right texture; affecting provider’s self-concept; doing whatever it takes; and making improvements.

Rationalizing the Use of Pureed Foods Rationalizing the use of pureed foods took several forms, but was essentially the accepting of a less than desirable product for the safe swallowing and nutritional health of consumers. For example: This is not what they truly in their heart want to eat. It’s more about quality of life, but when you weigh both, and that’s what we’re always trying to do is weight nutrition, safety, efficiency, all these kinds of issues. If that’s what it has to be then that’s what I’m going to recommend. But it [pureed texture] wouldn’t be my first choice ever from a quality of life standpoint. (Focus Group (FG) #4)

Even families of consumers were described as being resigned to the texture, ‘‘We do not hear them complain because I guess they know, like, you know, at that point, the family member . . . Has to. . . . Interviewer: Has to have it’’ (FG #9). Thus, part of rationalizing the use of this texture was recognizing that this was the only alternative to provide nutrition safely by mouth to these consumers. Safety was based on the need for consistent, smooth products, which would minimize choking and aspiration risk. Seeing safety as paramount resulted in diverse strategies such as rules for staff to follow around not adding anything to the food (FG #3) and deciding to outsource key products to promote a safe consistency (FG #1). These decisions resulted in less flexibility and variety, all justified for the safety of consumers. However, it meant that when a resident wanted other food, none was available. Participants also expressed their rationalizing the use of less desirable pureed foods by viewing the products solely as nutrition and not pleasure. The appeal of foods and what providers thought of the food was considered secondary to the necessity of providing a safe texture to consumers, ‘‘I don’t think it matters what, really, what we think—I mean, my opinion of pureed food shouldn’t matter; I’m not the one eating it’’ (FG #1). Thus, the focus was on getting sufficient nutrition, rather than seeing the food as a pleasurable experience for both consumers and providers. Knowing that this consistency

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was necessary meant that even family members, focused solely on the consumption of these foods: So the goal is just to get as much food in and they [family members] don’t really care what it looks like, tastes like, they just want to get it in. So they’ll put thickened juice and all kinds of combinations of things. (FG #4)

As pointed out in this quote, this often resulted in less dignified eating practices such as mixing foods together or concealing some foods in others that were more acceptable. Especially if the person had dementia, these were considered acceptable practices, as the desire to get anything in, was more important than the consumer’s and provider’s enjoyment of the experience: Well, if it is a necessity, it’s okay—well, all cases. But it’s much easier to do it when you have a patient who has got dementia and doesn’t know any different. It’s easier because they’ll just eat . . . a little more difficult for someone who really enjoys food, and you have to look at the slop. (FG #10)

In addition, knowing that these foods were required for safety meant that staff had no other alternatives to provide the resident=patient if they did not like the food: But you will try—I mean, you have to try. You have to try; it’s part of the job. If it’s only this [pureed], then the choices are narrowed, and I think it’s our job again as caregivers, that we have to at least try something. . . . Pureed food comes in . . . just that form, whereas somebody who was eating maybe . . . chicken and whatever, and they wanted maybe a . . . a peanut butter jelly sandwich, they can—we can get that. We can actually say, ‘‘Can you make this?’’ For pureed food, it’s one or the other, that’s it. (FG #3)

As a result, participants assisting residents to eat described apologizing for the food, hiding some products in more accepted foods as a way of ensuring that they were consumed, or offering a second helping of more acceptable products like soup or dessert. A final way of rationalizing the food texture was explaining to residents that despite the unappealing look, the food often tasted quite good and was needed for their recovery. Participants talked about convincing residents= patients to try the food to see that it tasted good and helping tablemates eating regular food to see that it was good: And sometimes when they’re sitting with other residents, and they’re not—they just have swallowing difficulties, but they’re—they don’t have dementia, it’s embarrassing that they have to eat something that looks so

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unappealing, because the other residents are going, ‘‘What’s that! Ew! That looks like dog food!’’ So then it’s our job to say, ‘‘Oh, no, it’s actually quite good. All it is, is put in a blender, the same food you’re eating,’’ you know, so I always used to say that, and they’d go, ‘‘Oh,’’ you know, so— (FG #3)

In addition to encouragement and promoting acceptance among tablemates, convincing the resident that the food was as necessary as medication was a way of rationalizing the provision of this less than acceptable food. For example: The problem is that, I look at the nature of the patients’ condition, and I take into consideration that the food is benefactory for you, because if you eat this food, it will help you to get strength, you know, you’ll be able to get in and . . . to take a medication, and for the medication to work effectively. So I would just try to encourage you, say, you have to eat it, because, like, you have dietitian that have assessed you, have gone through the assessment for swallowing and all of that, and they did know that. They decided for this to be your kind of meal, you know and I just have to encourage you to eat it. (FG #8)

These several strategies to convince residents, providers, and families that the current pureed food was the best for consumers reinforces that pureed food was not normal or desired and its use had to be rationalized for staff, family, and residents=patients. The stigma associated with this texture was evident in many provider comments, especially nursing staff that assisted residents=patients to consume these foods.

Providing the Right Texture Providing the right texture was paramount in the providers’ priorities with respect to pureed food; as noted, quality of life was secondary. Yet, providing the right texture that would be acceptable to all providers who assisted and residents=patients who consumed these foods was challenging. Even adding garnishes, such as a sprig of parsley, was considered a risk by some dietary staff (FG #9). In addition, what was considered the appropriate texture varied among cooks (FG #1) and among the dietary and the nursing staff that were assisting residents to eat. For example: I feel really positive about the pureed food from the back of the house perspective. I think we can control the texture, how it’s supposed to be served, but I lose confidence with the front of the house. How the perception of the care providers or the PSWs [personal support workers] can take a beautiful pureed meal and really not make it a positive experience for the client. (FG #4)

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They noted that there were varying perceptions of what was an appropriate thickness, and this resulted in different consistencies being provided to residents=patients because nursing staff would change the consistency by adding gravy, soup, other liquids, or mixing foods together (e.g., mashed potatoes with vegetables). These additions were done to not only improve the texture but also to improve the taste or cool down the product. Some of this difference in perception between nursing and dietary staff was due to the change in the product with sitting and waiting to be provided to the resident; products typically got thicker and stickier, and some developed a crust: I think it helps to get the trays out as soon as possible, because once the trays are up, if they sit there for thirty minutes, the food’s worse . . . we try to get the trays to the patient as fast as we can, because that’s when they’ll [the food trays] be at their best. (FG #10)

Individualization of texture was also identified as a reason for getting the texture right through these modifications, but in some cases, if a consistency was perceived to be challenging for a resident, the food was not offered at all. At one site (#1), there had been concerns around choking risk that resulted in moving to commercial products. This necessitated new rules around nursing staff not being able to alter this texture. As a result, these staff felt somewhat limited with these foods because they were no longer able to individualize the products as they had in the past. Participants also noted that some foods just did not puree as well as others (e.g., spinach, bread, meat, green beans). For example, ‘‘so there is that part which is the graininess [in meat products] . . . some of it is really like a pasty feel and it’s hard to be able to manipulate that as well, right?’’ (FG4). Dietary staff commented that the regulations to emulate the regular texture menu in the pureed menu forced the production of unnatural products, which sometimes had inappropriate textures, ‘‘I’m just wondering why we always try and focus on making pureed foods into what they’re not all the time, into, like a whole food, instead of accepting that it’s a pureed food, and trying to create products that are [uniquely pureed]’’ (FG #2). This participant wished that a pureed menu with acceptable products texturewise could be created from foods that were naturally this consistency (e.g., polenta) or pureed especially well (e.g., parsnips). Finally, staff noted that residents often became fatigued by the texture that was provided; although it was the ‘‘right’’ texture, this did not always mean it was acceptable to the resident=patient or their family, especially in the long term.

Affecting Providers’ Self-Concept Both dietary and nursing staff noted that their self-concept as nurturers and providers was linked to the quality of the pureed food products they

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provided to residents=patients. In sites where a great deal of effort went into either selecting quality commercial products or preparing in-house or adding to commercial products to increase appeal, dietary staff described feeling proud of their efforts and noting that the improvements they made had resulted in better consumption and quality of life for residents. For example: I do feel we’ve come quite a long way. Yes there are things to improve it and certainly the appeal, but it does taste very good. And the quality is very good. It’s also consistent quality . . . we’re really proud here because we’ve worked really hard on it over the years . . . we can keep people eating and improve quality of life longer than a lot of facilities. (FG #11)

On the other hand, where products were less appealing, staff described feeling bad or embarrassed (FG#2) about providing food that was so obviously disliked by consumers; they thought it was unfair that residents= patients who required this texture should have less choice=variety and noted it was more difficult to meet their preferences: P1: I don’t feel very good trying to get them to eat it, especially, you know, when they’re clamping down and . . . P2: But you will try—I mean, you have to try. You have to try; it’s part of the job. (FG #3)

However, when the product was acceptable to the resident: P1: Yeah, ‘cause you’ll say, ‘‘Oh, I know you love this!’’ And they smile and eat it. It is nice when they’re enjoying it. P2: Yeah, you feel good, you feel good that—it’s like you serve, you have a nice meal, yeah, it’s nice. (FG #3)

Participants believed that food was important for these residents and was a quality of life issue that needed to be supported. In some cases, providers believed that resident quality of life was being sacrificed for the cost of food products. Sauces and condiments had been eliminated (FG#11) or variety was reduced (FG #1, 3). For some, not only safety but cost containment with respect to labor was a choice that resulted in commercial product use. As a result, some staff described feeling disappointed with the use of commercial products because it felt good to make good tasting, quality food that was enjoyed by their residents=patients: P3: I’m disappointed that we have to go to a more convenient product. . . . I miss the home-cooked, cooking from scratch, because I’ve worked from one spectrum to the other over the years, and I do miss that. (FG #5)

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Whereas some felt that purchased products provided quality and consistency (FG#11), others missed having direct contact with and preparing the pureed texture. Regardless of their current perspective and improvements that had been made or decisions to out-source, all focus groups in some way acknowledged that the pureed texture had an impact on how they felt as care providers for their residents=patients.

Doing Whatever It Takes Whatever it takes is the theme that describes how staff manipulated or worked within the constraints of food production to meet the needs and preferences of their residents=patients. For staff, taste was considered most important for appeal, closely followed by appearance. However, staff described choosing alternative foods at the point of meal service based on the look and texture and smell (e.g., fish) of some foods; they would provide extra vegetables or desserts to the resident=patient to make up for the less acceptable product(s). Although they indicated that it was not allowed, they would mix foods together in an attempt to hide less acceptable foods, and typically the meat with some of the vegetables. This was not only to improve taste but also to address dry and sticky meat products: In my defense, in dementia [care] they do that [mixing food together] with some of my patients, but that’s the only way I’m going to get protein in because of the meat. So when they mix it together I have [a] better chance of getting all three things in. (FG #12)

Condiments were added if available and sauces, gravy, and butter or in some cases soup were added to products to enhance flavor and texture and to disguise some products. Kitchen staff and dietitians described additions to foods in production to enhance texture; for example, potatoes and breadcrumbs were added to vegetables to thicken and bind. Some sites also described working hard to promote as much variety as possible for residents and matching presentation to the regular foods; for example, ‘‘. . . I know the family members like, like [it when] we do the shepherd’s pie here, and they make it look like it’s shepherd’s pie, so it’s nice that they can actually have a plate that looks the same’’ (FG #2). In addition to adding things to food products to improve appeal, staff on the floors also described altering how the food was presented to the consumer to promote intake. For example, they would wait to serve products, especially those that were individually re-thermed in their commercial packages. Due to the fluid content and concerns with sufficiently heating to ensure food safety, these products were often too hot to provide to the patient=resident when delivered from the kitchen. They also described taking the film off of the commercial food dishes outside of patient’s rooms

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to allow aromas to disperse. When providing these foods, staff encouraged the resident=patient to try foods, so they would realize they tasted good and get past their appearance. Sometimes they alternated offerings of solids and fluids when they were assisting, not only to help with swallowing but also to overcome texture and taste fatigue. Some described talking to the patient=resident to distract them from the food being provided or starting with a more normal food like mashed potatoes that was well accepted. Others made attempts to describe the food to the resident to support interest in eating: And if you’re feeding them, you tell them what it is—‘‘This is a bite of carrot. This is bite—’’ I try not to mush it together. I try to make sure that if I can find where the separation is to say exactly what you’re giving them, so that they can match the smell and the taste—(FG#10)

Despite these ingredient manipulations to improve appeal and presentation strategies to promote intake, it was acknowledged that oral nutritional supplements were often required to enhance the nutrient intake for those requiring pureed foods. Although this was not an ideal situation, it was noted to sometimes be required for those who refused the food. Educating consumers, their families, and staff was an ongoing process to promote acceptance of the pureed texture. Having all staff involved in taste testing was used by some sites (#2 and #4) to promote acceptance and greater understanding of the products; however it was noted this needed to be an ongoing process to continually remind staff of the quality of products served: I find that so often a staff member would say ‘‘I wouldn’t feed that to my dog.’’ And then the patient has to eat it. That doesn’t make the patient feel good and then they don’t want to eat it . . . having them [staff] try the food is always a good thing. . . . (FG #11)

In-services with staff tended to focus on the different textures rather than taste-testing, and this idea of staff trying the food came up in many groups as a way of helping to improve their perceptions of the food. It was noted that continual education with family was also needed, especially as needs changed with progressive dementia and the family and consumer experienced further losses in capacity, ‘‘Families that aren’t coping with the diagnosis of dementia and continuum of changes . . . don’t cope well with the texture’’ (FG#11). Some nursing staff discussed needing to support the use of the pureed texture with family and consumers, even when they believed it to be inferior: I mean, you’re trying to promote it. And you’re the one that’s, you know, selling it to, per se, to you know, either a family member or a client. And,

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you know, again, when the comparison is made because you’re serving all three diets, and they’re looking at what even a minced is getting compared to what they’re [pureed consumer] getting, and especially even regular, like, it’s just no comparison, so. . . . (FG #2)

These participants also recognized that it was important to be advocates for these patients=residents about the food they were being offered because they often did not have a voice of their own. Where in-house pureed products were used, they noted that this was an opportunity to decrease feelings of being left out or different. With in-house production, they could inform the family and clients who consumed pureed food that the product was exactly the same food as provided to regular texture consumers. Knowing that it was the same promoted overall acceptance of this texture.

Making Improvements Making improvements included suggestions for change that would further promote the entire sensory experience for residents=patients and enhance food intake. Staff noted that being fully aware of what the food was and being able to describe it to the resident was important; currently they often had to guess what the food was as the odor, color, and taste were indistinctive: I can’t tell what it is. When I get a plate, I do not know. I actually look at the menu. I’m not sure what it is, which one’s the meat, which one’s the vegetable. I go by the color, and I try to go by the smell because— especially if you have to feed somebody—I don’t know what’s there. (FG #10)

Greater understanding of the products and their contents could be promoted with more detailed or specific menu sheets for in-house products or labels for commercial products. Furthermore, when a substitute in the daily set menu is made, providing information on what the substitute is would provide the necessary knowledge at the point of service to be able to describe food to consumers. Presentation could be further enhanced with a subtly divided plate that prevented food from running together; it was felt that such a round plate would be more natural and less hospital-like than a rectangular shape used by some commercial brands. Making improvements also included determining how to consistently provide the product so that its appeal was promoted. For example, consistency in recipes, type of ovens used for re-therming that made the best product (no crusting), and appropriate sauces being available were noted as needed improvements. Natural but vibrant colors were desired to stimulate the appetite and make the products distinctive; it was felt that many of the green vegetables and meat products all looked and tasted the same: ‘‘They

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do get tired of it quite easily. They get taste fatigue, it all tastes the same, one tray to the next’’ (FG#5). Garnishes (e.g., parsley leaf, lettuce leaf) were desired and it was noted that many of the residents=patients required feeding assistance; thus the concern for consuming such garnishes was often unwarranted. Colorful sauces (e.g., lemon, dill, cheese, cranberry) could be used to make products distinctive visually and in taste: ‘‘Or if you had a way of . . . sauces to—you know, in variety and that, that would make a simple meal, like, that could be enjoyed different ways and give some variety’’ (FG#5). Such sauces, if paired appropriately with food, could also promote understanding of what the food was (e.g., pureed pork with applesauce). As texture does not vary for consumers, other means of promoting the ‘distinctiveness’ of foods with garnishes and sauces was suggested as a way to overcome the perception that dishes were all the same. Increasing variety was a key concern identified by participants. It was noted that many vegetables did not puree well, resulting in a small rotation. Some commercial products in trays did not provide sufficient variety or flexibility and vegetarian and cultural options were extremely limited. New combinations of flavors and foods were also desired. It was noted that lunch and dinner were always the same hot meal, as recalled by one participant ‘‘One of my patients on spinal cord right now, cognitively intact. . . . She just says it’s so unnatural to have a full hot entre´e at lunch and supper’’ (FG#11). More cold options, other than sandwiches, were desired. Normalizing the pureed texture was seen as a way of making the products more acceptable. Creating food that was naturally soft and smooth (e.g., mousse, cheesecake, puree turnip, and sweet potato) for all texture diets were recommended to help provide consumers and their families a sense that residents=patients were being provided normal and comparable food to minced and regular texture consumers. By making the visual appeal as normal as possible, it was believed that this would decrease the feelings of being ostracized by other residents. There was also the perception that some commercial products looked artificial, either in their color, or the way they were presented (strips in a rectangular dish). An attempt to normalize by turning out onto a plate was one strategy used by some staff for this product line. Finally, it was important to participants that the smell and taste matched the food, yet for many products, pureeing enhanced unpleasant odors (e.g., fish, Brussels sprouts, and broccoli). As one participant stated: Yeah I think it helps. Strong aromas can be a really good thing like pureed apple crisp. I think that would be very stimulating, but there are certain aromas that I think can really turn off a client from eating. (FG #4)

Some mixed dishes like stews were considered unsatisfactory as the dominant flavor overtook the taste; it was recommended that mixed foods

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be carefully chosen to ensure that expected flavors were achieved. Increasing the distinctiveness of taste with tangy sauces and spices was desired; sauces as described, not only help with texture and recognition of the food but could add a much-needed distinctive flavor. Flavor packets were also suggested as a means of enhancing the taste for individual residents who might like spicy dishes.

DISCUSSION Participants of this qualitative study provide an in-depth view of their experience prescribing, planning, preparing, delivering, and assisting consumers with eating a pureed texture. As with residents and patients (10), perceptions of providers indicate that improvements are needed to promote sensory appeal, nutritional intake, and quality of life for consumers (9). Prevalence of use of this modified texture is anticipated to increase with the aging of society (12, 19, 20), thus it is relevant to work toward improving the experience for consumers and providers of pureed food. Contrary to some previous reports that suggested that pureed foods may be provided for convenience or for difficult-to-assist residents (19, 21), these participants described only choosing this texture as a last resort and when it was absolutely required. Direct care staff had to cajole or convince residents to consume this prescribed texture, and it would not be their choice to use pureed products unnecessarily. What is evident from this and prior work (13, 16, 22) is the high importance placed on safety, nutrient content, and then sensory appeal of food, which likely has the greatest impact on quality of life of residents=patients. This emphasizes the need to fully assess the necessity for a pureed texture before it is prescribed, and also when it is no longer required. The safety of swallowing and consuming any food orally was the primary reason for prescribing this texture. However, as with other research (3), staff needs to convince residents=patients and family of the importance of this texture for the health of the consumer. This realization that this texture was not desirable and sometimes considered unacceptable to consumers affected the self-concept of providers. Staff wished to provide the best possible food to consumers, and those who had worked hard at improving these products took great pride in these improvements and the heightened sensory appeal. Yet, for those who were dissatisfied with the food, they either brushed off their thoughts and their opinion of it, or felt bad about providing it to consumers. Previous work has noted the psychological and emotional impact of consuming pureed foods for consumers (3, 10) as well as providers, especially by food refusal (15, 22). Yet others have suggested that providers feel powerless to make change (9). This finding suggests that mealtime processes are complex in care environments and have the potential to

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influence the experience for all members, including staff. Furthermore, the health decline that often necessitates a modified texture, especially for persons with dementia, is a signal of declining capacity overall (3). As noted by participants in this study, this can be difficult for family and providers to cope with. As staff in long-term care (LTC) environments are especially encouraged to provide person-centered and relational care (23) including food provision, this conflict around self-concept and providing less than desirable foods may increase, leading to dissatisfaction with caring roles. Finding pride in the production of quality pureed meals is a potential way of overcoming this dissatisfaction. For the past decade, the nutritional quality and safety of pureed foods has received significant attention (4, 8, 13, 24, 25); these priorities were also evident in the comments made by providers involved in the focus groups of this study. Sensory appeal, although noted to be extremely important to adequate consumption, has received less attention (6, 16). Some work has been done on molding and forming products (13, 14, 26). However, participants in this study rarely mentioned these specialty products, but provided several suggestions to promote visual appeal that are consistent with other work (7, 27). Subtly divided round plates, use of colorful and distinctive sauces, creatively reshaping, and normalizing the pureed texture by offering these foods on the regular texture menu are all feasible and low-cost recommendations. Taste and texture could also be enhanced by sauces that do not unduly thin products. However, as noted by these participants, individualization around texture is often needed, due to thickening and increased stickiness of products upon standing. This suggests not only a need for better communication among those directly providing the products to the consumer and those who make these products about this care gap but also a need for understanding that flexibility in handling is sometimes needed. Increased communication around resident=patient needs is noted to improve compliance with pureed textures (28). Participants noted that flexibility in the ‘‘rules’’ around pureed food was needed. To encourage food intake a variety of techniques and ‘‘tricks of the trade’’ (15) often were employed. Even a dietitian noted that to get some residents with dementia to eat, different products needed to be mixed together. This suggests that the current recommendations or ‘‘rules’’ around food provision in LTC may not sufficiently consider individual needs. For example, as noted in this and other work (12), the perception that pureed foods should be the same products as regular textures can lead to the provision of poor quality pureed foods. These beliefs around how best to provide pureed food likely came out of a desire to protect these vulnerable consumers; however they have also made it challenging for caring providers to individualize products to best meet the needs of their residents=patients. In addition, swallowing capacity can change meal-to-meal and day to-day, necessitating tableside adjustments (21, 29), and nursing adjustment of texture is a common

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occurrence (15). Educating staff and empowering them to do the best they can for their residents=patients may be a better approach to achieving personalized care (8). It is important to note that units within hospitals and LTC homes have their own culture (15), and educating staff as a group within the unit may achieve improved behaviors with respect to the manipulation and presentation of pureed products. Fortification of pureed products with calories, protein, and micronutrients is another strategy that has been tried with success (11, 13, 30). This strategy may compensate for any nutritional deficits resulting in a consistent quality pureed product. Thickening products with energy and nutrient dense additions is a well-known strategy that promotes visual appeal. However, thickeners can change the mouth-feel and promote dryness (11, 13), and can negatively be perceived as fillers (12). As more effort is placed on creating standardized recipes with appropriate mouth-feel and taste (6, 26), the resulting increased acceptance of nutritious products will help to reduce the need for the rationalization that was evident in this study with the prescription of the pureed texture. Additionally, ensuring sufficient variety in color, taste, and temperature would help with long-term acceptance of this texture by alleviating the boredom that comes from consuming foods that are not perceptibly different from each other. In this study, lack of safety of products due to inconsistency in production and handling was a noted concern. Nutritional content could also vary with lack of standardized recipes (4), but this did not seem to be as worrisome to these participants. Previous work has noted that lack of standardized recipes is common (7, 31), but variation also occurs at the point of service as noted by participants in this study and others (10). Inconsistency in production can suggest a lack of understanding of the importance of consistency for a quality product that not only affects nutritional health and swallowing safety but also the experience of consumers and providers (10). This study and others (13) demonstrate that providers do notice a difference when standardization and quality is improved, and they value the care taken in production. These results further emphasize the need for constant communication among the members of the food chain so that improvements can continually be made. Such communication enhances understanding of divergent needs of providers who prepare and those who deliver and assist residents=clients with eating. As with other research (27), participants in this study noted that frequent taste-testing with all members of the food chain would help to improve this understanding. This education could be even extended to how foods are presented and if they need adjustment, how best to make these changes, promoting consistency where it is currently lacking (10). Educating staff on how to make the meal an ‘‘event’’ could also enhance affect and quality of life of patients=residents (32). This study has filled a gap in the current research on modified texture diets (9, 16), providing a better understanding of the issues and concerns

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held by providers of pureed food who are part of the food chain. This is the most extensive and rigorous study to date on provider perceptions, including a total of 12 focus groups with 80 participants representing diverse disciplines over five sites, resulting in robust data. Yet there are some limitations to this work. All of the providers were located in one province of Canada, which is influenced by regional policies and standards, especially for LTC homes. Thus, some practices in this region may not be common occurrences elsewhere (e.g., matching modified texture foods to regular menu) and issues identified in this work associated with these practices may not be transferable. In addition, one site provided only dietitians and no direct-care personnel, limiting out understanding of the perceptions held by those staff in this setting. Yet the inclusion of five diverse sites with a mix of pureed production and delivery models does promote confidence in findings. Further work should focus on education of staff and how to promote flexibility safely, so that individualized needs can be met. Methods for enhanced communication around individual needs require identification and systemization to promote responsiveness. End-points or outcomes for intervention research should include product acceptance, improved quality of life for residents=patients, and sense of self-concept for providers. In conclusion, this qualitative study delivers new and corroborating evidence around the challenges and issues of providing pureed textures to consumers. Provider perspectives were remarkably consistent with consumers (9, 10), noting key issues of consistency and sensory appeal. Yet these providers noted greater relevance of the need to be safe and how at this point, this means compromising on taste, mouth feel, and appearance. The resulting rationalizing of the texture to themselves and consumers meant that the mealtime experience was negative. Suggestions for making improvements were also consistent with those provided by consumers (10) and are believed to be highly feasible and low cost. In addition to specific recommendations to improve products, this work also exposed the need for education among food chain providers so that diverse perspectives are understood and consistency in product handling occurs. Greater effort needs to be made toward responding to these challenges and concerns producing more acceptable, nutritious products, rather that believing that nothing can be changed (9).

TAKE AWAY POINTS .

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Allied health care providers who provide pureed food to consumers note a tension between providing safe, consistent products, and needing to individualize pureed textures to meet the needs of consumers. Simple additions and manipulations to pureed food can promote increased acceptance. Taste-testing by all staff will help to dispel misconceptions

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about flavor and mouth-feel, and help staff to be able to describe and advocate for the use of products with consumers. Communication among staff within the food production and provision chain is needed to respond to individual needs in a manner that promotes safety as well as quality of life for residents=patients.

FUNDING The OMAFRA–University of Guelph Partnership program is acknowledged for funding this research.

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