From the View of a Nutrition Services Aide:

Workings of the Sholom Nutrition Services Department

and Opportunities for Improvement

Jessica Lehrke
FScN 4291: Independent Study
Fall 2016

From May 22nd until September 3, 2016, I worked 9 to 15 hours per week* as a nutrition services
aide for Sholom, a long-term care and assisted living facility, at the Shaller Campus in St. Paul,
Minnesota. During this time, I completed weekly journal entries and interviews with the Nutrition
Services Supervisor and on-staff Registered Dietitian (RD). While completing this experience, I had four
objectives in mind: 1) To enhance my knowledge of food preparation for specialized diets, 2) To learn
how to better communicate with residents regarding their diets and meal choices, 3) To learn how a
nutrition services department interacts with other areas of an organization to facilitate the resident
experience, and 4) To learn about the points of interaction between residents and the nutrition services
department. However, while journaling, I also noticed common recurring themes, issues that I
consistently wrote about and attempted to address while working. In this paper I will describe the
knowledge I gained related to four aforementioned topics as well as three areas in need of improvement
within Sholom Shaller Campus nutrition services with accompanying suggestions for change.
As a Nutrition Services Aide working evenings at Sholom, my primary duties include serving
meals in accordance with safety and health regulations, meal tickets, and Kosher guidelines as well as
maintaining kitchen and dining area to ensure proper safety and sanitation. A detailed list provides
guidance on the required tasks, aside from actually serving meals, for fulfilling these duties. A typical
evening shift proceeds as follows. Between 4:25 PM and 4:30 PM, I begin my shift in the main kitchen,
picking up the food for dinner along with an apron, hairnet, cleaning rag, meal tickets, and key set. I also
bring a pen, black permanent marker, and food thermometer. Provided the prepared food is ready at 4:30
PM, I will arrive to my assigned section by 4:40 PM. After putting the pans of food in the steam wells,
oven, and fridge as needed, I fill the dish buckets and separate the meal tickets. If changes to the meal
tickets are required, I edit them by hand and communicate necessary information, like changes or
quantities, to the nursing aides. The nursing aides, of which there are typically three on duty, use the
tickets to record resident meal choices. While they are communicating with residents, I take and record
food temperatures, make a few salads, and, if time allows, plate dessert. We begin serving dinner by 5:00
PM, serving residents in the dining room first, then serving room trays, finishing around 5:40 PM. After
dinner, I clean dishes, the kitchen, and the floors, attempting to complete all of the tasks on the list. While
cleaning and waiting for nursing aides to return dishes, I also check in with residents to see if they
enjoyed dinner or need anything else to eat or drink. I am to complete all duties, including bringing pans
back down to the main kitchen, and clock out by 7:30 PM.
The completion of this very lengthy list of duties in the limited time frame presents the first area
in need of improvement-- the expectations set forth for the nutrition services aides. The expectations for
what can be accomplished between 5:40 and 7:30 pm are very high. To complete every item on the list,
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and do it well, would mean everything going according to plan-- food items ready on time and with no
need for additional heating, no staff shortages, no food shortages or missing food items, no resident
behavior issues, no need to make alternate items for residents, nursing staff would bring dishes back in a
timely fashion, and in addition, there would be no time to converse with residents. This is an unrealistic
expectation. Instead, I propose that this daily task list be split up by day. Most of the items would be
completed every day, and there should be a general expectation of cleanliness, i.e. cleaning up any spills.
Other items, like cleaning the oven, dishwasher, cupboard doors, refrigerator, and disposal (which is not
on the list, but should be), would be split into two lists and completed every other day. Currently, many of
the items are not being completed, but instead aides are choosing which items to complete. This may
mean that certain items are always completed, while others are rarely done. If the expectations were
changed to be specific and more realistic, I believe nutrition services aides would be much more likely to
complete their listed duties.
While I believe that the number of cleaning tasks to complete in one shift should be reduced, I
believe that the expectations for nutrition services aides regarding nutrition knowledge should be
increased, along with responsibilities relating to residents. It should be expected that we check in with
residents after serving dinner to make sure they have gotten enough to eat and are satisfied with their
meals. This is not on the list, but I believe it is an important part of the job. We could also be an enormous
help to nursing staff by recording resident food intake. This is one of the duties assigned to nursing aides-to record the amount of food each resident eats. Nursing aides, however, are so busy with other duties that
it is difficult for them to track, remember, and record this information. Nutrition services aides should be
able to take ownership over this. We are both servers of the meal and owners of the meal tickets, so we
know how what and much food was served to each resident. Instead of waiting for nursing staff to clear
plates, we could clear them and record the amount eaten for each resident.
While serving residents dinner, I increased my knowledge in specialized diets. I worked with
residents who had various dietary needs, including the full range of textures in the National Dysphagia
Diet (NDD), low sodium, diabetic, cardiac, low fiber, and renal. Although I had already learned the
theoretical composition of these diets, I was able to see how they are produced in a foodservice setting,
and because of my previous knowledge, was able to improvise when needed.
The NDD1 meals, or the pureed diet meals, are made ahead of time and plated by one nutrition
services aide for the whole facility. Purees of the provided protein and vegetable are made by adding the
food to a blender along with water and a thickening powder. The starch with these meals is typically
mashed potatoes made from a powder. The three purees are then piped, using a pastry bag, onto plates and
brought to dining areas. The NDD2 meals, or mechanically altered meals, are made by using the protein
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to make a ground meat and, typically, using the vegetable and starch from the regular meal, as long as the
items are soft enough. The NDD3 meals, or dysphagia advanced meals, are similar to the NDD2 meals
except the protein may be in bite-sized pieces rather than ground. Certain vegetables that can be difficult
to smash with a fork, like broccoli, are supposed to be replaced with softer vegetables, like green beans.
Every meal is individualized for the resident, as some can handle a combination of textures that would fall
within different dysphagia levels. When meals are individualized for low sodium, diabetic, etc. diets,
alternative items are specified on the meal tickets. For instance, for those on a low sodium diet, salad will
frequently be substituted for soup, and for those on a diabetic diet, sugar-free desserts are specified.
However, there is a frequent problem at Sholom with special items-- they are often not prepared
by the kitchen staff. Sugar-free desserts, often specified on the meal tickets, are never available, nor are
the alternate soft vegetable options or low-fiber soups. This creates multiple difficulties. First, residents
with special dietary needs are not provided the range of options provided to other residents. Although we
can attempt to make due with other items provided, this may mean that residents do not get a serving of
vegetables with a meal. Without the sugar-free dessert option, some residents may not get the same
dessert (usually it is substituted with fruit), and they often get upset. Whether or not a resident with
diabetes receives the regular dessert often depends upon the permission of the nurse, who refers to their
recent blood glucose levels to determine if it is appropriate. The lack of special diet items also creates
difficulties for the nursing staff, who use the meal tickets like menus to get the residents orders. If I
receive the meal tickets prior to the meal service, I review them and make corrections, but if not, nursing
staff may offer residents items that we do not have, creating frustration for both residents and staff. The
larger issue that these missing items point to is a lack of effective communication between those creating
the menu (Nutrition Services management and RDs) and those producing the food. When I spoke to the
staff dietitians about this, they were unaware that there was an issue. In other words, they are investing
time and energy into creating a balanced menu that addresses all residents nutritional needs, but their
guidance is not being followed.
I believe there is a fairly simple solution to this problem. According to the Nutrition Services
Supervisor, there are production reports for the kitchen that can be printed from their database. It is my
understanding that these reports are not currently being used in their complete form. These reports include
everything that needs to be produced for a given daily menu, including alternative items for special diets.
I have noticed that sometimes the kitchen simply does not have an item in stock. In this case, the problem
could be rectified by doing a product inventory ahead of time using the production reports. Product can
then either be ordered or replaced with a different item. Overall, it appears that the Sholom Nutrition
Services Department needs to take advantage of their database capabilities and take time to plan ahead.
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Lastly, if, in fact, all of these suggestions are actually being implemented and menu items are still
missing, this becomes a staff training opportunity. Addressing this one issue-- missing menu items-- could
have far-reaching effects, including happier, healthier residents, improved dietary and nursing staff
relations, and more efficient meal services.
As described previously, nursing staff use the meal tickets like menus to get orders from
residents. Although this was always supposed to be the standard method for meal service, it was not put
into regular practice until recently. This is a good practice for a number of reasons, including: 1) if
residents choose from their own personalized meal ticket, they cannot, theoretically, choose an item that
contradicts their diet; 2) the nutrition services aide has a written record of meal choices, so they do not
have to remember the orders; and 3) it empowers the residents to make their own food choices. For these
reasons, I have found this to be the best way to communicate with residents for meal service, and so use it
every time I work.
I have also learned how to better communicate with residents one-on-one. The best way to
communicate effectively with residents is by first getting to know them-- their likes and dislikes, their
communication style, and their limitations. Many of the residents have some form of dementia, so
learning to read their body language and tone of voice, as well as picking up on key words amongst a slew
of what appears to be nonsense, is all incredibly important. For those residents who do understand, I have
found it is best to be up front about their diet plans, showing them their meal ticket, discussing why some
items may be excluded or changed, and then working with them and the nurse to provide them with a
satisfying meal. Unfortunately, these conversations do not happen as often as they should. This is the
down-side of the previously described system. Nursing aides serve as an intermediary between the
nutrition services aide and the residents, and typically the nursing aides cannot or do not want to take the
time to communicate this way with residents, and it is very difficult for the nutrition services aide to step
away from serving to speak with one person. Doing so would also appear to undermine the nursing aides,
putting a strain on the relationship. Unfortunately, then, the opportunity for empowerment and education
of the resident is lost.
This lost opportunity highlights the tenuous nature of the relationship between nutrition services
aides and nursing staff, particularly nursing aides, presenting another opportunity for improvement.
Serving dinner means working cohesively with nursing staff, but currently, the communication between
nutrition services aides and nursing staff is strained. In my experience, the issues arising between the two
groups stem from a lack of understanding of job duties, a lack of recognition of the importance of
nutrition, and outside forces. Two of the outside forces have already been discussed-- missing food items
and time constraints (for both Nutrition Services and nursing staff). A third will be discussed later.
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A lack of understanding of job duties amongst Nutrition Services and nursing staff, specifically
regarding meal service, is common. In general, Nutrition Services and Nursing staff to not have a good
understanding of each others responsibilities, so it is difficult to understand the time constraints for each
group. Recently hired nursing aides often do not know that bussing dishes from tables to the dishroom
one of their responsibilities. Currently, they do this so that they can track amounts eaten by residents.
After speaking with one nursing aide, I discovered that many do not know that they are also supposed to
wipe the tables clean, which explains why some residents have complained that the tables are sticky. On
the other hand, the role that the nutrition services aides have in stocking the kitchen is somewhat unclear,
i.e. when and what items are stocked. For example, a nursing aide I was working with was complaining
that Nutrition Services staff do not stock items, like thickened coffee powder. However, I was unaware
that we even had this item, so was unaware that it needed to be stocked. The nursing aides that I have
worked with have also been unaware of our combined responsibilities to discuss dietary changes (like
giving regular dessert to a resident with diabetes when sugar-free is unavailable) with the nurse on duty. I
have explained many times that it is my responsibility to follow the meal tickets-- that it is important to do
so for the health and safety of the resident. We are to discuss changes like this with the nurse so that if, for
example, the persons blood sugar is too high, they can then discuss that with the resident. On the other
hand, the nurse can approve it and record the change in the residents record. I have had to explain this
process many times to the nursing aides that I work with, and they are still reluctant to have the
conversation with the nurse and/or the resident. This also relates to not recognizing the importance of
nutrition, not recognizing how dangerous a change like this can be.
The lack of recognition of nutrition as an important form of care is obvious amongst Nutrition
Services and Nursing staff. Attitudes around eating are very cavalier. Whether a resident eats or not is
often simply something to be recorded rather that something to act upon. For example, one resident
frequently refuses the food given to her or only eats a few bites. During or after dinner I check in with her,
offering her other things to eat, which she usually accepts. I have been told by residents family members
that other nutrition services aides do not do this. Because nursing aides have not been given the
instruction to help feed this person, they give no additional assistance. When I asked one nursing aide
about how a resident is assigned additional feeding assistance, she was not sure, just that it needed to be in
their record. I believe that if all staff involved in meal service were clear about their job responsibilities
and recognized the importance of nutrition in health care, health outcomes of residents would improve.
There has been some discussion at Sholom regarding a potential training session involving both
Nursing and Nutrition Services staff. I fully support this idea. Representatives from the nutrition services
aides and nursing aides groups should be involved in the development of this training. The training should
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address job responsibilities related to meal service, best practices for serving residents/addressing issues
specific to the population, and the importance of nutrition in health care/components of a well-balanced
meal. A combined training session like this would help staff members work more cohesively and could
lead to improved resident health, greater resident satisfaction, more efficient meal service, and greater job
satisfaction.
Aside from the Nursing Department, the Nutrition Services Department interacts with speech
pathologists, medical doctors, s ocial workers, Minimum Data Set (MDS) coordinators, physical and
occupational therapists (PT/OT), therapeutic recreation, and the administrator when facilitating the
resident experience. If a resident seems to be having difficulties chewing or swallowing, nutrition services
aides are to report this to the nutrition services supervisor, who will communicate the information to
Nursing, the MD, speech pathology, and/or the RDs as needed. Swallow tests may be done, or the RD
may decide to change the texture of a residents meals based on their conversations with staff and
observations. The RDs meet with the interdisciplinary team at 9:00 AM every day, which includes social
workers, nurse managers, MDS coordinators, PT/OT or rehab managers, and therapeutic recreation. This
group discusses new patients on the Transitional Care Unit (TCU) and any occurrences from the previous
evening that need the groups attention. Having all of these departments in one room to discuss residents
allow them to coordinate and delegate care effectively. Lastly, Nutrition Services management requests
administrative intervention when they feel it is necessary, for example, if protocols are not being
followed, leading to improper resident care. The administrator will then, typically, send an email
addressing the problem to a department, department managers, or the entire staff of Sholom. These issues
may also be addressed in upcoming trainings.
There are five primary ways that the Nutrition Services Department interacts with residents at
Sholom. I have already described the meal service, which is, obviously, the most important contact point.
In addition, the department communicates with residents via written messaging, a monthly Food
Committee meeting, one-on-one meetings with the Nutrition Services Supervisor, and various types of
meetings with an RD. Written communications include the weekly posted menu, meal tickets, and
food-related flyers. The Food Committee meeting is a forum for residents to provide feedback to the
nutrition services supervisor regarding the food and food service. The nutrition services supervisor also
visits one-on-one with residents who have requested to speak with her or who have complaints or special
requests. Lastly, the RDs interact with residents in a variety of ways. Within the first three days of moving
into Sholom, an RD will meet with a resident to discuss their current diet, food allergies, chewing or
swallowing issues, appetite, likes and dislikes, bowel function, usual body weight, weight history, and
height and find out if they have dentures or natural teeth. After the initial visit, an RD will visit residents
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on the third and fourth floor (long-term care) every three months. On the second floor, the TCU, an RD
will check in every month if they are determined to be at risk. At risk residents have lost a significant
amount of weight, are on a tube feeding or dialysis, have an active cancer diagnosis, or have open
wounds. An RD will also visit residents on wound rounds most Wednesday mornings or if a nurse or
doctor thinks it is needed. Care conferences, short check-in meetings for long-term care residents, are
also held on Thursday mornings with an RD, nurse manager, social worker, and typically the resident
and/or their family members. The numerous resident contact points discussed here are only those for the
Nutrition Services Department, and this list may not be all encompassing.
Clearly, Sholom residents are well cared-for. As a nutrition services aide, I have learned the
workings of the Sholom Nutrition Services Department and have increased my personal knowledge about
special diets and resident communication. I can attest that the Nutrition Services Department, in
partnership with nursing staff, social workers, and others, provide high-quality food and nutrition care.
Residents are given food options and empowered to make their own choices. Nursing staff truly care
about the residents and work with nutrition services aides to provide efficient meal service. RDs closely
monitor residents diets and health, and systems are in place to coordinate nutrition care with other
departments. All of these things make Sholom a desirable place to live for those in need of assisted living
or long-term care. However, there are always opportunities for improvement. From my vantage point as a
nutrition services aide, there are three such opportunities that stand out: 1) improving communication
between nursing staff and nutrition services aides via interdepartmental training, 2) improving
intradepartmental communications regarding menus via use of already existing database tools, and 3)
improving overall meal service efficiency and nutrition care via changes in the nutrition services aide job
description. I have laid out the reasoning behind these proposed changes. Overall, I believe that making
even one of these changes could have a positive ripple-effect on the whole of Sholom.