Outcome | Measure metrics and validity evidence documented in available studies [in brackets] and as emerged in this study | Source(s) of data |
---|---|---|
Edinburgh Feeding Evaluation in Dementia scale (EdFED) | From 0 total independent, to 20 totally dependent [19, 20] Reliability Cronbach alpha = 0.909 | Direct observation during lunch time |
Appropriate level of care required by the resident (only supportive/educative; partly or wholly compensatory) (EdFED) | ||
Individual level | ||
 Age, Sex | – | Data was extracted from the NH and regional database |
 Functional dependence using the Barthel Index (10 items) | From 0 total dependent, to 100 total independent [21] Reliability Cronbach alpha = 0.945 | |
 Cognitive Performance Scale (6 items) | From 0 intact, to 6 severe impairment; scores ≥4 indicate moderate/severe impairment [22] Reliability Cronbach alpha = 0.937 | |
 Depression Rating Scale (14 items) | From 0 to 14; scores ≥3 indicate minor or major depressive disorders [23] Reliability Cronbach alpha = 0.834 | |
 Pain Intensity Scale (1 item) | From 0 no pain, to 3 severe pain [24] | |
 Night restlessness (1 item) | Each scored from 0 absent, to 4 always present [25] | |
 Verbal aggressiveness (1 item) | ||
 Physical aggressiveness (1 item) | ||
 Clinical Instability Score (1 item) | From 0 clinically stable, to 4 high instability [25] | |
 Close/intimate relationships with family relatives (1 item) | Yes/no [25] | |
 Where the resident habitually eats  -in his/her bedroom, alone  -in the dining room, near one resident (on left or right side)  -near two residents (on left and right)  -near two residents (on left/right and in front)  -surrounded by other residents (on left, right and in front) | From 0 eating alone, to 4 surrounded by other residents | |
Nursing care level | ||
 (a) environmental interventions: starting the mealtime ritual by stimulating hearing and sight memory (1. ringing a bell, 2. opening the dining room), promoting the desire to eat by stimulating smell and visual memory (3. setting the tables in advance as in a restaurant, 4. entering the dining room with a meal trolley); creating and maintaining a peaceful environment allowing residents’ concentration (5. lowering distracting stimuli; 6. balancing the presence of the family) | (a) From 0 none, to 6 all interventions are daily performed [18] | Nursing Staff observation via checklist |
 (b) resident interventions: knowing the resident (1. collecting and sharing their stories and habits; 2. understanding their daily variances and adapting routines; 3. establishing residual self-feeding abilities), escalating feeding care (4. verbal, 5. behavioural, 6. motivational prompts; 7. respecting refusals and waiting; 8. balancing insistence and resistance; 9. deciding the best position), de-escalating difficulties due to meals/utensils (10. by adapting the consistency of food, and utensils) | (b) From 0 none, to 10 all interventions are daily performed [18] | |
NH level | ||
 Units composing each NH  Beds of the NH unit where each resident was living | Number Number | Data was extracted from the regional database |
 Therapeutic Environment Screening Survey for Nursing Home (TESS-NH) (84 items categorised in 13 domains [26, 27] | Higher scores in each domain indicates high environment quality [26, 28] Reliability resulted in all evaluable dimensions in Cronbach alpha = > 0.600 | Direct observation |
  - ‘Unit autonomy’: nursing station presence/type; nursing station for paperwork; desk for paperwork; combined work area for paper work; enclosed workroom, not a nursing station; unit use as pathway between other units; residents eat on/off units; formal activities on/off unit; residents bathe on/off unit (9 items) | - Scores 0, 1, 2 or 3 according to the item | |
  - ‘Outdoor access’: enclosed courtyard; attractiveness of courtyard; courtyard is functional (3 items) | - Scores 0, 1, 2 or 3 according to the item | |
  - ‘Privacy’: privacy curtain provides only separation between beds in semiprivate rooms (1 item) | - Score 0 or 1 | |
  - ‘Exit control’: doors of rest of facility distinguished; doors to outside distinguished; number of exits off of the unit; number of elevators off of the unit; doors are looked; locking device triggered by approach; look disengaged by keypad/switch; looked at night/during bed weather; doors are alarmed; alarm triggered by device worn by resident; alarm disengaged using keypad, card or switch (12 items) | - Scores 0, 1 or 2 or Not applicable according to the item - | |
  - ‘Maintenance’: maintenance of social space; of halls; of residents’ rooms; of resident bathrooms (4 items) | - Scores 0, 1 or 2 | |
  - ‘Cleanliness’: cleanliness of social spaces; of halls; resident rooms; resident bathrooms; bodily excretion odour in public area; in resident rooms (6 items) | - Scores 0, 1 or 2 | |
  - ‘Safety’: floor surfaces in social spaces; in halls; in resident rooms; in resident bathrooms; handrails in hallways; in bathrooms (6 items) | - Scores 0, 1 or 2 | |
  - ‘Lighting’: intensity in hallways; in activity areas; in resident rooms; glare in hallways; in activity areas; in resident rooms; lighting evenness in hallways; in activity areas; in resident rooms (9 items) | - Scores 0, 1, 2 or 3 according to the item | |
  - ‘Visual/tactile stimulation’: bedrooms with a view of the courtyard; public areas with a view of the courtyard; tactile stimulation opportunities; visual stimulation opportunities (4 items) | - Scores 0, 1 or 3 | |
  - ‘Noise’: status of the television in main activity areas; resident screaming/calling out; staff screaming/calling out; T/radio noise; loud speakers/intercom noise; alarm/call bell noise; other machine noise (7 items) | - Scores 0, 1, 2 or 6 | |
  - ‘Space/seating’: % of rooms with a chair per person; public room inventory; path leads to dead ends; path with places to sit; configuration of rooms on unit (5 items) | - From 0 to 1, 2 or 3 or Not applicable according to the item | |
  - ‘Familiarity/home likeness’: public areas homelike; kitchen of the unit; pictures/mementos in resident room; non-institutional furniture in resident rooms; residents’ appearance (5 items) | - Scores 0, 1, 2 or 3 according to the item | |
  - ‘Orientation/cueing’: doors left open; resident’s name on/near door; current picture of the resident; old picture of the resident; object of personal significance; room numbers; colour coding; bathroom door left open, toilet visible from the bed; bathroom door left open; toilet non visible from the bed; bathroom door closed, picture or graphic; activity areas visible from the 50% of resident rooms; visual indicator of activity areas visible from 50% of resident rooms; direction, identification sign visible from 50% of resident room (13 items) | - Scores 0 or 1 | |
 Therapeutic Environment Screening Survey for Nursing Home (TESS-NH) global single item (1 item) | From 1 low, distinctly unpleasant, negative, non-functional, to 10 high, quite pleasant, positive, and functional environment [26] | Direct observation |