Purpose and Goal of Needs Assessment 1. What is the general perception of happiness in the nursing home? 2. What special programs are in place to create a sense of community and belonging? 3. Does the staff members appear happy with their jobs or do they view their job and the patients as burdens? 4. What is the access to transportation outside of the home? 5. Dose any of the staff have specific certifications or unique skills which make them more of an asset to the community? 6. How do one-on-one interactions occur? Are they all forced or do the residents feel comfortable with the staff and converse with them? 7. Does the staff generally take their time with their duties or do they focus on certain duties and let others fall by the wayside? 8. Is the dining experience unique for each individual resident or do they all get the same basic meal? 9. Is there alternative entertainment during dining such as television or background music? 10. Does the community promote interaction and events with the children and grandchildren of residents?

Literature Review on Dining Experiences in Relation to General Feelings of Happiness
“A comfortable old age is the reward of a well-spent youth. Instead of its bringing sad and melancholy prospects of decay, it would give us hopes of eternal youth in a better world.” This quote from the late French actor Maurice Chevalier describes the hopes that all people have as they get older. Sadly, not everyone has the comfortable old age that they desire and for those elderly people who reside in nursing homes, it is the duty of caregivers to provide them with a hospitable and comfortable living experience. In particular, the dining experience of the residents should be of primary importance because not only is it nourishing for the body but it can also be, as the metaphor states, nourishing for the soul. By analyzing the maintenance of feelings of independence in residents, the positive effects which can be seen from meaningful experiences, and different approaches for improving residents’ dining it will be shown that this is one area which can make a significant impact on their lives. Within the dining experience itself, the evaluation of dining experiences on residents’ moods, the ways in which staff interact with residents, and the issues of implementing dining assistance programs will be discussed as areas which need to be improved and maintained.
The first thing to analyze is the role of nursing homes in American culture and in particular how studies are completed when analyzing new or previously existing programs. When looking at the role of nursing homes, one must also analyze the uniquely American way in which we view the elderly. Whereas in some cultures around the world the children take care of their aging parents, in the United States the elderly are often left to live on their own or in specially designed and run communities to keep them with their peers. However, due to the nature of nursing homes and certain retirement communities, the nature of aging is one where to Americans, “elders are regarded as vulnerable populations akin to children or prisoners” and subsequently their competence is questionable. (Rash, 2007) The public views the elderly in homes as people who must be taken care of like the children that they are compared with. Children like to think that their parents are happy, well fed, and taken care of when they are unable to care for their parents in their homes. Because of the fear that the elderly are not receiving adequate care, “the Office of Inspector General (OIG) has undertaken an extensive body of work dealing with nursing homes in the areas of oversight, financing, and quality of care” (Emerging Practices in Nursing Homes, 2005). This research includes on site investigations and reviews, interviews with residents about level of care and happiness, and into the psychological makeup of residents in nursing homes dealing with their state of happiness. The reports are kept simple and to the point and the interviews which are conducted have strict guidelines to prevent data mismatch and misreading of problems. The interviews must, “have enough substance so that, according to the people we interviewed, the practices appear to make a significant contribution to high-quality care in the home” and review of new policies can only occur once they “have been in place for sufficient time to be considered a success by the nursing home administrators and seem likely to continue at the home” (Emerging Practices in Nursing Homes, 2005). Once a program has been evaluated and given a success rating by the government, it can either be replicated in another area or it can be shut down if it proves to be detrimental to the lives and feelings of the residents. However, during the evaluation process there are outlying variables as well as resident whose opinions are not taken. In some trial period evaluations, “it is unclear as to whether social support is present in cases of critically ill, incoherent recipients, in cases of negative outcomes in which either the recipient or provider perceive the support actions as positive, in support given from or to an organization, the community, or a professional, and in support that has a negative intent or is given grudgingly” (Rash, 2007) Because certain individuals lack the ability to fully communicate their thoughts and feelings, the results have unknown variables which mean that some programs might not be a necessarily positive experience while others might be aimed at these groups and are subsequently dismissed because they don’t receive the promotion from the group affected the most.
After analyzing the evaluation of new programs in nursing homes and retirement communities, one might ask the significance of these programs in an aging person’s life. In the late twentieth century, the perception of nursing homes in popular culture was that they were places where elderly people were shut away by their children who could not or did not want to deal with their aging parents. The importance of these institutions had not escaped the government and “the generalized perception of substandard quality of life in nursing homes, the Institute of Medicine recommended in 1985 that residents should be cared for in such an environment as will promote maintenance or enhancement of their quality of life” (Rash, 2007). This act lead to program reformation through the previously discussed processes, a reformation system which still is in place over 25 years later. As such, each new program is a test unto itself and must qualify as a positive impact on the lives of residents due to the position taken by the institute of medicine. All nursing homes must be accredited and certified by governing agencies which maintain a set of standards and procedures which must be followed. Because of the nature of nursing homes keeping people happy and healthy, there exists a “tenuous balance that necessitates a degree of conformity and routine that is likely to be counterproductive to a homelike atmosphere and the development of internal social support structures” (Rash, 2007). Similar facilities must, at the least, provide food, shelter, entertainment, social interaction, and a quality of life that is dignified and deserving of people who are at the end of their lives. Because of the medical nature and sometimes anti-social behavior of the elderly, this balance is in need of constant monitoring and re-evaluation. The common name for transforming old programs into new ones to promote the general health of the aging public is called “culture change” This revolution in policies and procedures support individually created environments “where both older adults and their caregivers are able to express choice and practice self-determination in meaningful ways at every level of daily life. Culture change transformation may require changes in organization practices, physical environments, relationships at all levels and workforce models.” (CMS, 2010) The process keeps everything in balance and makes sure that the financial needs of the business as well as the personal needs of patients are all maintained within the goal of promoting the future.
Why is maintenance of balancing medical and social needs of the elderly difficult in monitored homes and in the health care field in general? First, the disengagement theory states that “that social involvement decreases with aging, and is a normal part of the aging process that is independent of other aging phenomena (such as debility), and is mutually beneficial for both the individual and society” (Rash, 2007). While the young must interact in order to build relationships and eventually procreate, the theory states that the lessening of interaction in the elderly is needed because they are slowly leaving the social circles that they had previously been ingratiated into in order to make way for the next generation. During the maintenance of nursing home programs and procedures, the resident well being must be taken into account even if they are isolated and separated from the general public in their needs, wants, and desires in all contexts throughout the day. A lifestyle which is perceived to be poor, “including the perception of loneliness and isolation can lead to depression and poor nutritional intake” (СMS, 2010). There are many contexts that an individual is put into throughout the waking hours. Some activities which are monitored to determine happiness include “special locations, dining activities, daily routines such as hygiene, medical interventions, and activities that were either formally arranged by the facility, such as guest entertainers or Bingo games, or more informally determined by the facility such as television viewing” (Rash, 2007). The well being of individual patients is analyzed when any new program affects any of their daily activities and then compares it to happiness levels during regularly activities as a base assumption of mood and feelings.
The dining experience is a time when residents can interact with one another, have one on one interaction with staff members that they might otherwise have no interaction with, and at the same time there are refueling their bodies with a healthy diet which promotes individual health and dietary needs. “The positive relationship found between food enjoyment and overall satisfaction in the nursing home… highlights the critical importance of food in the elder’s overall nursing home experience” (Burak, 2010). The process of eating is mechanical but is also enjoyable at its heart. While certain foods might meet dietary guidelines and necessary levels of fat, protein, and carbohydrates, research has shown that the process of eating is also a positive reinforcement of feelings of happiness. Food is important in one way or another to all groups and all cultures around the world, both cultures of ethnic background as well as those of social circles. Because of this, the importance of eating, food, “and the dining experience have been staples within many culture change models. Some changes advocated for include family-style dining instead of tray service, increased choice in food options, and greater access to food at all times of day” (Burak, 2010). While different models require different commitment levels from staff, certain models have a better effect on the temperament of patients and of residents as well as the interactions with their children when visiting and eating together. For staff, there are certain aspects which can make these experiences with minor oversight and understanding of the perception of the people being observed. The key to running dining experiences for staff members to understand is that they are not just watching people eat, “they are watching the entire dining experience. Watch for room temperatures that are too cold or hot, lighting, staff communication, food handling and variety of choices. Surveyors will stay in the dining room during clean up to watch infection control practices” (Whitepages, 2010). Staff members each have their own duties when dealing with residents eating and enjoying themselves, but by keeping an eye on the entire experience each staff member has the ability to increase the enjoyment of their patients. After understanding the significance of dining experiences in the lives of nursing home residents, one must then look at other factors within the dining process which can have the greatest impact on happiness and general satisfaction. In particular, the perceptions of dignity and self worth have been shown to promote happiness and general feelings of importance of residents in nursing home communities. Dignity and perceived ideas of well being are important because they maintain the image of self sufficiency and not an image of burdening others, a fear of many elderly people. “Most nursing home residents are frail physically, and many have conditions such as dementia that place them in need of intensive health services. As a result, residents are susceptible to adverse events, such as falls, pressure sores, and weight loss” (Emerging Practices in Nursing Homes, 2005). This leads to feelings of burden and helplessness which are counter to their mental health. With respect to dining experiences, dignity and individuality are important because freedom during eating is a signifier of independence. When staff controlled programs and administrative mandates determine that a person is unfit to maintain this right, “the freedom to choose when and what to eat, and when to perform personal hygiene activities were lost to the dependence rendered by disability and overshadowed by facility regimentation” (Burak, 2010). This loss of dependence independence is sometimes needed for the health and safety of the residents in cases where feeding their selves could put them at risk to choking or other health problems. While individual eating plans are difficult to maintain, the modification of individual foods to the tastes and dietary needs of each patient are key because “the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality” (AHCA, 2008). If the needs are met and the perception is that the individual has lost a portion of their independence and subsequently their dignity has been affected, then alternative programs and dining experiences need to be implemented. In general, the dining experience is as important because the pairing of “spiritual well-being and food enjoyment were also significant positive predictors of elders’ overall satisfaction with the nursing home. The domain of spiritual well-being may relate to perceptions of the nursing home as a “good place” for people to be” (Burak, 2010). While the programs are the cause of benefits or losses to dignity and independence, the staff also has a large role to play in maintaining the moral and mood of the residents who are entrusted to their care. If the staff lacks the skills or a caring demeanor towards their patients, then research has shown a drop in perceived happiness in general life and in dining experiences in particular. Dignity and the image of independence have been shown to be important to the elderly, for the staff “it is particularly important to teach and reinforce these behaviors. Supporting dignity should be the basis on which to build relationships between staff members and elders” (Burak, 2010). If one of the residents is able to take care of themselves during dining times then the staff should take as many steps to maintaining their independence as possible. However, staff members much also maintain a watchful eye for problems. Because the turnover of nurse aides and staff members are so high, it is commonplace for residents to be “constantly receiving care from new staff who often lack experience and knowledge of individual residents” (Emerging Practices in Nursing Homes, 2005). New aids need to understand coming into a new environment that each individual has their own patterns, eating habits, and pet peeves that are unique to them. If new nurses remember this then they will be able to maintain a working and social relationship with their charges and better the perception of residents. “The manner in which staff relates to persons for whom they are caring has the potential for great impact on the individual resident’s sense of self and well-being” and at the same time, lack of interest can negatively affect a resident due to the lack of impact and change in their lives. (AHCA, 2008) By educating and keeping new staff up to date with changes in policies and procedures as well as promoting socialization with residents during dining experiences and in general life, the overall morale and feelings of happiness throughout the community will increase. After discussing the positive effects of staff interaction, maintenance of dignity, and individualized dining experiences, the final event to analyze is the Dining Assistance program. Keeping in line with promoting feelings of individuality and promoting the happiness of individuals within the community, Dining Assistance programs are tailored to smaller groups than general dining guidelines. Because they are flexible, “they can involve only one or two residents or only several staff, and be implemented on only one unit or one shift. They can involve community volunteers or paid workers, or in-house non-nursing staff looking for opportunities to advance to direct care work” (CMS, 2010). However, the integration of a dining assistance program is a difficult task seeing as how some residents might feel isolated and therefore affect their morale and sense of individuality as well as the difficulty of maintaining health guidelines across multiple groups. Due to the possibility of imbalance in these programs, many states do not allow Dining Assistance programs at all and since the state must monitor all nursing homes due to the nature of the protected class, they are often not allowed even if the state allows them. Some National Health administrators dislike the presence of DA’s because of the need for “greater scrutiny of nutrition- and dining-related compliance issues. However, a program that is implemented according to federal and state guidelines should not risk a compliance violation” (CMS, 2010). These programs have the possibility to alleviate isolationist tendencies within some residents, promote the general healthcare of the residents, and also can increase the perceptions of staff on their roles within the community. While dining experiences are not thought of as a privilege that we have during our younger years, at the end of our lives the process of maintaining independent and dignified even in such a simple process becomes more important. Just as with other areas of living such as bathing, sleeping, and going to the bathroom, the basic process of eating on our own is one which must be taken away if one becomes a danger to themselves but if a person is able to continue with their routine, then it is better for their mental and social well beings. After analyzing the positive benefits from dining experience monitoring, the role of staff within the dining experience, and alternatives to traditional models such as the Dining Assistance program, it is clear that there are a number of ways to maintain the image of independence as residents of nursing communities age. Initiating the change to these programs should be a point of interest for all communities because the maintenance of the happiness and mental health of each resident is the primary directive for all communities around the US and as the population of the elderly continues to grow this will become a hot topic time and again.

Bibliography
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Burack, Orah R., Audrey S. Weiner, Joann P. Reinhardt, and Rachel A. Annunziato. "What Matters Most to Nursing Home Elders: Quality of Life in the Nursing Home." Journal of the American Medical Directors Association, 2010.
CMS. "Creating Home in the Nursing Home II." PioneerNetwork :. 2010. "Emerging Practices in Nursing Homes." George Grob to Dennis G. Smith. March 2, 2005.
Rash, Elizabeth M. "Social Support in Elderly Nursing Home Populations: Manifestations and Influences." Nova Online. September 3, 2007.
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