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Table 1 Overview of the context, process of implementation, and outcomes in participating homes

From: Implementing nutrition guidelines for older people in residential care homes: a qualitative study using Normalization Process Theory

  Home 1 Home 2 Home 3 Home 4 Home 5
Context Deprived ex-mining community Isolated rural community Strong management support Unsettled staffing with unfilled posts Study coincided with consultation regarding closure of the home
  Pride in existing menus Strong resistance to external guidelines Located on city outskirts Rural setting Health-conscious staff
  Compliant staff Pride in existing menus Keen to update menus Changes coincided with appointment of new manager and new cook Less emphasis on home cooking`
   Empowered staff Manager and head cook have experience of Slimming World1   
Institutional support Manager required cooks to adhere to new menus but provided little support for cooks in dealing with negative feedback Manager delegated all responsibility to cooks and study team Manager supportive of guidelines and required cooks to adhere to new menus New manager keen to change menu structure Manager instrumental in identifying key members of care staff to contribute to the process of menu development but otherwise had little hands-on involvement
     New manager undermined implementation of guidelines by making changes based on her own preferences and ideas  
Approach to introducing modified menus Menus devised by study dietitian; emphasis on implementing the nutrition guidelines Some attempt to engage cooks in process of menu development but insufficient time to achieve ownership Emphasis on working towards the nutrition guidelines Emphasis on working towards the nutrition guidelines Emphasis on working towards the nutrition guidelines
   Menus largely devised by study dietitian Majority of menu development carried out by cooks Majority of menu development carried out by new cook Care staff involved in process of menu development
   Emphasis on implementing the nutrition guidelines Variable levels of involvement of cooks   Cooks happy to let study dietitian take the lead
      Emphasis on changing recipes rather than dishes
Outcomes Cooks working to rule and abdicating responsibility for menus to the study team Cooks refused to implement modified menus Adherence to modified menus varied between cooks Old cooks still providing cover tended not to stick to modified menus Changes largely unnoticed by clients
  Modified menus perceived as too extreme and restrictive Limited changes made Emphasis on sticking rigidly to modified menus Some dissatisfaction amongst clients Some variability between cooks
  Reported client dissatisfaction Some cooks implemented changes in ways intended to fail Little room for cooks to exercise judgement Cooks modified menus in light of client feedback Care staff more engaged and supportive of changes
  Problems with loose bowels due to rapid increase in fiber Client resistance to changes in the menu Tendency to revert to old dishes where new dishes unpopular rather than modifying recipes New manager changed menus while head cook on holiday in line with her own preferences and views  
  Cooks waiting for study team to leave before devising new hybrid menus   Reduction in number of client falls reported by manager   
  1. 1Slimming World is a UK slimming organisation.