Victoria Lawton

Purpose of the ProgramThe purpose of my Senior Nutrition educational program is to increase the

nutritional knowledge and nutritional health of the senior participants through

educational demonstrations, presentations, and activities.

Rationale

The average age of a person in the United States is 76, a number that

increases drastically every century as we develop new ways to eradicate major

diseases and increase the average person’s knowledge of health. As people age their

health needs change drastically to the point that many persons cannot safely live in

their own homes any longer. To address their health needs many families seek out

assisted living facilities that can provide nutritious meals for their loved one. These

facilities are becoming a more prominent option for elders, to the point that

approximately “half a million people reside in assisted living facilities” in the United

States. (Mitty, 2003, p. 32- 43) Many residents are depending on these facilities to

provide them with nutritious meals, but do not have the knowledge to determine

whether or not this expectation is being upheld. It is important to educate this

population in order for them to be more aware of their health.

A study done to assess the risk of malnutrition in seniors, aged 75 years,

living in a community, found that 21.3% had a medium risk and 1% had a high risk

for malnutrition. (Bachrach-Lindström, Christensson, Johansson, Idvall &

Söderhamn, 2009) These seniors were malnourished and didn’t realize that they are

making themselves susceptible to many problems associated with deficiencies,

including low body weight. Malnutrition and low body weight can go hand in hand if

the subject is not aware of what classifies a healthy weight, and how to achieve a

healthy weight while still satisfying all nutritional needs. A study done in a senior

community defined low body weight as having a BMI of 21 or less, and sought to

determine what factors contribute to low weight in seniors. The study found seniors

had a “misconception of what a normal weight was for their age group.” (Kayser-

Jones, Martin, Porter, Sivarajan Froelicher, Stotts, 2005) My survey data expressed

that 63% of the participants had not been educated about the changes in their

nutritional needs and had not been told about the RDAs as advised by the

government. This data shows that there is a need to educate about what the RDAs

are in general and how it can change depending on certain factors.

Most facilities that are considered assisted living or long term care plan their

meals based on the government’s recommendations for consumption, ie the food

guide pyramid or its equivalency. (Greenwood, Weinberg, Wendland, Young, 2003)

A study done in a long-term care facility in Canada assessed two types of diets

offered to determine if the nutritional value of the meals were actually meeting the

recommended daily allowance for specific nutrients. The study found that “the

diet(s) does not attain, on average, the RDA for a number of vitamins and minerals,”

meaning that even if the person consumed the entire meal, which is not the norm for

most seniors, they would still be deficient in these specific areas. Therefore, the

study concluded that any malnutrition that occurred in the residents could be

deemed “iatrogenic in nature,” meaning the fault of the facility because of the

nutrient deficient meals being provided to them. (Greenwood, et al., 2003) These

programs are designed to meet the needs of the “healthy” residents and do not

account for the increased nutrient requirements of residents with healing wounds

or diseases. My survey results yielded that 63% of the participants surveyed did not

feel the meals provided were balanced and provide adequate calories and nutrients.

Therefore, it is important to educate the residents about what their needs are, how

they may change depending on the situation, and that they are responsible for

tailoring their meals to fit their needs.

The research has also hit on the topic of availability as having an affect on the

nutritional status of the residents. Ronni Chernoff states that “not having access to

adequate food” can be a problem. (Chernoff, 2009, p. 177) Although he is talking

about the elderly not living in a community, it is still a topic of interest. My survey

assessed the availability of food choices present in the facility, besides the menu,

and 100% of participants identified the village store as an option. I also surveyed

about the accessibility of the grocery store as well as their own ability to cook. 100%

of the participants indicated that they did have access to a store and 63% indicated

that they were able to cook. Availability of choices does not appear to be an

problem, but possibly the lack of education prevents them from utilizing what is

available to them.

This research has identified critical issues that need to be addressed in a

nutrition education program:

The importance of knowing what malnutrition is and the associated health

risks

Individualized nutritional needs depending on health status

What are the generalized nutritional needs (government recommendations)

At Cardinal Village there are approximately 200 residents with varying

health issues. Ronni Chernoff states that “establishing ranges of nutrient

requirements for a heterogeneous population is difficult when they are healthy”

but when they all have differing health conditions it becomes even more difficult.

(Chernoff, 2009, p. 176) As stated above these types of facilities have to cater to

the needs of the majority, and cannot tailor their services to 200 individual

cases. Therefore, there is a need for an educational program to establish

awareness of individual needs, so that each individual can tailor their choices to

their own specific needs. Eighty-eight percent of the participants acknowledged

that there is not an educational nutrition program present in the facility, and

verbally expressed interest in such a program. I propose that we implement a

nutrition program to education the residents of cardinal village about their

nutritional needs, the generalized government recommendations, and the

associated risks of becoming malnourished if one is not getting enough

nourishment.

Target Population

There are approximately 100 residents residing in the independent living

section of Cardinal Village and about thirty of these residents participate in the

monthly group nutrition meetings run by the dietary services director. For the

Senior Nutrition program, the individuals who reside in the independent living

section of the facility and attend the monthly nutrition meetings, are the target

population. The remainder of the residents who live in the independent section of

Cardinal Village but do not attend the monthly nutrition meetings are the secondary

target population.

Needs Assessment

In order to assess the needs of the population I would begin by surveying and

collecting data from the senior citizens living at Cardinal Retirement Village. The

four major steps to be taken for this assessment would be: 1. Determine their

current situation as it relates to their health 2. Analyze the data collected from the

survey 3. Rank the needs expressed in order of importance 4. Validate that the

needs identified are truly the needs the community views as most important.

(Mckenzie, 2009, p. 100-107)

When first determining the current health status of the population, I would

use the PRECEDE model that includes the following: 1. Social diagnosis 2.

Epidemiological diagnosis 3. Environmental/Behavioral Diagnosis 4.

Educational/organizational diagnosis 5. Administrative diagnosis. For this target

population of senior citizens living at Cardinal Retirement Village in Sewell, NJ the

social diagnosis would be used to assess the quality of life of these individuals. To do

this assessment a survey would be distributed to residents prior to brunch service.

Questions would focus on the risk factors associated with living in the Cardinal

Village complex. Also, focus groups could be conducted at Resident council or the

monthly nutrition meetings to obtain a more concise view of the needs being

expressed by the general population and then more specifically by those who are

more active in the community.

Next, I would do an epidemiological diagnosis to determine the health of the

residents. This would be done by gathering information from the marketing and

dietary departments about the number of residents living in the community as well

as the types of foods provided to the residents. Information could also be gathered

from the nursing department about the extra nutritional attention that some

residents need.

The survey would also include questions that would diagnose any

environmental/behavioral issues present in the community. Questions concerning

the availability of nutritional resources in the community and in the surrounding

area would also be asked.

Next, when referring to the organizational/educational diagnosis, I would

need to determine the predisposing factors (provides motivation/rationale such as

knowledge, attitudes, and beliefs), enabling factors (enable motivation to be

realized; availability of resources, health care facilities), and reinforcing factors

(subsequent to behavior; provides rewards for continuum of behavior) (McKenzie,

2009, p.22). Questions that reflect these areas would be present in the resident

surveys given to the general population and the focus groups at resident council

and the monthly nutrition meetings. An example of predisposing factors would be

the residents knowledge, attitudes, and beliefs about nutrition options. Enabling

factors, could includes the types of food available in the facility. Finally, reinforcing

factors could include staff support and promotion of good nutritional habits and

peer role models. If the residents were to have more healthy options and have the

support of their healthcare providers and peer role models they can make better

choices.

Finally, using an administrative diagnosis, I would determine what resources

are available for us in the intervention. To obtain this information I would have to

meet with the Business Director and the Administrator to figure out what funds are

available to put towards a educational program.

After obtaining all of the information I will be able to analyze the data. The

analysis would be done by tallying the results from the survey and finding an

average response to the open-ended questions. After doing this I would list any

concerns I have with the data collected.

When I prioritize the needs indicated, I would determine the importance of

the concerns expressed because with limited resources the most important needs

should be addressed first. After we determine the nature and the severity of the

problems, we can start to develop appropriate interventions and set about

implementing them.

Finally, to validate the prioritized needs, I would have to go back through the

needs expressed by the general population are the same as those expressed by the

focus groups, and are the actual needs of the community.

Theoretical Basis

Constructs from the Social Cognitive Theory will guide the development of

this program. This theory acknowledges that personal beliefs, social interaction, and

environmental factors all simultaneously influence a person’s health decisions. This

theory is useful for a group nutrition education program because this population,

senior citizens, is more likely to participate in programs when there is a social

element involved. The social element will draw more residents into the program,

and as a result there will be a decrease in disease associated with overindulgence in

one food or mineral group such as high cholesterol, hypertension, and type two

diabetes.

This theory helps to predict behavioral choices of the target population by

identifying internal and external factors that either encourage or discourage the

target behavior. “In this model of reciprocal causality, internal personal factors in

the form of cognitive, affective, and biological events, behavioral patterns, and

environmental influences all operate as interacting determinants that influence one

another bidirectionally” (Bandura, 2001, pp. 14-15) This means that it is not just

one thing influences behavior, but a culmination of all of these factors influencing

each other that creates the change.

The constructs from the SCT that will be emphasized are self-control,

observational learning, behavioral capability, reciprocal determinism, and collective

efficacy. At the beginning of this program the residents will be asked to record their

food choices for a few days which will make them more aware of the choices they

are making, and begin their development of self-control over their eating habits. In

this program the residents will be taught what the proper portion sizes of food

groups are, and how to make a balanced plate, this way the residents will know how

to perform this behavior (observational learning). The residents typically eat all of

their meals together in a communal dining room so individuals observe others

demonstrating the ideal behavior and will learn how to perform the behavior

themselves (behavioral capability). These persons live in a senior community where

their meals are prepared for them, so their environment affects the food choices

that are available to them. If the residents come together as a group and request

changes to the menu they can influence their environment by regulating the choices

offered to them (reciprocal determinism). In order for the change to occur the group

must first believe that they have the ability to make that big of a change to their

environment (collective efficacy).

Intervention Behavioral Determinants Intermediate Behavioral Outcomes

Group Nutrition Education Observational Learning Increased Knowledge about portion sizes

Behavioral Capability Eating meals at the same table Reciprocal Determinism Increased support for the change

Collective Efficacy

Food Record Self-control Increased awareness of food choices

Ultimate Behavioral Outcomes

Residents will eat properly proportioned Meals.

Agency Information

Purpose of the Agency

The mission of Cardinal Village is to provide its residents and staff with a

safe, home-like environment in which to work and live by offering various health

treatment and prevention programs which emphasize nutrition and disease

prevention.

Goals of the Agency

To improve the overall health and safety of the residents living in our facility

To increase the occurrence of healthy nutritional behaviors in the residents

of the community.

To provide the most up to date information regarding the maintenance of

good physical and mental health during aging.

To provide balanced meals that meet the government recommendations for

the specific age bracket

To provide a forum in which the residents may voice their opinions and

objections to the food options provided by dining services.

To provide educational programs to reduce the occurrence of disease and ill

health in the residents of the community.

To incorporate programs into the community which emphasize proper

nutrition and help to develop trust between the residents and staff.

Expertise of Agency in Conducting Proposed Program

Cardinal Village Senior Living has been Gloucester County’s prime senior

living facility since it’s founding in 1989. The professional full-time staff of Cardinal

Village provides the most individualized and nutritious meals of the senior living

facilities in the Gloucester county area. Cardinal Village’s nursing staff is a mix of

CNA, HHA, CHA, CMT, LPN, and RNs who assist in the maintenance of the resident’s

nutritional health. There is also a visiting registered dietician who comes once a

month to review the meal plans to assure that they have appropriate nutritional

content. Trish Bronsky, Director of Nursing, has been at Cardinal Village for five

years and the facility has truly benefitted from her presence. She has improved the

facility by demanding that her staff maintain the highest standard of living for the

residents and bringing a sense of compassionate and an insistence on individuality

of residents. Working in conjunction with the director of food services, Ms. Bronsky,

is able to enhance quality of life by staving off nutrient deficiencies and

malnourishment in the residents.

The “Elderly Nutrition” program would provide residents with a supportive

environment in which to learn proper eating habits. By carefully selecting means the

educator will be able to deliver a program aimed at educating the participants about

the most pressing issues in nutrition so that they may stave off the diseases that

commonly decrease the quality of life in the elderly.

Also, the topics presented in the program could be customized to meet each

individual’s needs. Education is a key element of this program and informative

lectures will be scheduled regularly. By presenting this program in a way that

focuses on the group as well as the individual this program will take advantage of

group social influence on behavior change. This program will provide a safe and

supportive environment that will facilitate group education and discussions.

Program Plan/Intervention

Demonstration

Each thirty-minute session will focus on a different aspect of proper portion

sizes. The sessions will be held twice a week for a month, creating eight

opportunities for demonstrations. The portion demonstration topics will include:

fruits, vegetables, grains, protein, dairy, oils, vitamins and minerals, and reading

food labels. Each demonstration will highlight key misconceptions about portion

sizes and demonstrate how to determine portions without measurement tools. I will

use the visual of a dinner plate and draw sections representing the different food

groups. Fake foods will be used to show portions on the dinner plate. The final

session of the program will address how to read food labels especially the area that

lists the serving size. After each session there will be a short quiz to ensure that the

residents are watching and understanding the message of the demonstration.

Food Log

The residents will be introduced to the idea of tracking all of the food and

drink they consume for a weeklong period. The log must include every food and

drink consumed, including snacks and desserts and how much of each item was

consumed, recorded as accurately as possible. The residents will meet with the

program manager to determine what their caloric intake should be for their age and

physical activity level.

Food Log discussion

After a week’s time the resident will meet individually with the program

manager to discuss the log. In this meeting the manager will see how closely the

participant was to their ideal caloric intake. The manager will also show the

resident, with the use of my plate resources, the breakdown of each meal regarding

calories, vitamin and mineral content, and RDAs for key nutrients.

PowerPoint

There will be a twenty-minute PowerPoint presentation, which will be given

once a week for a month. These presentations will highlight the importance of

calcium and vitamin D to the health of the elderly. This program will discuss how

both affect bone health, how much of each is required to maintain the health of

bones, good sources of both, and the negative repercussions of not getting enough

calcium and vitamin D in the diet.

Marketing

I plan to promote my program using fliers posted around the facility. The

residents of this facility on average are not very technologically inclined. All of our

residents are in their late 70’s and on so they do not have smart phones or

computers/tablets so trying an electronic marketing plan would not be a good way

to get their attention. In the facility each resident has a mailbox outside of their

room in which we can put fliers for programs; we will utilize this as a way to reach

each of our residents individually. Also, there are large bulletin boards posted

around the facility with calendars of activities and fliers of events and programs. I

could post the fliers on these boards and also on the smaller bulletin boards in the

mailroom and village store. Posting and distributing fliers will ensure that every

resident knows that this program is going on and hopefully get the residents talking

about participating.

Program Evaluation

Process Evaluation

During implementation the program administrator would have to evaluate

the program to see if it needed any alterations before continuing on with the rest of

the program. When we begin process evaluation for this program we will ensure

that the demonstrations are being held twice weekly after brunch and are lasting

thirty minutes each (fidelity of the program). Also, participants will be given an

open-ended survey that will ask them to express their feelings about the program

thus far and give an area to supply suggestions on how to make the program better.

Another part of the process evaluation will be to assess how the participants felt

about the food logs and whether they found the activity helpful towards increasing

their understanding of proper nutrition habits. We would use a 1-5 rating scale to

assess the effectiveness of this activity. The second to last part of process we would

have to assess is the informational powerpoint presentation. I would distribute a

similar survey to the one used to assess the demonstrations that would ask the

participants if the sessions are running on time, the quality of the information being

given, and if the information conveyed was new to them or not. The last part of

process to be assessed is the effectiveness of group meal times and discussions

during this time. I would distribute a survey with the Likert scale that would ask

them to rank their degree of agreement or not with statements about the usefulness

of group meal times and mealtime discussions. Therefore, process variables would

include organized demonstration and informational lecture times, effectiveness of

the program, and quality of the information given (effectiveness of observational

learning techniques, behavioral capability, reciprocal determinism, group efficacy).

Questions that would appear on the open-ended survey would ask for comments

about the punctuality of the instructor, effectiveness of the instructor, effectiveness

of demonstration techniques, and an area for any additional constructive comments

the participants might want to include. The scale used to assess the food log would

use a 1 to represent not effective/helpful at all and a 5 to represent extremely

effective/helpful. Questions would ask about the instructions given before the

journal was assigned, the effectiveness of the journal itself, and if it helped them to

better understand the topics that were lectured on. To questions on the powerpoint

assessment survey will be open-ended to allow for the most honest feedback from

the participants. Questions would ask about the quality of information given, the

professionalism of the delivery method, and how entertaining/interactive the

presentation was. The Likert scale is to be used to assess group meal times.

Statements such as “Group meal times give me the opportunity to discuss important

issues with my peers” or “Group mealtimes help me to eat better” would be

incorporated into this section. It is important to assess the program now so that

improvements can be implemented if the participants think they are necessary.

Impact Evaluation

Impact evaluation assesses the immediate effects that the program has on

the participant. This evaluation is performed right after the completion of the

program. Impact assessment will be performed by having each of the thirty

participants perform a practical test in which they will have to identify the correct

portion size of a certain food group. Impact assessment will also be done on the food

logs that the residents have been asked to keep. To assess the discussion of the food

logs the participants will be asked to complete a Likert scale which will have

statements that the participant will have to rank their agreement or not. The last

intervention that needs to be assessed for impact is whether or not half of the thirty

participants have increased their dairy intake by one serving. To assess if

participants increased their daily dairy intake they would be asked to record their

food and drink intake for a couple more days so that we can compare that to their

original food log. Therefore impact variables to be assessed are the degree to which

the participants understood and remember the information presented to them, the

degree to which the food log increased their awareness of their dietary habits, and if

there was an increase in the number of dairy servings consumed (observational

learning, self control, behavioral capability).

The practical exam will require each participant to determine if the portion

shown is the correct serving size. They will have to do this ten separate times for

different items in the food group and will have to be correct for eight out of the ten

portions shown. The Likert scale will display questions such as “the discussion of

my food log was helpful in identifying my dietary trends” or “the discussion gave me

a good sense of what I need to do to improve my diet.” To assess if there was a

positive change in their dairy intake I would go back and count the servings of dairy

they consumed before the discussion and educational interventions and compare

that to the number of dairy servings consumed after the educational interventions

were completed.

Outcome Evaluation

Outcome objectives are measured six months to a year after the intervention

has been completed. The first outcome objective to be assessed is the participant’s

ability to retain the information about portion sizes that were conveyed through live

demonstration. To assess their memory of the portion sizes we will do the same test

used during the impact phase and the participants will have to again earn an eighty

percent proficiency on the exam. The other outcome objective to be assessed is

whether or not the residents had negotiated with the food service director to

increase the availability of dairy products during mealtimes. To assess this we

would have to ask the dietary director for the meal plans from six months prior,

before any interventions began, and count the servings of dairy that were shown on

the menu and compare them to the menus now. The outcome variables are the

maintenance of nutritional knowledge six months after the demonstrations have

been completed and the negotiation and change in the amount of dairy products

available (observational learning, reciprocal determinism, collective efficacy).

Outcome evaluations are important so that the researcher can see if the

interventions had a long term effect on the target population’s self control and

reciprocal determinism with regard to changing the options available to them at

meal times and if the main outcome variable of increased nutritional knowledge in

senior participants was reached.

Project Personnel

Job Descriptions and Qualifications

Victoria Lawton- Lecturer, Nutrition Counselor

Victoria is a registered dietician who specializes in geriatric nutrition and

prevention of diseases related to malnutrition. Victoria has a bachelor’s degree in

health and exercise science with a specialization in health promotion from Rowan

University and has obtained her Master’s degree in geriatric nutrition from the

University of Connecticut. Victoria has been working within Cardinal Village since

2010 and has assisted with doing nutrition assessments and tracking of nutritional

status since she was in school acquiring her bachelor’s from Rowan University.

Victoria will be the sole lecturer and nutrition counselor for the Geriatric Nutrition

Program.

Salary Range: $30.00 per hour

TimelineJan Feb Mar Apr May June Jul

Develop program rationale

✔

Conduct needs assessment

✔

Develop goals and objectives

✔

Create the intervention

✔

Conduct formative evaluation

✔

Assemble necessary resources

✔

Market program ✔ Phase in food logs and discussions

✔

Process evaluation of food log

✔

Impact evaluation of food log

✔

Phase in nutrition demonstrations

✔

Process evaluation of nutrition demonstrations

✔

Impact

evaluation of nutrition demonstrationsPhase in Powerpoints

✔

Process evaluation of powerpoints

✔

Impact evaluation of powerpoints

Dec. Jan. Feb Mar. AprOutcome evaluation for food logs

✔

Outcome evaluation for nutrition demonstrations

✔

Outcome evaluation for powerpoints

✔

Prepare evaluation report ✔Distribute report ✔

*Outcome evaluation will be done six months after intervention implementation

Budget Explanation

Personnel for this project will include one nutrition specialist whose duty it

will be to lecture and counsel the participants about nutrition. As a registered

clinical dietician Victoria makes approximately $58,000 a year working within

hospitals that specialize in geriatric care. At $28.00 an hour, the cost of one staff

member for 21 hours would total $588.00 for facilitating the program. There would

be an additional charge of $140.00 for five hours of program planning, (5 * 28)

$336.00 for twelve hours of clerical work (12 *28), and $336.00 for twelve hours of

evaluation (12 * 28). The staff member will have to commute 20 miles to the facility

to run this program, travel costs are based on mileage and the staff member will be

reimbursed. Total travel costs for this staff member will approximately total

$135.24. Space in the facility is available on an hourly basis ($150.00 per hour).

The space required for this program will require that the facility usage total 21

hours, totaling $3150.00 for the duration of the program.

My marketing strategy involves distributing fliers to every resident in the

independent side of the facility. The best way to assure every resident gets the flyer

I would have to mail the fliers so that they will be put in their individual mailboxes

within the facility. Postage for each flier costs $0.46, for 110 fliers to be mailed it

would cost $50.60. Also, each flier would have to be put into an envelope before

being mailed ($7.99 for a box of 100). It costs $0.10 per copy, and we need 110

copies, totaling $11.00 in printing costs (cost of paper will be figured into

curriculum materials). The total cost of marketing supplies, excluding postage is

$18.99.

With regard to printing/office supplies, booklet costs were calculated based

on the number of participants (approximately 30). Booklets will contain

educational information that supplements the demonstration and PowerPoint

lecture topics. Based on 30 binders ($3.00= $90.00 total) containing approximately

30 pages each, plus paper for quizzes after each demonstration and presentation

900 sheets of paper ($17.97 for 1,500 sheets) are needed. Also, I will be handing out

quizzes after each demonstration and presentation for each of thirty participants,

adding 360 pages to the sheet count, consequently raising the total to 1,260 sheets

of paper. Add in 110 copies for the fliers used for marketing, bringing the total up to

1,370 sheets of paper. Copy costs ($0.10 per copy) would total $126.00 for the

booklets and quizzes. Also, I will have to purchase thirty composition books for food

tracking ($1.49 each) would total $44.70. Three containers of pens ($1.29 per

container) for test completion, etc., would total $3.87. With all costs considered the

total amount for printing/office supplies is $282.54.

Equipment necessary for the program will include a projector ($175.00) and

projector screen ($1327.92) to be used for the presentations. Also, I would need a

plastic food play set ($19.97) to demonstrate portion sizes on a typical dinner plate.

I will borrow the dinner plate from the kitchen so that it is more applicable to the

participants. I will also need to purchase a measuring cup and spoon set ($9.69)

along with a clear measuring cup ($7.00) for liquids for the demonstration, totaling

$16.69 for measuring supplies. Equipment costs total $1539.58.

There will be no income from this program because we will not be charging

the residents a participation fee. As an incentive, a $100.00 Visa gift card will be the

prize at the end of the program. Each participant will write their name on a piece of

paper and put it into a jar, on the last day of the program a name will drawn and that

person will win the gift card. The person whose name was drawn would have had to

participate throughout the entire program and have earned above an 80% on each

quiz given. The total cost of the program is $6,676.95

Sample Budget Sheet

Revenue Amount

Contribution from sponsors 0

Gifts 0

Grants 0

Participant fee 0

Sale of curriculum material 0

Total income: 0

Expenditures

Curriculum Materials $282.54

Equipment $1539.58

Incentives $100.00

Marketing

Print Advertising $18.99

Other media 0

Meetings 0

Personnel (1 person)

For planning $140

Program facilitators $588.00

Clerical $336.00

Evaluator(s) $336.00

Participants 0

Postage $50.60

Space $3150.00

Supplies See curriculum materials and

equipment

Travel $135.24

Total Expenses $6,676.95

Balance $6,676.95

References

Bachrach-Lindström, M., Christensson, L., Idvall, E., Johansson, A., & Söderhamn, U. (2009). Factors associated with nutritional risk in 75-year-old community living people. International Journal of Older People Nursing, 4-9.

Bednar, C., Longley, C., & Strohl, M. (2012). Residents’ Perceptions of Food and Nutrition Services at Assisted Living Facilities. Family & Consumer Sciences Research Journal, 252-253.

Castle, N. G. (2003). Searching for and Selecting a Nursing Facility, Medical Care Research and Review. 223.

Chernoff, R. (2009). Issues in Geriatric Nutrition. American Society for Parenteral and Enteral Nutrition, 176-177.

Greenwood, C. E., Weinberg, I., Wendland, B. E., & Young, W. H. (2003). Malnutrition in Institutionalized Seniors: The Iatrogenic Component. American Geriatrics Society, 85-90.

Kayser-Jones, J., Martin, C. T., Porter, C., Sivarajan Froelicher, E., & Stotts, N. A. (2005). Factors Contributing to Low Weight in Community-Living Older Adults. Journal of the American Academy of Nurse Practitioners, 425-430.

Mckenzie, James F., Neiger, Brad L., Thackeray, Rosemary (2013). Planning, Implementing & Evaluating Health Promotion Programs: a primer. United States of America: Pearson Education, Inc.

Mitty, E. L. (2003). Policy Perspectives: Assisted Living and the Role of Nursing: As many as half a million people reside in assisted living facilities, the regulations of which vary from state to state. Nurses have an opportunity—and an obligation—to help develop policies. AJN The American Journal of Nursing, 103(8), 32-43.