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Aim: The aim was to explore the outcome, on a local level, of steering, organisation and practices of elderly care foodservice by Swedish municipalities, and changes relative to national actions.

Methods: A survey using a web-based questionnaire about elderly care foodservice targeting all Swedish municipalities (n=290) was conducted in 2006 and 2013/14. The questionnaire included the topics: organisation of foodservice, its practice in elderly care, and steering devices such as guidelines and policies. Based on the share of a rural population, municipalities were divided into groups: rural (≥50%), urban (<50%) and city (≤20%).

Results: The response rate from municipalities was 80% in 2006 and 56% in 2013/14; 45% participated in both surveys. The results showed increased use of local food policies (P=0.03) and meal choice (P<0.001), while access to clinical/community dietitians declined (P=0.01) between the surveys. In home-help services, daily delivered cook-serve meals declined (P<0.001) and chilled meals delivered three times a week increased (P=0.002) between the surveys. City municipalities used private foodservice organisations the most, (P<0.001) and reported reduced use of cook-serve systems in favour of chilled. In rural municipalities, the use of public providers (98%) and a cook-serve system (94%) were firmly established. Urban municipalities were placed between the other groups.

Conclusions: National actions such as soft governance and benchmarking appear largely to determine local level outcomes. However, conditions for adapting these measures vary between municipality groups. While efficiency enhancing trends were prominent, questions remain whether national actions should be expanded beyond performance to also examine their consequences.

Objectives: The aim is to explore the effects of antecedent, structural and process quality indicators of nutritional care practice on meal satisfaction and screened nutritional status among older adults in residential care homes. Design: Data for this Swedish cross-sectional study regarding older adults living in residential care homes were collected by i) a national questionnaire, ii) records from the quality registry Senior Alert, iii) data from an Open Comparison survey of elderly care in 2013/2014. The data represented 1154 individuals in 117 of 290 Swedish municipalities. Measurements: Meal satisfaction (%) and adequate nutritional status, screened by the Mini Nutritional Assessment Short Form (MNA-SF), were the two outcome variables assessed through their association with population density of municipalities and residents’ age, together with 12 quality indicators pertaining to structure and process domains in the Donabedian model of care. Results: Meal satisfaction was associated with rural and urban municipalities, with the structure quality indicators: local food policies, private meal providers, on-site cooking, availability of clinical/community dietitians, foodservice dietitians, and with the process quality indicators: meal choice, satisfaction surveys, and ‘meal councils’. Adequate nutritional status was positively associated with availability of clinical/community dietitians, and energy and nutrient calculated menus, and negatively associated with chilled food production systems. Conclusion: Municipality characteristics and structure quality indicators had the strongest associations with meal satisfaction, and quality indicators with local characteristics emerge as important for meal satisfaction. Nutritional competence appears vital for residents to be well-nourished.

Guided by the i-PARIHS framework, this study investigates perceived facilitators in the process of adopting a new regulation launched in 2015 which aims to prevent and treat malnutrition. In May 2016, a national web-based questionnaire was emailed to chief medical nurses in elderly care in all Swedish municipalities (n = 290). The response rate in this cross-sectional study was 75% (n = 217). Fifty per cent of the municipalities had adopted new routines, 42% had started and 8% had not. One third of the respondents considered malnutrition to be a major problem in elderly care and about half considered the new national regulation to have strengthened local work. A logistic regression showed that the odds for having adopted new routines were higher for CMNs with long experience in elderly care and who had previously worked to prevent malnutrition, and for those who considered the new national regulation helpful. To extract underlying factors in the adoption process, two principal component analyses were performed for key actors and support. For key actors, the analysis yielded four factors, explaining 67% of the total variance; (a) first line team, (b) expert team, (c) management team and (d) surrounding resources. For support, the analysis yielded three factors, which explained 65% of the total variance; (a) agile teamwork, (b) management and leadership and (c) acceptance. The slow adoption rate of the regulation raises questions about its impact; this might be an effect of the general trend of decentralisation in the Swedish welfare sector, and in elderly care in particular, making it hard to attain change that is steered centrally. However, malnutrition is a pronounced problem in elderly care and the mandatory nature of the new regulation therefore warrants further investigation of whether its launch has contributed to a reduction of malnutrition by investigating outcomes and preventive actions carried out in practice.

Malnutrition constitutes a serious and challenging problem in elderly care. In 2015, a Swedish regulation that aims to prevent and treat malnutrition came into effect. This study set out to explore associations between level of adoption of the regulation reported as: no, started, yes, in a previous survey, and registrations in a national quality registry. Registry data on screening and actions extracted from the first trimester in 2014 (n=18967), 2016 (n=20318) and 2017 (n= 25669) represented 209, 197 and 199 of 290 Swedish municipalities respectively. A repeated measures ANOVA showed that there was no effect on screened nutritional status, Pearson's chi-square that there were minor differences in types of actions, and regression analysis that the number of actions increased on average by 0.3 due to a higher level of adoption of the regulation. Over the years studied, five actions were prominent regardless of level of adoption or screened nutritional status. Hence, to date, no firm conclusions regarding effects of the regulation can be drawn. Despite the regulatory nature, it appear as if the regulation and the level of adoption reported so far is routine in theory, although not yet leveraged to an implemented practice visible in the quality registry but instead decoupled from practice.