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More than any other single feature, a domestic kitchen defines a home. This is the hub and heart of most domestic homes (Brawley, 2006). It is familiar and the tasks associated with it are

distinctive and orienting. The act of eating and drinking is nourishing and develops a sense of communal life.

Unit kitchens and the preparation and serving of food distinguish an HMU from a TMU (Grant

& Norton, 2003). TMU’s are defined by meals being cooked and prepared in centralized kitchens away from the unit. In some TMU’s, residents eat in a centralized dining room, while in others food is brought down from the centralized kitchens to unit dining rooms. Whilst the provision of food is always a defining event in residential life, the preparation of food in the TMU’s is

institutionalized and outside the life of each unit.

There is some flexibility in how different HMU’s use their kitchen areas (Cutler & Kane, 2005). HMU kitchens can prepare and cook bread, biscuits and pastries. Some HMU kitchens are able to

prepare full meals. However, given that most HMU’s were created from larger centralized nursing homes with centralized and efficient kitchens and staff in situ, most HMU’s have the main meals prepared by these centralized kitchens, and delivered from here to the HMU’s to be kept warm,

and cutlery, for keeping food ready to serve for those unable to be present at a mealtime and for storing easily prepared food.

Although a kitchen component is part of the definition of a small house or household model of residential care, there are few, if any, studies which investigate how the kitchens are used

therapeutically (Calkins, 2003b). Kitchens are not used for residents due to Health and Safety and Infection Control issues, poor initial design, poor staff training and insufficient staffing allocated to work within them. In practice, most kitchens fail to achieve their therapeutic potential (Cutler & Kane, 2009; Nagy, 2002; Saperstein, Calkins, Van Haitsma, & Curyto, 2004).

The physical design of an environment determines if kitchens are used. These are some of the key points to consider for the design of the kitchen.

 Residents and relatives do not make use of unit kitchens which are physically separated from the main living areas (Nagy, 2002).

 A kitchen is less meaningful to residents if they see it, but do not partake in its functions (Saperstein, Calkins, Van Haitsma, & Curyto, 2004). For kitchens to be used they must open into the communal living areas so that they are actively used and integrated into the life of the unit (Alden, 2010; Nagy, 2002).

 Placing the unit kitchens prominently within an open plan space allows staff to undertake the domestic tasks while, at the same time, being able to interact with and visually monitor the residents in an open plan space.

 This comprehensive multiple tasking makes the role of a homemaker assigned to the kitchen area useful, multifaceted, efficient and effective, meaning that the kitchens

and open plan area are more likely to be consistently staffed (Milke, Beck, Danes, & Leask, 2009).

Familiar domestic activities are able to engage more people with dementia than craft or other leisure activities (Beck, 2001; Brooker, 2008). Having a home like household environment offers

an exceptional opportunity for engagement in interactive occupations. Domestic tasks are ‘over- learned’ through decades of repetition and are, therefore, familiar, engaging and motivating (Alzheimer's Australia, 2004; Brawley, 2006; Calkins, 1988), for previous home makers. The task components are simple and repetitive and within the capability of many without the need for any new learning. Linking with one’s own past identity provides pleasure for people with dementia (Brooker, 2008). For example, the benefits of cooking and kitchen tasks for residents with

dementia include:

 providing familiarity and connection to one’s past and one’s identity (Brawley, 2006; Calkins, 1988); creating interest and a familiar remembered stimulation (Nagy, 2002);

 encouraging interest and social interaction (Brawley, 2006; Calkins, 1988);

 promoting feelings of comfort, participation, competence and self-esteem (Brawley, 2006; Calkins, 1988);

 encouraging a sense of being in control and at home (Alzheimer's Australia, 2004; Nagy, 2002; Saperstein, Calkins, Van Haitsma, & Curyto, 2004; Smith, Mathews & Gresham, 2010);

 stimulating improvement in eating and drinking, decreased meal time agitation, and improved attention span after the meal which are all correlated with assisting in food preparation (Clarke, 2009);

 maintaining skills (Saperstein, Calkins, Van Haitsma, & Curyto, 2004).

 improving quality of life and slowing functional decline (Nagy, 2002).

Identity is shaped by what a person chooses to do and how they do it (Christiansen, 1999; College of Occupational Therapists, 2007). Growing vegetables, cooking a meal or milking cows

are examples of how occupations define a person. Involvement in occupations and social interactions gives a sense of meaning (Phinney, Chaudhury & O’Connor, 2007; Rowles, 2008) and coherence (Christiansen, 1999) to life.

People with dementia lose feedback from social engagement and interactive occupations which are critical to maintaining a person’s identity (Christiansen, 1999). Previous skills and abilities are lost due to cognitive and physical decline. They lose their ability to maintain concentration and to pay attention, as well as losing their ability to self-initiate personal

involvement in activities (Kolanowski, Litaker, & Buettner, 2005). As expressed by Lawton’s Docility Theory (Lawton, 2001b) people with dementia become increasingly reliant on the environment, and people within this environment, to stimulate and provide engagement and interaction for them. People with dementia living in a nursing home are at risk of reduced activity

levels, increased passivity and overly dependent behaviour (Holthe, Thorsen, & Josephsson, 2007).

Some nursing homes allow relative and assisted resident access to the kitchens (Smith, Mathews, & Gresham, 2010), whilst for many the kitchen is a staff facility only (Saperstein,

Calkins, Van Haitsma, & Curyto, 2004). There is a tension between Infection Control and Health and Safety on one side, and, person centred care and improved quality of life experiences on the other (Torrington, 2007).

As their dementia progresses many residents start to eat less and less. Staff time is required to ensure that these residents are eating enough to sustain themselves. However, the self-feeding behaviour of residents increases as a result of the visual, olfactory and auditory stimulation of meal preparation (Cleary, Van Soest, Milke, & Misiaszek, 2008). A familiar domestic environment

has been shown to be associated with higher food and fluid intake (Cioffi, Fleming, Wilkes, Sinfield, & Le Miere, 2007; Reed, Zimmerman, Sloane, Williams, & Boustani, 2005). In addition,

having a unit kitchen is associated with better resident-staff interactions and decreased agitation of the residents (Cioffi, Fleming, Wilkes, Sinfield, & Le Miere, 2007; Sloane, Mitchell, Preisser, Phillips, & Commander, 1998).

The research study of Altus, Engelman and Mathews (2002a) explores how operational procedures around food can directly impact the communication and active participation of residents at mealtime. The researchers found low rates of resident communication (5% of time use) and active participation (10% of time use) when food was served already plated up.

However, when residents were allowed to help themselves from bowls of food put on the tables, their communication and participation doubled. Moreover, after staff were trained in how to prompt and praise behaviours, resident participation rose to 65% of all observations and communication rose to 18% of all observations (Altus, Engelman & Mathews, 2002a).

The provision of food and beverages in a nursing home are important anchoring events around which the rest of the day revolves. It is of huge significance whether or not the provision of food is institutionalized and ritualized, as rotas and routines can disable residents, or whether

food provision is cooperative and person centred, and assists the person to interact, become engaged and interactive and maintain skills and identity.