Managers in nursing homes: Optimize work organization with staggered meals

The number of residents in long-term care facilities around the world is rising, and this trend is especially pronounced in English-speaking countries. In the United States for example, approximately 1.3 million older adults reside in nursing homes, representing around 2.3 % of the population aged 65 and older. At the same time, dependence among these residents is intensifying: ageing, chronic disease, cognitive decline and mobility loss converge, forcing institutions to rethink the very pace of daily life. In this context meals are not just breaks in the schedule: they become structuring moments of the internal time of a dependent person.

When a resident steps into a nursing home at an advanced stage of care dependency, the rhythm of their day is increasingly dictated by physiological needs rather than by personal choice. Independent adults plan their meals according to appetite, social contact or activity, whereas a dependent resident must often eat at set times, with assistance, in a common dining room and at a pace imposed by the institution. Research on mealtime situations in nursing homes shows that how meals are organised has a strong influence on residents’ sense of autonomy, identity and continuity of life. In such an environment the fixed meal schedule becomes a marker of institutional time rather than personal time.

This shift matters deeply for management. When internal time is compressed into three peaks (breakfast, lunch, dinner) all residents are served simultaneously, care teams face intense pressure. Peaks of activity lead to stress for staff and reduced individualised attention for residents. At the same time, for residents with cognitive or behavioral disorders, this synchronous rhythm can generate agitation, lost meals, or nutritional decline. A recent integrative review of mealtime interventions in care homes highlights that interventions which adapt timing, place or pace of meals show promising results for resident well-being.

Entering a Collective Environment and Losing Temporal Landmarks

The Psychological Construction of Internal Time

When an older adult enters a nursing home, the shift from personal routines to institutional schedules profoundly impacts their psychological perception of time. Internal time is built through the integration of bodily signals, social cues, and the ability to remember the past and anticipate the future. Scientific literature shows that cognitive processes such as “mental time travel” and the subjective experience of time are disrupted in dementia syndromes, weakening the sense of continuity and orientation throughout the day.

Executive Functions and Dopamine at the Core of Temporal Processing

Temporal cognition depends heavily on executive functions controlled by the prefrontal cortex, including sustained attention, working memory and cognitive flexibility. Age-related decline in these functions is well documented, leading to measurable reductions in temporal acuity. Dopamine plays a central role in this mechanism. It modulates cognitive effort, working memory updating and the ability to maintain engagement in demanding tasks. When dopaminergic activity decreases, navigating daily sequences or adhering to timed events becomes more costly and more difficult.

Dopamine and the Perception of Time

Dopamine is not only linked to cognition but also directly influences how humans estimate duration and experience the flow of time. Research shows that dopamine is critical for interval timing and temporal prediction. In Parkinson’s disease, characterized by dopaminergic depletion, patients frequently show underestimation or distortion of short time intervals. Pharmacological treatments partially restore timing abilities, indicating that dopamine participates in maintaining the brain’s internal clock. In a care setting, deficits in this system can make timed routines such as meals feel rushed, confusing or disconnected from bodily rhythms.

Neurodegenerative Disorders and Distorted Temporal Experience

Neurodegenerative diseases profoundly alter the experience of time. Reviews highlight that both perception of time and mental projection into time are commonly disrupted in dementia. In Alzheimer’s disease specifically, distortions are linked to episodic memory failure and disorientation. Large European data sets show that approximately 68% of nursing home residents have cognitive impairment and 81% require assistance with basic activities of daily living. A global meta-analysis estimates the prevalence of mild cognitive impairment among long-term care residents around 20% in Europe and North America. This strong overlap between dependency and cognitive decline explains why institutional time often overrides internal time for residents.

Emotional Vulnerability and Institutional Time

Entering a collective environment represents a major test for temporal orientation. The resident arrives with a lifelong internal chronology and suddenly must adapt to an institutional clock, designed for safety, staffing and standardized routines. As dependency increases, physiological needs such as hunger or fatigue dictate the rhythm more strongly, while executive functions may no longer support flexible adaptation. Research also indicates that in older adults, emotional states strongly modulate time perception, making transitions more challenging during anxiety, evening agitation or environmental stressors. Reorganizing daily life to align more closely with internal physiological time — especially around meals, which are physiologically and socially structuring — becomes an ethical imperative for maintaining dignity, comfort and orientation.

Levers of Dopamine: Pleasure, Intellectual Life and Pathways of Engagement

The Role of Dopamine in Motivation and Cognitive Effort

Dopamine is often associated with simple reward signals, but research clearly demonstrates that it plays a deeper role in motivating cognitive effort. In one key study published in Neuron, the authors noted how dopamine translates incentive information into actual cognitive effort, essentially influencing whether an individual chooses to engage in a demanding mental task.  Another study found that the brain increases dopamine production when individuals complete cognitively demanding tasks, and that higher dopamine release correlates with greater task efficiency, thus linking dopamine directly to cognitive flexibility and engagement. What this means for older adults in a care environment is clear: when opportunities for meaningful intellectual engagement, novelty or challenge are scarce, the dopaminergic system receives fewer activating triggers, potentially reducing the willingness and capacity of a resident to engage in life and thus increasing passivity.

Pleasure, Intellectual Life and Neuroprotection

Engaging in intellectual or meaningful activity is not simply a matter of passing time; it has measurable neurobiological benefits. While many studies focus on physical activity, the concept of “cognitive exercise” is gaining traction, as illustrated in research showing that older adults who engage regularly in cognitively demanding tasks have a lower risk of cognitive decline. One systematic review found that moderate to high levels of physical or cognitive activity among older adults were associated with a 28–45% lower likelihood of developing Alzheimer’s disease when compared to sedentary individuals. Although this review emphasises physical activity, the overlap with cognitive and social engagement suggests that avenues of pleasure and intellectual stimulation may contribute positively to dopaminergic activation and thereby sustain brain health. Furthermore, environments of enrichment which offer novelty, complexity and meaningful interaction stimulate synaptic plasticity and thereby support cognitive reserve.

Engagement in Activity: Practical Implications for Elderly Care

If dopamine is sensitised by reward, novelty and effort, then the design of activity programmes in nursing homes must consider not just “keeping busy” but creating opportunities for intellectual agency, choice, progression, and feedback. For example, a gardening programme, a language workshop, or a small-group discussion around meaningful topics each provide an opportunity for mastery, novelty and social connection — components known to stimulate dopamine pathways. From an organisational perspective, this suggests that meals, for instance, should not be seen only as nutrition events but as occasions for choice, involvement, conversation and autonomy. When residents feel they are actors rather than passive recipients, their dopaminergic system is engaged, their mood improves and their sense of self is reinforced. Practically, one might measure engagement by tracking how many residents choose a menu, express an opinion, take part in meal planning or assist in setting the table. While I did not find a study quantifying dopamine release in nursing-home cognitive engagement specifically, the broader neuroscience literature strongly supports designing environments that offer effortful reward for the brain.

Integrating Dopamine Levers into Organisational Strategy

For managers in nursing homes, realising the importance of dopamine means shifting from a purely logistical view of “activities” to a strategic view of engagement scaffolds. It means structuring opportunities for residents to experience challenge, novelty and autonomy within their dependency limitations. It means training staff to present choices, tailor tasks, monitor progress and celebrate small successes. It means recognising that a resident who chooses the music for a dinner, helps fold napkins or engages in a multilingual conversation is not just “occupied” but cognitively and chemically stimulated. The outcome of such strategies may include better mood, fewer behavioural issues, increased participation and, over time, improved quality of life and possibly reduced cognitive decline.

Conclusion

As clearly shown, entering a nursing home — whether chosen or imposed by circumstances — has deep consequences on a resident’s capacity to remain engaged in their inner life. When temporal landmarks fade and the link between personal initiative and the unfolding of daily life weakens, the vital drive risks diminishing. The resident no longer lives their time; they wait for it. They become spectators of a rhythm that no longer belongs to them.

In this context, the internal organization of the facility plays a decisive role. Preserving, as far as possible, the resident’s internal temporal scheme is not a luxury but an ethical, clinical and psychological requirement. The goal is not to maintain a fictional autonomy, but to support the continuous sense of self, where each day still holds coherence and meaning.

Such a transformation cannot rely on occasional activities, regardless of their quality. What is needed is a structural approach to everyday life in care settings: greater flexibility where rigidity overwhelms, room for choice where protocol dominates, opportunities for engagement where passivity becomes the norm. Meals must regain their meaning as times of autonomy and social participation, transitions must become breathable pauses instead of logistical constraints, and the presence of caregivers must provide a reliable framework to anchor residents in time.

Respecting the resident’s internal time means safeguarding their dignity. It means acknowledging that quality of care is not measured solely by technical performance but also by the extent to which the organisational environment sustains the feeling of being alive, at one’s own rhythm. A nursing home that understands this does not simply become a place where life continues longer; it becomes a place where life continues to be lived.

This article is part of a broader reflection on dignity, time and engagement in long-term care settings. I support organisations in translating scientific and ethical insights into clear, responsible CSR and institutional content, adapted to highly regulated environments.