Evaluation of Patient Satisfaction With Hospital Foodservice During Treatment at a General Hospital in Mainland Greece

ABSTRACT

Background

Adequate hospital foodservice is important to improve patient's nutritional status. Research aimed to evaluate patients' satisfaction with hospital foodservice during their treatment at a general hospital in Greece using a validated instrument, adding to the existing research.

Methodology

A cross‐sectional study was conducted on a random sample of patients aged > 18 years who were hospitalized for at least 2 days in the selected hospital between March and April 2022. The hospital applies a conventional cooking preparation system, a central distribution system, and a quality management system. Data were collected using a Greek‐translated version of the “Acute Care Hospital Foodservice Patient Satisfaction Questionnaire”, and analysed using descriptive measures, parametric and non‐parametric tests.

Results

In total, 202 questionnaires (response rate 87.7%) were included in the analysis. The majority (90.1%) stated an overall satisfaction of “good” or “very good”. Questions related to “Staff & Service” received the highest scores, while questions related to “Food Quality” and “Meal Size” received the lowest. “Food Quality” was found to have the greatest effect on overall satisfaction. There were differences between wards. Men and younger patients were more likely to report hunger after and between meals.

Conclusions

Hospital foodservice faces the challenge of catering to a range of nutritional needs of different patients. Systematic assessment of patient satisfaction is crucial to improving evidence‐based, patient‐centered care. Although patients' overall satisfaction with foodservice was high, reflection on the interpretation of results is required as patient satisfaction is a complex measure, and the study was conducted during a pandemic.

Systematic assessment of patient satisfaction is crucial to improving evidence‐based, patient‐centered care. Patients were highly satisfied with the foodservice, particularly with “Staff & Service”. “Food Quality” had the greatest impact on satisfaction. Differences in patient satisfaction between clinics and in terms of gender and age were detected.

Summary

• The present study evaluated patient satisfaction with hospital foodservice during their treatment at a general hospital using a validated instrument.

• 90.1% of participants rated an overall satisfaction of “good” or “very good”. “Staff & Service” received the highest scores, while “Food Quality” and “Meal Size” received the lowest. “Food Quality” had the greatest impact on overall patient satisfaction.

• Differences in patient satisfaction between clinics and in terms of sex and age were detected.

• Systematic assessment of patient satisfaction is essential for improving patient‐centered, evidence‐based care.

1. Introduction

Hospital food is an integral part of treatment, while patient satisfaction deriving from hospital foodservice functions as a qualitative multiplier to the overall hospital experience [1, 2]. Provision of appropriate nutritional care (a fundamental right of patients) [3] is the duty of health professionals and health managers, while the continuous reassessment of patient satisfaction with foodservice constitutes a key priority for any hospital institution seeking to maximize the value of the services provided, as perceived by patients [1, 4].

Poor food intake ( ≤ 50% of meals) by patients during hospitalization in various healthcare units has been recorded [5, 6]. It often leads to the development or worsening of malnutrition [7, 8], resulting in serious adverse effects on the human body and the clinical outcome [9]. The latter contributes to higher morbidity and mortality rates and a significant financial burden on health systems due to increased length, and cost of hospitalization and frequent readmissions compared to well‐nourished patients with similar characteristics [2, 8, 10, 11]. Factors associated with poor food intake include the patient's condition (postoperative complications, additional medication, etc) and the patient dissatisfaction with the quality of foodservice [12]. Evaluation studies helping to understand patients' perceptions and identify areas that need improvement are necessary to manage dissatisfaction and its consequences.

The concept of satisfaction from experience is conceived as the sum of satisfaction from any individual characteristics of product and services which make up the experience [13]. According to findings of available studies evaluating patient satisfaction with foodservice, satisfaction with meal quality determines the overall patient satisfaction with variables related to taste and temperature of the meal often receiving low ratings. Satisfaction with staff/service accounts the highest scores in evaluations [14, 15]. The causes of “quality” problems are attributed to the complexity of the functioning of foodservice, while the key elements that define optimal hospital foodservice have not yet been identified [16]. Questionnaires have mainly been used to investigate patient satisfaction with hospital foodservice [14]. The Acute Care Hospital Foodservice Patient Satisfaction Questionnaire (ACHFPSO) [17] focuses on food quality, meal service quality, meal size, and environmental and staffing issues. The Meal Assessment Tool discriminates meal components in terms of quality, taste, and appearance and is useful to quickly assess patient's views on meal items [18]. Additionally, a hospital dining experience questionnaire [19] examines food quality, service quality, social environment, personal patient's characteristics, and immediate eating environment. According to a systematic review, most studies have been conducted in America, Australia, Canada, and fewer in Europe (e.g., United Kingdom, Italy, and Switzerland) [14]. Studies in other countries (e.g. South Africa [20], and Pakistan [21]) have shown more heterogeneous results (dissatisfaction with food quality, service reliability, and communication with staff).

The number of published evaluation studies in Greece [22, 23] is very limited, and a knowledge gap is recorded concerning the effect of foodservice on patient satisfaction. The research herein aimed to (1) evaluate patient satisfaction with foodservice at a general hospital in mainland Greece, (2) study the influence of variables related to patient characteristics, length of stay, and food catering on overall perceived satisfaction, and (3) determine any differences between clinics. The study was conducted during the COVID‐19 pandemic [24], with the selected hospital being a hospital that also treats patients with COVID‐19. The research results will contribute to filling the knowledge gap recorded in the Greek territory and add to the existing available knowledge.

2. Methods

2.1. Study Population

The study population of the present research was 202 consecutive patients aged > 18 years, who needed to be hospitalized for at least 2 days, from March 16 to April 19, 2022, at the cardiology, obstetrics/gynaecology, pathology, orthopaedics, surgery, urology, and nephrology departments of a general hospital in mainland Greece. The paediatric ward was excluded from the study because it is difficult to assess patient satisfaction [14]. Patients were excluded if nursing staff considered their condition too poor, if they were not served food (no oral diet), or if they were too confused to answer or provide consent. Each patient could only answer the questionnaire once, and those who chose not to participate in the study returned a blank questionnaire. The selected secondary care hospital serves up to 300 portions per day at each meal. The hospital foodservice applies a conventional cook‐serve system, a central distribution system, and a certified Food Safety Management System (ISO 22,000/2018), which ensures the safety and quality of meals from production to consumption. Meals are based on a seasonal cyclic 6‐week menu and are served by a food waiter/waitress three times daily: breakfast at 07:30–08:30 h, lunch at 12:00–12:30 h, and dinner at 18:30–19:00 h. No snacks are available between meals. The food is ordered by the nurse responsible for the ward on the basis of the medical prescription on the clinical chart. When no food restrictions apply, patients may choose between two main courses different at each meal (mainly chicken, beef or fish with pasta, potatoes, rice or barley), plus salad, fruit, and cream or yoghurt. Meals are cooked using a mix of fresh and frozen ingredients.

The study was conducted during the COVID‐19 pandemic. The Nutrition Department had to adapt the way it operated to ensure that patients could continue being fed safely and prevent any potential spread. The most affected area was meal distribution. Work‐related stress concerned with the specific reasons of the pandemic–fear of being infected, or transmitting the infection to family–was expressed by employees, the management of which was vital to avoid mistakes and for each employee to remain safe and able to meet the demands of his/her work.

2.2. Research Instrument

The ACHFPSO by Capra et al. [17] was used in the present study, with the permission of the authors and its semantic translation into Greek. It was chosen because it is internationally recognized as a valid and reliable questionnaire for evaluating patient satisfaction with hospital foodservice as an overall process and takes a short time to complete. The same questionnaire has been used in Australia [4, 25, 26], Italy [27], and Sweden [28]. The translation was carried out following forward translation (clinical dietitian and a nurse), backward translation (official translator), and review by a review committee (two clinical dietitians and a nurse). All professionals were bilingual with many years of experience in the field. Different individuals participated at each stage of the process. This translation is considered linguistic and cultural adaptation [29]. However, due to the general nature of the questions and cultural similarities, there was no need to seek alternative expressions of concepts. The two versions of the questionnaire (original‐translated) capture equivalent concepts with culturally compatible expressions of the mentioned concepts.

The questionnaire contains 29 simply worded questions. The first 16 are related to four quality factors of catering services, each containing several variables representing it. The estimated dimensions are (number of questions in parentheses): Food Quality (7), Meal Service Quality (3), Staff/Service (3), and Physical Environment (3). The next three questions assess the patient's appetite, measured as the amount of food intake. Patients report their responses on a 5‐point scale (always/often/sometimes/rarely/never). Two questions follow, one to explore overall satisfaction with the foodservice (answered on a 5‐point scale: very good/good/satisfactory/poor/very poor) and an open question for comments. Finally, general information is collected, including patient demographics (sex, age), length of hospital stay, self‐reported food intake compared to usual intake, prescribed therapeutic diet, and whether assistance was needed to complete the questionnaire. The internal consistency reliability (Cronbach's α index) for the overall foodservice satisfaction score of the Greek‐translated version of the questionnaire was 0.703 while for the individual factors it ranged from 0.524 to 0.721 –“Food Quality” α = 0.721, “Meal Service Quality” α = 0.704, values that are considered satisfactory, while “Staff/Service” α = 0.524 and “Physical Environment” α = 0.546, values that indicate medium reliability.

The researchers informed the clinic managers and trained the hospital staff involved in the study. Training was provided both verbally and through an information leaflet that covered topics such as patient eligibility, exclusion criteria, and confidentiality. The survey questionnaire and a consent form were delivered to patients in the ward. The consent form explained the purpose of the study, assured patients that participation was voluntary, and the response would remain confidential. Questionnaires were distributed at lunch and collected at dinner, with all safety measures observed by trained nurses or other hospital staff who were not involved or responsible at any stage of production of the foodservice. Participants were given the opportunity to be assisted in completing the questionnaire by the trained staff when requested or there was a confirmed need. Clinic managers informed researchers daily about which patients (ward and number) could participate in the study. A code, including the ward and a number (e.g., A1: urology clinic patient 1), was written on the top right side of the questionnaire. Using this information and the code, the researchers ensured that all patients were given the opportunity to complete the questionnaire. The researchers were present at the location to assist when necessary and collected the completed questionnaires daily from the clinic managers while selectively monitoring data collection to ensure the smooth conduct of the study.

2.3. Data Analysis Methods

The data were entered into automated spreadsheets (supply information of the dimension scores) provided by the creators, and the statistical program “Statistical Package for Social Sciences” was used for processing. Frequencies and percentages, bar graphs, quartiles, means, and standard deviations were used to analyse questions measuring satisfaction with foodservice, demographic characteristics, and questions included in the general information category. To investigate the research questions non‐parametric Mann–Whitney and Kruskal–Wallis test, and parametric one‐way ANOVA were used to examine the difference in mean values. The internal validity reliability of the dimensions was tested with the Cronbach's a criterion, and finally, the hierarchical linear regression method was used to find those dimensions that influence the overall satisfaction of patients with foodservice.

2.4. Ethics Statement

The research was approved by institutional/local review boards. The researchers obtained written informed consent from all study participants before data collection. The participants were not identifiable.

The study was reported according to the STROBE cross‐sectional guidelines [30].

3. Results

A total of 230 questionnaires were distributed, 28 were returned blank and 202 completed constituting the study sample (response rate 87.7%). The majority of respondents belonged to the age group of 60–79 years (42.0%), were female (53.5%), were hospitalized for less than a week (77.2%), and were hospitalized in the cardiology department of the hospital (22.3%). Furthermore, most patients (71.3%) consumed the same amount during their hospital stay compared to their usual food intake, followed a Standard/Diabetic/Cardiac menu (58.4%), and almost all (97.0%) did not need assistance in completing the questionnaire (Table 1).

Table 1.

Demographic and general information data for the study sample (n = 202).

Demographic characteristics	Absolute frequency (N)	Relative frequency (%)
1. Age Group
20 to 39 year	29	14.5
40 to 59 year	65	32.5
60 to 79 year	84	42.0
80 year and over	22	11.0
Overall	200	100
Missing values	2
Total	202
2. Sex
Male	94	46.5
Female	108	53.5
Total	202	100,0
General information
3. Ward
Cardiology	45	22.3
Orthopaedic	39	19.3
Obstetrics/Gynaecology	39	19.3
Pathology	25	12.4
Nephrology	23	11.4
Urology	18	8.9
Surgery	13	6.4
Total	202	100.0
4. Length of hospital stay
Less than 1 week	156	77.2
1‐2 weeks	32	15.8
2‐4 weeks	10	5.0
1‐2 months	3	1.5
More than 2 months	1	0.5
Total	202	100.0
5. Self‐estimated food intake
Unchanged	144	71.3
More than usual	11	5.4
Less than usual	47	23.3
Total	202	100.0
6. Sort of hospital diet
Standard/Diabetic/Cardiac menu	118	58.4
Don't know	45	22.3
Restricted diet for medical reasons e.g. renal diet, gluten‐ free, allergy	29	14.4
High Protein/High Energy menu	8	4.0
Minced or Pureed diet	2	1.0
Total	202	100.0
7. Need Assistance
No	196	97.0
Yes	6	3.0
Total	202	100.0

Note: Bold terms indicate where the majority of participants in the survey belonged.

The majority (90.1%) of participants rated their overall satisfaction with hospital foodservice as “good” or “very good”, 9.4% as “moderate”, and only one out of 202 was dissatisfied with hospital foodservice.

Patient satisfaction was higher for the dimensions “Staff/Service”, “Meal Services Quality”, and “Physical Environment” (mean values 4.83, 4.78, and 4.60, respectively) and lower for “Food Quality” and “Meal Size” (mean values 3.48 and 2.26, respectively). Except food quality dimension (Kolmogorov‐Smirnov test=0.62, p‐value = 0.057), all the other dimensions were not normally distributed (p‐values < 0.05). Therefore, to observe the position of data, medians, and interquartile ranges were used instead of means and confidence intervals. The questions that showed higher variability in answers were: Q1. The hospital food has been as good as I expected, Q5. I am able to choose a healthy meal in hospital, Q13. The menu has enough variety for me to choose meals that I want to eat, and Q18. The meat is tough and dry, which were related to food quality and Q12. I like to be able to choose different sized meals, which was related to meal size (Table 2). To examine which and how much of the five dimensions–food quality, meal service quality, staff/service issues, physical environment, and meal size–explain the variability of overall satisfaction, the linear regression model was used. Using the stepwise method, the model automatically rejected the dimensions of meal service quality, physical environment, and meal size, as they were not statistically significant. One‐way ANOVA test showed that only “Food Quality” and “Staff/Service” had a statistically significant effect on overall satisfaction (p‐values = 0.000, both), explaining 32.5% of the variability. “Food Quality” had the greatest effect explaining the 28.7% variability in overall satisfaction. Regarding “Food Quality”, researchers found statistically significant differences between the clinics. The score patients assigned for food quality varied by clinic, with the largest difference being found between nephrology and urology clinics. One‐way ANOVA test was conducted to examine potential differences in food quality across clinics, as the Kolmogorov–Smirnov test indicated that the distributions were normally distributed, and results revealed a statistically significant difference (Fantastic = 4.37, p = 0.00). LSD Post‐Hoc multiple comparison test showed that patients of the nephrology clinic were the most satisfied with food quality (mean_nephrology= 3.86), while those from the urology clinic were the most dissatisfied (mean_urology = 2.86) (Figure 1). Regarding the “Staff/Service” dimension, results revealed a statistically significant difference (Kruskal–Wallis statistic = 19.604, p = 0.003, Kolmogorov–Smirnov test did not show distribution normality). Pair‐wise comparisons across clinics showed a statistically significant difference between the pathology and nephrology clinics (Τest‐statistic = 47.792, p‐value = 0.009). The degree of patient satisfaction in the nephrology clinic (mean rank = 127.65) was higher than that in the pathology clinic (mean rank = 79.86) (Table 3). Results revealed differences in satisfaction regarding food expectation (Q1) (Kruskal–Wallis statistic = 18.223, p = 0.006). Pair‐wise comparisons across expectations and clinics showed statistically significant differences between the nephrology and urology (Test‐statistic = 57.187, p‐value = 0.018) and cardiology (Test‐statistic = 50.390 p‐value = 0.007) clinics. Patients in nephrology (mean_nephrology= 4.43) were more satisfied compared to urology (mean_urology= 3.61) and cardiology clinic (mean_cardiology = 3.67).

Table 2.

The score (calculated individual average) for the six foodservice dimensions and group medians, and quartiles for the associated questionnaire items reported on a scale from 1 = never to 5 = always.

	Median (p25; p75)
Overall, how would you rate your satisfaction with the food service	4.00 (4.00; 5.00)
Foodservice dimension 1. Food quality Score: 3.48 (n = 202)	3.42 (3.10; 3,85)
Q1. The hospital food has been as good as I expected	4.00 (3.00; 5.00)
Q5. I am able to choose a healthy meal in hospital	3.00 (1.00; 4.00)
Q8. I like the way the vegetables are cooked*	4.00 (4.00; 5.00)
Q9. The meals taste nice	4.00 (4.00; 4.00)
Q13. The menu has enough variety for me to choose meals that I want to eat	2.00 (1.00; 3.00)
Q16. The meals have excellent and distinct flavours	4.00 (4.00; 4.00)
Q18. The meat is tough and dry	4.00 (3.00; 5.00)
Foodservice dimension 2. Meal Service Quality Score: 4.78 (n = 202)	5.00 (4.66; 5.00)
Q7. The cold drinks are just the right temperature	5.00 (5.00;5.00)
Q10. The hot drinks are just the right temperature	5.00 (5.00; 5.00)
Q14. The cold foods are the right temperature	5.00 (5.00;5.00)
Foodservice dimension 3. Staff/Service issues Score: 4.83 (n = 202)	5.00 (4.66; 5.00)
Q3. The staff who deliver my meals are neat and clean	5.00 (5.00; 5.00)
Q11. The staff who take away my finished meal tray are friendly and polite	5.00 (5.00; 5.00)
Q15. The staff who deliver my menus are helpful	5.00 (5.00; 5.00)
Foodservice dimension 4. Physical Environment Score: 4.59 (n = 202)	4.66 (4.33; 5.00)
Q2. The crockery and cutlery are chipped and/or stained	5.00 (5.00; 5.00)
Q4. The hospital smells stop me from enjoying my meals	5.00 (4.00; 5.00)
Q6. I am disturbed by the noise of the finished meal trays being removed	5.00 (4.00; 5.00)
Foodservice dimension 5. Meal Size Score: 2.26 (n = 202)Q12. I like to be able to choose different‐sized meals	2.00 (1.00; 3.00)
Foodservice dimension 6. Temperature of Hot Foods Score: 4.49 (n = 202) Q17. The hot foods are just the right temperature	5.00 (4.00; 5.00)
Additional questions Q20. I receive enough food	5.00 (5.00; 5.00)
Q21. I still feel hungry after my meal	1.00 (1.00; 2.00)
Q22. I feel hungry in between meals	2.00 (1.00; 3.00)

Note: Questions Q1, 5, 12, 13, and 18 showed higher variability in answers. Score (average) of Q2, 4, 6, 18 which had a negative meaning, calculated by reversing numerical value so that 1 = 5, and 5 = 1. The response alternative “always” was assigned a value of one, while the alternative “never” was assigned the value of five.

Figure 1.

Box‐plot of patient satisfaction with “Food Quality” by Ward. Within each box, the middle line indicates the median of the data which is not affected by extreme values, boxes extend from the 25th to the 75th percentile of each group's distribution of values, the number above median line indicates the mean food quality for each clinic, the trend of the data is the same as with the means plot. The best score was given by the nephrology patients and the worst by the urology patients. The circled numbers indicate cases with extreme values. Statistically significant differences revealed between (i) nephrology and cardiology (p‐value = 0.003), obstetrics/gynaecology (p‐value = 0.014), urology (p‐value = 0.00), and surgery (p‐value = 0.037); (ii) cardiology and orthopaedic (p‐value = 0.029), and urology (p‐value = 0.021); (iii) urology and orthopaedics (p‐value = 0.00), pathology (p‐value = 0.003), and obstetrics/gynaecology (p‐value = 0.007).

Table 3.

Comparison of Mean Rank of the degree of satisfaction with “Staff and Service” per Ward.

	Ward	N	Mean Rank
STAFF & SERVICE	Nephrology	23	127.65
	Cardiology	45	91.94
	Orthopaedic	39	116.37
	Pathology	25	79.86
	Obstetrics/Gynaecology	39	102.51
	Urology	18	88.33
	Surgery	13	100.50

Note: Statistical significant difference was found between Pathology and Nephrology clinics (Τest statistic = 47.792, p‐value = 0.009).

Comparisons were made in relation to sex, age, self‐reported food intake relative to perceived during hospitalization compared to usual food intake (Table 4), and length of stay with overall satisfaction. In particular, using the nonparametric test of Mann–Whitney for the comparison of satisfaction in relation to sex, findings indicate that women compared to men were more likely to report receiving enough food (p = 0.038) and less likely to report feeling hungry after meals (p = 0.026). Women were more satisfied with the quantity of food. The nonparametric test of Kruskal–Wallis was used to compare overall satisfaction for the dimensions of hunger and food quantity in relation to the age group. The results reveal that satisfaction is statistically significant different between the age groups. Specifically, from the pair‐wise comparison, the age group 60–79 years old were less likely to report feeling hungry after meals or between meals than the age groups 20–39 and 40–59 years old (p‐values < 0.05). Additionally, the age group 60–79 years old were more likely to report receiving enough food than the age group 20–39 years old (p = 0.023). Overall, older patients expressed higher satisfaction with the food quantity compared to younger patients. There was a statistically significant difference (Kruskal–Wallis statistic = 7.338, p = 0.026) in overall satisfaction and patients' food intake. Specifically, those who reported receiving more food than usual have higher levels of overall satisfaction (mean_more = 4.73) than those who reported receiving the same (mean_same= 4.21, p‐value = 0.021) or less (mean_less= 4.19, p‐value = 0.038) food. No statistically significant difference was found between overall satisfaction and sex and age. The length of hospital stay did not seem to affect the rating given by the patients to the foodservice overall (Kruskal–Wallis test = 1.984, p‐value = 0.739). Most respondents' comments on the open question were related to the Food Quality dimension about how unsalted the food was. This comment was provided by some patients from nearly all wards except nephrology. Additionally, difficulty in eating the roasted meats was reported, with the presence of artificial dentures being pointed out by the patients. For example, a 76‐year‐old woman with a 4‐month hospital stay at the orthopaedic clinic (the patient with the longest length of stay) recorded, “The stews are good and very tasty. But the roast meats are tough, and I cannot eat them. I have dentures.” Positive comments were made about “Staff/Service” regarding their friendliness, empathy, and active listening, which they appreciated due to the pandemic restrictions. No comments were connected to the “Physical Environment” or “Meal Service Quality”.

Table 4.

Comparison of overall satisfaction for the dimensions of hunger and food quantity (Q20, Q21, and Q22) in relation to sex and age groups using nonparametric tests of Mann–Whitney and Kruskal–Wallis, respectively. Significance level p < 0.05.

Questions	Sex.			Age groups.
	Womena	Mena	p ‐value Mann– Whitney test	20–39 years old (1st group)a	40–59 years old (2nd group)a	60–79 years old (3rd group)a	80 years and over (4th group)a	p‐valueb Kruskall – Wallis test	Statistical significant p‐value of pair‐wise comparisonsc
Q20. I receive enough food	4.76 ± 0.58	4.60 ± 0.68	0.038	4.48 ± 0.74	4.6 ± 0.74	4.83 ± 0.43	4.68 ± 0.65	0.022	0.023 of 1st and 3rd group comparison
Q21.I still feel hungry after my meal	1.44 ± 0.81	1.67 ± 0.91	0.026	1.9 ± 1.15	1.69 ± 0.9	1.3 ± 0.66	1.55 ± 0.80	0.002	0.016 of 1st and 3rd group comparison and 0.080 of 2nd and 3rd group comparison
Q22. I feel hungry in between meals	1.9 ± 1.00	2.0 ± 0.97	0.348	2.52 ± 1.21	2.05 ± 0.89	1.67 ± 0.86	1.82 ± 1.00	0.001	0.002 of 1st and 3rd group comparison and 0.044 of 2nd and 3rd group comparison

Note: Questionnaire items reported on 5‐point scale (1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Always)

^a Mean ± standard deviation

^b Significance values of the difference in satisfaction between the age groups

^c Significance values adjusted with the Bonferroni correction for mass significance (p‐value of pair‐wise comparisons)

4. Discussion

The most important findings that emerged were: (i) the majority of patients were satisfied with hospital foodservice; (ii) the highest satisfaction rate was recorded in the dimension “Staff/Service” and “Meal Service Quality”, while the lowest satisfaction was with “Food Quality” and “Meal Size”; (iii) “Staff/Service” and “Food Quality” were found to be variables that statistically significantly affect overall patient satisfaction, with the second variable having the greatest effect; (iv) statistically significant difference in patient satisfaction with the “Staff/Service”, and “Food Quality” was found between clinics; and (v) differences in the degree of satisfaction for the dimensions of hunger and food quantity between patients in terms of sex, and age were detected.

More specifically, in the present study, the percentage of patients' overall satisfaction with the provided foodservice was very high (90.1%). However, a study in Ireland that examined patients' satisfaction with foodservice response rates before and following discharge from the hospital showed that patients were less satisfied after discharge [31]. Of the individual factors that make up the experience, the patients were particularly satisfied with the service and the catering staff (with the percentage saying always satisfied exceeding 81%). Patients may have expressed the perception of the emotional support of the catering staff as “added value” in their evaluations. The statistical difference identified between specific clinics indicates that the dimension “Staff/Service” should be investigated and the retraining of the catering staff should be a corrective action. Meal size received the lowest score. Patients could not choose the size of their meals provided, at the time of the study.

Patient satisfaction with “Food Quality” received, as mentioned, the lowest rating. As patient statements constitute complaints from service consumers, it is necessary to address these concerns. The subjects that dissatisfied the patients were the above:

(a) quantity of salt in the meal

Heterogeneity in patient's perceptions of salt content in the same meals also emerges in other studies [32]. Disease and medication determine the type of hospital diet (required to meet certain criteria for the patient's healing/symptom relief), which differs from the usual diet. In this study, almost a quarter of the participants did not know the type of diet they were receiving. Nephrology patients always reported knowing their diet and therefore adjusted expectations, which may explain why they were more satisfied with the meals' quality. Providing more detailed information to patients about the diet characteristics they should receive could reduce the observed heterogeneity.

(b) toughness of roast meat

Difficulties related to patients of different age groups with artificial dentures were identified. These patients needed the meat to be chopped or minced to eat it, only in meals with roast meat. Highlighting the need for modifications in the cooking or serving of the meals for these patients and checking for possible failures.

(c) absence of a wide meal variety

The foodservice in this hospital applies a traditional conventional cooking system which has a cyclic menu providing few daily meal choices. Newer delivery systems such as room service and electronic bedside meal ordering systems, which provide choices, are associated with increased satisfaction and nutritional prevention while reducing food costs and waste [33, 34].

The scores for foodservice quality dimensions in the present study were similar to other studies using the same questionnaire in Australia and Europe, such as Wright et al. [4], Fallon et al. [26], Messina et al. [27], and Rapo et al. [28]. More specifically, compared to the recent Swedish study by Rapo et al. [28], which provided similar data on the operation of catering services to those in this study, a higher percentage of overall satisfaction (90.1% vs. 80%) and a lower percentage of satisfaction with the variable “Food Quality” (mean 3.48 vs. 3.71) are noted. Comparing the study results with the Greek studies (non‐use of the same questionnaire), it can be seen that the dimension of “Food Quality” is patients' priority and concern.

The high response rate reported (87.7%) was partly due to the need of patients to express their opinions and the timing of the study; amongs the measures taken to limit the spread of the disease were restrictions on hospital visits, with patients agreeing to participate in the research so that, as they stated, “We would have something to occupy ourselves with”.

Regarding the research instrument, the Greek‐translated version of ACHFPSQ was well received–the good response rate confirms this–by Greek context, and it provided a general overview that pointed out foodservice areas with potential for improvement.

Strengths of this study include that it is the first one conducted in a Health Unit in the region of western Greece and, differs from previous studies in Greece, as it evaluates patient satisfaction with foodservice in a hospital that applies a food safety quality system (not all hospitals have ISO). Additionally, this research was conducted during a pandemic. Four limitations should be considered. First, some of the questions in the questionnaire implied the opportunity to make menu choices (Q5, 12, 13), which patients at this hospital could not do at the time of the study. Second, the non‐representativeness of the sample concerning the length of stay restricts comparisons between groups. Most patients (77.2%) were hospitalized for less than 1 week, and under these conditions, a prolonged hospitalization did not appear to affect the overall satisfaction scores; Finally, patients' overall satisfaction with foodservice is difficult to measure and quantify since it is subjective and influenced by many factors (disease/medication) [13, 19].

In conclusion, this research study showed that the majority of patients were satisfied with the foodservice provided at the selected general hospital in mainland Greece. Systematic evaluation of patient satisfaction is crucial to improving evidence‐based patient‐centered care. Although patients' overall satisfaction with foodservice was high, reflexivity when interpreting empirical results is required as patient satisfaction is a complex measure and the study was conducted during a pandemic. Due to the complexity of foodservice, it would be useful to conduct future research that examines patient satisfaction and staff well‐being at the same time, to more comprehensively reflect on the existing situation and to achieve optimal interventions. The study findings could be helpful to policymakers when considering courses of action to improve and maintain the quality of foodservice and reduce malnutrition and its consequences in Greek public hospitals.

Author Contributions

F.P. designed the study, translated the questionnaire (forward translation), and was responsible for the collection, analysis, and interpretation of data, and drafting and writing the manuscript. A.S. supervised the study and analysis of the data, as well as the writing and editing of the manuscript. All authors approved the final version of the article. The contents have not been published elsewhere.

Ethics Statement

The research was carried out after permission ethical appropriateness from the Scientific Council of General Hospital of Ioannina “G. Hatzikosta” (Reg. no. 28/25.02.2022) and the 6th Health Region of Peloponnese—Ionian Islands—Epirus & Western Greece (Reg. no.12716/13.03.2022). The researchers obtained written informed consent from all study participants before data collection. The participants were not identifiable.

Conflicts of Interest

The authors declare no conflicts of interest.

1. Peer Review

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/jhn.70026.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.