Hospital inpatients’ experiences of access to food: a qualitative interview and observational study

Abstract

Background  Hospital surveys indicate that overall patients are satisfied with hospital food. However undernutrition is common and associated with a number of negative clinical outcomes. There is little information regarding food access from the patients’ perspective.

Purpose  To examine in‐patients’ experiences of access to food in hospitals.

Methods  Qualitative semi‐structured interviews with 48 patients from eight acute wards in two London teaching hospitals. Responses were coded and analysed thematically using NVivo.

Results  Most patients were satisfied with the quality of the meals, which met their expectations. Almost half of the patients reported feeling hungry during their stay and identified a variety of difficulties in accessing food. These were categorized as: organizational barriers (e.g. unsuitable serving times, menus not enabling informed decision about what food met their needs, inflexible ordering systems); physical barriers (not in a comfortable position to eat, food out of reach, utensils or packaging presenting difficulties for eating); and environmental factors (e.g. staff interrupting during mealtimes, disruptive and noisy behaviour of other patients, repetitive sounds or unpleasant smells). Surgical and elderly patients and those with physical disabilities experienced greatest difficulty accessing food, whereas younger patients were more concerned about choice, timing and the delivery of food.

Conclusions  Hospital in‐patients often experienced feeling hungry and having difficulty accessing food. These problems generally remain hidden because staff fail to notice and because patients are reluctant to request assistance.

Introduction

Undernutrition is common in hospital in‐patients, with a prevalence of between 13% and 40% reported in the UK ¹ , ² , ³ and throughout the world. ⁴ Undernutrition is independently associated with a number of negative clinical outcomes, including increased complication rates, mortality, longer hospital stays and increased costs. ⁵ Hospital admission can be associated with a deterioration in the nutritional status of both normally nourished and undernourished patients. ¹ This arises from a range of factors including the pathophysiological and metabolic consequences of illness, together with a relative failure of food intake. Ensuring that patients receive adequate nutrition is therefore an essential part of clinical care as recognized by the recommendations of the Council of Europe. ⁴

In the United Kingdom, a number of reports have identified inadequacies in dietary intake of inpatients, including Hungry in Hospital ⁶ and more recently, Hungry to be Heard. ⁷ In response to these and other reports, the issue of food access in hospitals has moved up the agenda of professional bodies ⁸ and the government. ⁹ One core standard recommends that ‘there should be sufficient information to allow patients to access appropriate food; food provided should meet the patient’s needs, missed meals should be replaced; assistance to eat and drink should be provided where necessary; and food should be appropriately presented and consumed in a conducive environment’. ⁹ These objectives are currently being addressed through the National Health Service Plan ¹⁰ and the Better Hospital Food initiative. ¹¹

The role of the doctor is underlined in the report Nutrition and Patients: a Doctors Responsibility ⁸ , which emphasizes that doctors should be ‘familiar with relevant aspects of food service to their patients and the importance of dietary intake’. Recent surveys indicate that overall, patients reported a positive experience of their time in hospital. ¹² , ¹³ Since 2002, the Inpatient surveys commissioned by the Healthcare Commission have reported little change in how patients have rated hospital food. Over half of patients are said to be satisfied with hospital food; 54% of patients rated the food as ‘very good, or good’ in 2006. The survey also found that almost four‐fifths of patients (79%) said they were given a choice of food while in hospital ¹³ . However there is little information regarding the patient’s experience of the organization and environmental factors that affect their eating experience. The aim of this study was therefore to investigate hospital patients’ experiences of access to food in terms of satisfaction with meals and factors influencing their physical ability to eat and the quality of meals.

Methods

Study design

A qualitative approach using semi‐structured interviews with hospital in‐patients, supplemented by informal observations of mealtimes.

Study setting

The study was conducted on eight acute wards across two London teaching hospital sites. Each ward contained approximately 29 beds comprising four patient bays (4–6 beds per bay) and four single side rooms. Both hospitals used a bulk‐order system, whereby food is prepared in the hospital kitchens, delivered in bulk to individual wards and then reheated in a heating trolley. At mealtimes the trolley was wheeled into the ward corridor. A catering assistant served patients’ meals to nurses, health‐care assistants or support staff whose responsibility it is to serve the food to patients and provide assistance when required. At the end of the meal the catering assistant collected the plates. Breakfast was served between 7:30 and 8:00, lunch service began at 12:00 and lasted 45 min and the evening meal service began at 18:00 and was similar to lunch in terms of the service, choice of food available and duration.

Observations

Exploratory non‐participant observations were carried out on wards to understand the organization of mealtimes, to inform the topic guide and to validate patients’ accounts. Thirty two mealtimes were observed with lunch service being the main focus, although breakfast and evening meals were also observed. Notes were taken during and after the observation period describing the food service, interactions between patient, staff and visitors, types of difficulties experienced by patients during mealtimes and the ways in which their problems were responded to by staff.

Recruitment of respondents

The researcher initially identified potential study participants through contact with the ward managers, who identified patients without cognitive impairment. Potential participants were then approached, an information sheet was given, the study explained and they were then given time to consider taking part (a day or longer if family members needed to be consulted). The study aim was to achieve a diverse sample with respect to gender, ethnicity and age.

Interviews

Questions were open ended and explored perceptions of food, perceived dietary requirements, patients’ eating experience during bedside mealtimes, impressions of the standard and acceptability of hospital food and food service, systems for food delivery and arrangements for mealtimes, problems of hospital food and the role of visitors in supplementing hospital food (Box 1). Interviews were conducted at the patient’s bedside and were recorded using written notes with the patients’ consent.

Table Box 1.

 Interview topic guide

Perceived dietary requirements

Were you offered the kinds of meals you like to eat?

What did you think of the choice of dishes available to you?

Are there any foods/dishes that you particularly like/dislike eating?

Is the food you eat here similar to what you eat at home?

Patients’ eating experience during bedside mealtimes

Can you describe the ward atmosphere during meal times?

Can you describe how food is delivered to you?

Have your meal times ever been interrupted? What happened?

Impressions of the standard and acceptability of hospital food and food service

What is your overall opinion of the food service? Staff serving the food

What do you think about the quality of the meals on this ward?

Have you experienced any problems with the quality of the meals on this ward?

Systems for food delivery and arrangements for mealtimes

Can you describe how you order food in this ward?

Have you ever experience any problems in ordering your food?

Were the meal times suitable?

Have you always got the meal you wanted from the trolley/ordered from the menu?

What is your opinion of the staff serving the meal?

Have you every asked for assistance during meal services? How quickly did they respond?

Problems of hospital food and the role of visitors in supplementing hospital food

Have you experienced any problems while eating your food? Difficulties in reaching or cutting/chewing/swallowing food?

Have you experienced problems of having food but being unable to eat? ever felt sick/thirsty/hungry?

During your stay have you ever missed a meal? Were you offered a replacement meal?

While you’ve been in hospital, have any friends of family brought food in for you?

What have they brought? Why? What time of day? Has it affected your appetite/the amount of hospital food you eat?

Data analysis

All interviews were transcribed, anonymized, and entered into QSR Nvivo and analysed using a thematic approach. Initially transcripts were open coded, followed by more detailed coding of items as these emerged. The items were group in terms of aspects of patient satisfaction with food, their eating experience and perceived problems during mealtimes. The data were mapped onto the some dimensions of access; ¹⁴ these included physical barriers, organizational and environmental factors. For each aspect both positive and negative experiences were categorized together with the ways in which their problems were responded to by staff. Each stage of the analysis coding and interpretations discussed with the team and a consensus reached.

Ward managers gave informed consent to the researcher being present as an observer and conducting interviews with staff after they received written information about the study. Ethical approval was granted by the hospital trust.

Results

Forty‐eight patient interviews (six patients per ward) were conducted on eight acute wards: cancer, renal, surgical, elderly care, stroke, orthopaedics, acute and general medical. Ten patients refused to be interviewed as they were too tired, not interested or in too much pain. A diverse sample of 48 patients were interviewed, comprising 28 female and 20 male patients, with 10 from minority ethnic groups. Ages ranged from 25 to 88 years with 23 patients aged over the age of 65 years (Table 1).

Table 1.

 Characteristics of patients

Characteristics	Frequency
Gender
Female	28
Male	20
Age(years)
Mean (range)	60 (22–88)
<65	25
≥65	23
Ethnicity
White	38
Black African	4
Black British	1
Indian	1
Other (Mauritius, Philippians, Iranian, Ugandan)	4
Living arrangement
Live alone	27
Live with other	21
Length of stay(days)
Two weeks or less	33
Greater than 2 weeks and less than 4 weeks	6
4 weeks or more	9

The majority of patients said they were satisfied with the food, which met their expectations, and could access hospital meals and snacks. However, nearly half of patients experienced feeling hungry at some point during their stay arising from a variety of difficulties in accessing food.

Over half of the patients (26/48) said they experienced difficulties relating to food access at some point during their hospital stay, which determined whether or not they ate the meal and how much they ate. The types of difficulties identified by patients were specific to the nature of their illness, their treatment and age group. For example, cancer patients identified problems of swallowing and elderly and stroke patients experienced the greatest physical difficulties in manipulating and transporting food to the mouth. ¹⁵ , ¹⁶

Satisfaction with food

Patients were initially asked their views about the food they ate in hospital. Their general responses were that it was ‘fine’ or ‘alright’, often qualified by such statements as:

It’s okay. It’s basic; I don’t have high expectations of hospital food so I’m not disappointed. (Acute ward – male, 65 years)

Further probing related to patients’ perceptions of the quality of the meals in terms of taste, temperature, appearance and portion size, and they were asked to explain why they liked or disliked a particular dish. Responses to these questions were categorized into three groups: (i) patients (22/48) who described food as acceptable but also commented on the process and constraints of mass catering; (ii) patients (17/48) who said they were ‘not bothered’ about the food, either because they would be in hospital for only a very short time and or felt that liking or disliking food was a low priority as they were mainly concerned about their treatment or operation, and (iii) patients (9/48) who were dissatisfied with the quality of the food, regarding it as unhealthy (e.g. fried), not cooked to their personal taste, not served attractively or not smelling appetising. An opinion held by over half (6/10) of minority ethnic patients. Elderly patients’ were reported to be dissatisfied and put off by the portion sizes, with even the standard size regarded as too large particularly during periods of inactivity and when they experiences a loss of appetite.

Organizational barriers

Frequently cited (25/48) causes of patients feeling hungry were that hospital food was not available after admission, between meal times and after their treatment.

When I came here on this ward they said I had to wait and see a doctor, we waited for ages I didn’t get to sleep till 12 and all that time we waited I didn’t have anything to eat. I was hungry. I asked the nurse for a cup of tea and she gave me one but I didn’t have anything to eat. (Care of the Elderly ward – female, 69 years)

Another difficulty was the early time of the evening meal:

I do get hungry around 8 or 9 o’clock, that’s because they serve dinner too early. That’s when I get really hungry. They do give us a cup of tea and some biscuits but that isn’t enough really. I’m still hungry. (Stroke ward – male, 81 years)

Patients also reported a lack of access to snacks and drinks between meals, and some patients who were offered snacks considered that the amount provided was inadequate. Two patients reported that a lack of food resulted in them feeling very agitated and finding it difficult to rest.

They didn’t offer my anything, they didn’t check on me and see if I was hungry, if I wanted anything to eat…. I’m glad I had something before I came because I didn’t have anything after that, nothing come to think of that…. I was hungry; I didn’t sleep that night. (Surgical ward – female, 51 years)

The solution for some patients was for family members to bring food in for them. For three patients, outside meals were regarded as the main meal of the day.

Always evening meal, my wife can only visit in the evenings. She will bring me a variety of things, from M&S sandwiches, cold meat and cooked dinners, like casseroles, pies. I never go hungry. She brings that every day so I don’t have to worry about going hungry. (Surgical ward – male, 56 years)

Ordering system

All patients were able to accurately describe the system for ordering meals and reported it to be simple and straightforward. However 16 patients experienced difficulties in ordering meals, with the most common problem (12/16) being that menus did not provide enough information about the ingredients used and the nutritional value of meals to allow them to make an informed decision about which meal met their needs.

I’m diabetic, I have to be careful when I choose what food to eat. Here it is difficult to tell which foods are good and which are bad. There isn’t enough information on the sheet so you can’t get a clear idea of what is in the food and in my case whether it is suitable for me, suitable for a diabetic…. I get my wife to have a look at it and she’ll tell me what is good and what is bad. She has some difficulty with it as well because she can only guess whether the food is low in sugar or not. (Stroke ward – male, 81 years)

Another problem for patients with visual impairments or poor literacy was the usefulness of menus if assistance was not given. Observational data revealed that these types of problems were more likely to be avoided or corrected quickly on wards where food service was supervised by a senior staff member or supported by a longstanding catering assistant.

Serving times

Over a third of patients (19/48) reported that meals were served at times that were not consistent with their normal habits. Although patients often considered that breakfast was served too early, this was not perceived as a major problem because breakfast was not the most important meal of the day. The majority of patients considered the evening meal as their main meal. As a result of early service of the evening meal (6 pm), a few patients (8/48) either skipped their meal or were unable eat the meal and as a result felt hungry later in the evening.

Enough time to eat

The majority of patients said they had enough time finish their meal. However post‐surgical patients and patients with difficulties in eating due to disability or age commented that there was insufficient time to eat. Although patients said they were not overtly pressured from staff to stop eating, they felt rushed and compelled to stop eating when staff returned to collect their plates.

It takes a long time to eat because I have to use my left hand. Picking up food and cutting is a bit tricky. I can do, I don’t need help but it takes a long time… usually the time they give would be sufficient but because I have to use my other hand eating takes longer. I’m sure they would give us more time but when the lady comes round with the trolley collecting up the plates I tend to give her mine even when I haven’t finished. I feel I have to. She looks fed up and I get the impression that she wouldn’t be too happy if I ask her to come back later. (Care of the elderly ward – male, 76 years)

Physical barriers

Physical barriers to eating presented difficulties for a many elderly patients (9/48) and post‐surgical patients (7/48). These included inappropriate seating and trolley positioning resulting in food being placed out of reach and patients experiencing difficulties in transporting food to mouth; and being given inappropriate utensils to feed themselves.

The only problem with dessert is using the dessertspoon. They are so big and I can’t open my mouth wide enough because of all the sores, they will start to weep or bleed and it’s actually really painful. I can’t use it. (Cancer ward – female, 86 years)

Observational data supported this but also identified that patients with visual or hearing impairments were not always aware that food and drink had been served.

Help and assistance

Elderly patients, post‐surgical patients and those with physical disabilities faced greater barriers to eating compared with other patients and more often expressed dissatisfaction with lack of support during mealtimes.

Observations revealed that this often meant that assisting and monitoring patients during meal times was often sidelined as a low priority activity. Staff were seen to complete paper work, change beds and arrange care plans during mealtimes.

Twelve patients required assistance and nine of them reported difficulties in getting staff attention and felt that problems reported to support staff were not always followed up.

They rarely walk around the bay during meal times. So when I’ve wanted their help they’re not around or I’d have to wait a long time before I could get someone’s attention. I can’t really be bothered to wait so I get on with it. I do what I can, the things I can reach and cut I eat, the things I can’t I leave. (Orthopaedic ward – female, 57 years)

When I’ve needed my food cutting or if I’ve dropped something . . . sometimes they’ve forgotten and I have to ask them again. Once I waited for over 10 minutes before someone came and helped me. It’s difficult sometimes to get their attention because they don’t always come into the room… I can see they are still around but they seem to be doing paper work or something. (Stroke ward – female, 81 years)

Observations made during meal times indicated that if meals were left, the assumption made by staff was that patients did not want them and so they were removed. However, the reason for some patients was that they were unable to feed themselves.

Five of the 12 patients who experienced physical difficulties were reluctant to inform staff and felt powerless to complain:

I was having my dressing changed when lunch came. They asked me if I wanted my food to be served. I said yes because the nurse said it wouldn’t take long but it did. By the time she’d finished my food had gone cold, well it was lukewarm and everyone else had finished eating. I wasn’t happy about that but what can you do. I like my food to be hot; the food was lukewarm. I ate it anyway because I was hungry but the food was spoilt, it had gone cold. (Orthopaedic ward – female, 51 years)

Environmental factors

Patients were asked to describe the environment on the ward during meal times. Five out of the eight wards were perceived as noisy. Patients staying in general and emergency wards identified particular noise problems, in terms of the sounds of equipment and the movement of patients and different medical staff through the wards at meal times. Patients (13/48) also stated that the disruptive behaviour of other patients, the repetitive sounds of equipment and unpleasant smells had a negative effect on meal consumption and the overall eating experience.

It has been noisy; staff are always rushing in and out of the bays… The lady in the end bed she’s got some problem with her bowels. While I was having my lunch she used the commode, which is off putting… but what made it worse is that they left it by the side. The smell was awful. That put me right off my food. It made me heave at one point, I kept my eyes locked on the window and tried to think about something else just to distract me and stop me from being sick. (Acute ward – female, 34 years)

Altogether eleven patients’ described the working practices of staff during meal times as disruptive:

When they put things in that bin (points to bin at the entrance of the bay) the lid when it comes down makes an awful bang sound. It goes on at night as well. It’s really irritating. It’s so loud. Staff sometimes clean the floor around you when you’re eating that can be annoying. (Elderly ward – female, 82 years)

Some patients also identified interruptions by doctors as a factor responsible of temporarily stopping or preventing them from eating their meal.

The doctor came round, I think she was running late, she said she would only be a little while and I could have me lunch brought in but she said for ages. By the time she left my food had gone cold, so I didn’t eat it. (General medical – male 76 years)

Discussion

This study indicates that the overall quality of food is acceptable to the majority of patients and supports existing studies measuring inpatients’ satisfaction with hospital food. ¹⁴ , ¹⁷ Patients’ responses about food acceptability were however often influenced by their low expectations of hospital food and food provision, their understanding of the constraints of the processes of mass catering, their high regard of medical treatment over importance of food taste and the ability to seek out alternative ways to access food of their choice. However the current study goes beyond this and takes into consideration factors outside of the food itself that impact upon the patients’ experience, and identified organizational, physical, and environmental barriers have a major impact on patients’ experiences of mealtimes in hospital.

Over half the patients felt hungry at some point during their stay in hospital, with this being widespread across men and women and different age groups. This was partly the result of limited availability of food outside of meal times, especially immediately following admission where patients may have missed their evening meal. Other common problems were that breakfast and the evening meal were viewed as being too early, with little food being available between meals. Some patients were looking to eat in ways that would promote their health, but were not enabled to contribute to their own care in this way because of features of the meal delivery system in hospital. For example some patients experienced difficulties choosing meals or specials diets because of a lack of information available. Whereas for others difficulties arose through not being able to reach food, manipulate utensils or to feed themselves, which was particularly important if they were given insufficient time to finish eating or if needed help was not provided. This corresponds with findings from the 2006 Healthcare commission survey which indicated that 20% patients said they did not get enough help from staff to eat their meals. Of those patients who needed help to eat their meals, fewer said they always received it. ¹³

Our study indicated that physical, organizational and environmental factors affecting the quality of hospital meal times were widespread, and included interruptions for medical or nursing care, noises and smells from other patients, or cleaning being carried out around the patients’ beds.

The Protected Mealtimes scheme introduced in 2001 is an initiative aimed at improving the eating experience for patients in hospital, from presentation of food to assistance at mealtimes. Audits indicate that where this scheme has been implemented patients report greater satisfaction with their meals and fewer interruptions. ¹⁸ However in many cases this scheme has not been fully implemented and surveys indicate that patients’ still experience interruptions by hospital providers during mealtimes. ⁶ , ¹⁹ , ²⁰ Studies implementing a Protected Mealtimes scheme have often shown that this can lead to tension between nursing staff who try to ensure it works and medical colleagues who are not convinced of its value. ²¹ Our study supports this, with patients’ accounts or observation identifying occasions when Protected Mealtimes were not fully implemented by all health‐care staff working within the wards. In some wards it appeared more difficult to implement Protected Mealtimes, for example on surgical and acute wards surgeons were seen consulting during mealtimes and on the renal ward patient’s dialysis treatment clashed with meal service.

Whereas previous studies have shown that undernutrition increased with and longer length of stay, ²² , ²³ in our study, short stay patients (less than 2 weeks) reported more problems arising from the quality of food and food service during mealtimes compared with long stay patients (longer than a month). Reasons may be that long stay patients may have already learned coping strategies and therefore be better prepared to deal with potential difficulties compared with short stay patients or that family and friends provide food and assistance while eating.

Studies that have attempted to address problems of undernutrition have highlighted the importance of reducing organizational, physical and environmental barriers to accessing hospital food. For example a trial among patients on elderly wards, showed that eating at a dining table increased their energy intake, ²⁴ and protected them from interruption during mealtimes leading to improve nutritional status (less weight loss and improved mid‐arm circumference). ²⁵ The current study supports the importance of organizational and environmental factors and indicates that these have significant influences on access to food among all ages and not only elderly patients.

Strengths and limitations of study

A strength of this study was that it included different types of wards and included both elderly and young patients with a wide range of medical conditions. A limitation is that the study was carried out in only two hospitals, both of which used bulk ordering systems. Different food service systems can result in differences in food consumption and food wastage ²⁶ , ²⁷ and it is possible that they may have different implications for patients’ experiences of food access, choice and other aspects of patient care. A second limitation was that only those patients who were able to give informed consent and were well enough to be interviewed were recruited. Patients who were too ill to participate, or unable to consent, may well be those with additional problems of food access and at the greatest risk of undernutrition. A third limitation of the study was that interviews focused on the problems and barriers patients experienced at mealtimes and did not explore in depth what they found positively helpful or their thoughts about potential solutions to the difficulties they experienced.

Conclusions

Currently nutritional care has a low priority in hospitals. ⁶ , ⁷ Our study indicates that all age groups experienced organizational and environmental barriers during mealtimes on hospital wards and many elderly and post‐surgical patients had physical difficulties in eating while a more general difficulties was the unavailability of food between meals and the missing of meals. These problems led to many patients feeling hungry at some point during their hospital stay. However, these difficulties of accessing food often remain hidden because staff fail to notice and patients are reluctant to request assistance. This indicates that patients’ eating experience and nutritional care requires adherence with the principles of Protected Mealtimes where other activities are not undertaken on the ward while meals are served or eaten and increased attention to identifying and addressing patients’ needs for assistance. However in circumstances where this is not practical an alternative solution would be to positively suggest to patients that they might enjoy their food more if it was taken away and kept hot while the doctor spoke with them. This flexible approach requires the organization and availability of sufficient staff able to assist with ordering and feeding and increased importance assigned to this aspect of patient care, as well as good co‐ordination of activities among catering assistants, nurses and domestic staff.

Declarations

• 1This study was approved by the research Ethics Committee of Guy’s Hospital, London.
• 2 The Guy’s and St Thomas’ Charity funded the study.
• 3 None of the authors is aware of any conflict of interest with respect to this paper.