Foods and Beverages Available to Nurses in Hospital Cafeterias, Vending Machines, and Gift Shops

Abstract

Purpose:

Hospitals are important workplaces for nurses with many perceived barriers to healthy eating, but objective assessments are lacking. This study evaluated the healthfulness of hospital consumer food environments.

Design:

Cross-sectional observational

Setting:

South Carolina

Subjects:

Cafeterias, vending machines, and gift shops in hospitals of varying size, urbanization, and region.

Measures:

Using the Hospital Nutrition Environment Scan (HNES), primary outcomes of interest included availability, access, prices, and location of healthy foods in relation to nursing units.

Analysis:

Descriptive and inferential statistics by independent samples t-test, ANOVA, Mann Whitney U, χ² or Fisher’s exact test as appropriate.

Results:

Thirty-one hospitals were observed from December 2019 to February 2020. Average composite HNES score (n=28) was 46.3±14.9 (−45 to 173 range), indicating sub-optimal food environments. Cafeterias (n=31) scored an average of 30.9±10.5 (−33 to 86 range). Average vending machine (n=31) and gift shop (n=28) scores were 11.6±6.0 (−6 to 55 range) and 2.9±4.0 (−6 to 32 range), respectively. Small hospitals (≤100 beds) had lower average cafeteria score (22.4±10.3) than extra-large hospitals (≥500 beds; 42±5.2, p<0.01). Small hospitals also had lower composite HNES scores (34.4±17.1) compared to extra-large hospitals (61.0±14.4, p=0.02). Data regarding availability, access, prices, and location were also reported.

Conclusion:

Due to abundant availability of unhealthy foods and beverages, hospital consumer food environments scored low on observations using the HNES, highlighting the opportunity to improve the healthfulness of facility offerings.

In Brief

Hospitals are important workplaces for nurses with many perceived barriers to healthy eating, but empirical data on the healthfulness of hospital food environments is limited. Using the Hospital Nutrition Environment Scan for Cafeterias, Vending Machines, and Gift Shops (HNES), this cross-sectional study evaluated the foods and beverages for sale in hospitals across South Carolina. The primary environmental barriers reported by hospital nurses (availability, access, prices, and location of healthy foods in relation to nursing units) were also measured and reported. Thirty-one hospitals of varying bed size, urbanization, and region were observed in 2019 and 2020 with low average scores in all categories, indicating sub-optimal food environments. Small hospitals (≤100 beds) had lower average cafeteria scores and composite HNES scores compared to extra-large hospitals (≥500 beds). To make hospital consumer food environments healthier and to diminish primary barriers for nurses, more fruits/vegetables and other healthy foods and beverages need to be accessible 24/7 in grab-and-go packaging and for cheaper.

Introduction

Hospitals are important workplaces in the United States (U.S.), with over 7,000 locations and 6.3 million employees.¹ Registered Nurses (RNs) make up the largest proportion of hospital employees, with about 1.6 million nationwide.² Similar to the general U.S. adult population, nurses struggle to meet recommended daily intake of fruits and vegetables^3,4 and frequently have overweight/obesity.^4–6 In South Carolina (SC), 54% of nurses work in hospitals⁷ and 61% have overweight/obesity.⁶

Although food choices are influenced by multiple socio-ecological factors (e.g., personal, social, and policy), the workplace built environment can play an important role.^8.9 Nurses cite hospital food environment factors as the primary barrier to healthy eating while at work, including limited cafeteria hours, disproportionate availability of unhealthy foods, and higher prices for healthy foods.^10,11 Additionally, as nurses need to stay near patients throughout the entire shift, long distances to acquire healthy foods impose substantial challenges.^10,11

Behavioral design strategies that include increasing availability of healthy options, product placement, promotion, and pricing within workplace food environments can facilitate employees’ selection of healthier food purchases.^12–15 Recognizing the potential of hospitals in encouraging healthy behaviors, several prominent groups such as the American Hospital Association¹⁶, Centers for Disease Control and Prevention (CDC)¹⁷, and American Medical Association¹⁸ have called for hospitals to exemplify health-promoting food environments. Objective data on hospital consumer food environments is limited but reveals the need for improvement.^19–23 For example, in a survey of U.S. hospitals with wellness programs, only 40% of those with on-site food venues had current policies for either offering healthy foods or increasing healthy food options.²⁴ Greater insight about the hospital consumer food environment is particularly important in the Southeastern states, which have high rates of diet-related conditions such as overweight/obesity, hypertension, diabetes, and heart disease.²⁵ However, to our knowledge no studies have examined hospital consumer food environments in the Southeast.

The purpose of this study was to measure the consumer food environment in hospitals across SC, with a focus on primary environmental barriers reported by nurses: access, availability, price, and location. Because data regarding hospital characteristics and consumer food environments are limited, we explored environmental differences according to hospital urbanization (urban or rural), size (according to number of beds), and teaching status (teaching or non-teaching).

Methods

Design

This cross-sectional study was exempted by a university institutional review board and reported according to STROBE guidelines.²⁶

Sample

A list of SC hospitals was obtained from the publicly available Homeland Infrastructure Foundation-Level Data (HIFLD) on U.S. hospitals.²⁷ The HIFLD dataset included hospital name, address, county, type, number of beds, and websites for all U.S. hospitals. Duplicate addresses were eliminated. Closed, psychiatric, or correctional facilities, and hospitals located inside a larger hospital (rehab, long-term acute care) were excluded, leaving 83 hospitals that could potentially be observed. Hospitals were then categorized into size groups set by the Hospital Nutrition Environment Scan for Cafeterias, Vending Machines, and Gift Shops (HNES) survey tool: 1) small, 1–100 beds; 2) medium, 101–300 beds; 3) large, 301–500; and 4) extra-large, >500 beds.²⁸ Urbanization was determined using the hospital zip code and RUCA designation.²⁹ Hospitals in zip codes with a non-metropolitan RUCA code (codes four to ten) were classified as rural; the remainder were urban.²⁹ Information from the Centers for Medicare and Medicaid Services was used to delineate hospital teaching status.³⁰ A convenience sample of hospitals representing varying sizes, urbanization, teaching status, and regions within the state were selected for observation. Target sample size was 30% of eligible hospitals; 37% were observed from December 2019 to February 2020.

Measures

The HNES is a valid and reliable observational tool based on the Nutrition Environment Measures Scan (NEMS) for restaurants, stores, and vending machines.^28,31–33 The lead researcher conducted all observations after completing NEMS training in September 2019. Foods and beverages were classified as “healthy” or “unhealthy” according to the NEMS protocols for stores and restaurants, which were based on the Dietary Guidelines for Americans.^31,32 The NEMS-Vending protocol was based on the Health and Sustainability Guidelines for Federal Concessions and Vending Operations.³³ “Healthy” foods/beverages represented components of a healthy diet (e.g., fruits, vegetables, whole grains, low-sugar, low-sodium, and low-fat foods/beverages), whereas “unhealthy” foods/beverages did not.^31–33 The HNES includes measures of accessibility (hours of operation), availability (options offered for sale), and prices.²⁸ Proportions were measured by the number of healthy options divided by the total number of options.²⁸ Prices were compared between healthy and unhealthy items (as specified by the HNES) of comparable size and food/beverage type (e.g., price of healthy granola bar versus candy bar).²⁸

The HNES is divided into three venue sections: 1) cafeterias, 2) vending machines (VM), and 3) gift shops (GS; including coffee carts and snack shops), with each section further divided into subsections consisting of both categorical and continuous variables.²⁸ Point scoring ranges from −3 to 3 based on varying degrees of healthfulness for select items. For example, for the question “are there unhealthy options near the point-of-purchase”, an answer of “no” carries 3 points. However, if the answer was “yes”, the number of unhealthy options were scored from −1 (one to five items) up to −3 (> 20 items). Positive points are awarded for recommended environmental practices, with higher scores indicating a healthier food environment. The cafeteria section points range from −33 to 86 points with subsections: 1) facilitators/barriers to healthy eating, 2) grab-and-go items, 3) menu review, and 4) point-of-purchase assessment.²⁸ The VM section (−6 to 55 points) measures both food and beverage machines with subsections: 1) facilitators/barriers to healthy eating, 2) food, and 3) beverage.²⁸ The GS section (−6 to 32 points) includes subsections: 1) media and marketing of healthy items, 2) access to healthy options, and 3) point-of-purchase assessment.²⁸

In addition to the HNES measures, environmental barriers reported by hospital shift nurses (e.g., location of healthy foods, access to fruits/vegetables) were also assessed.¹⁰ The lead researcher made observations and field notes regarding the general location of VM, cafeterias, and fruits and vegetables for sale in relation to nursing units. If a hospital had more than one cafeteria open during the observation, the larger cafeteria was scored. Observations were made for the presence and price of grab-and-go packaged fresh cut fruit and vegetables in cafeterias not located on the salad bar. Coffee carts and snack shops were surveyed in lieu of the GS if open at the time of observation. VM and GS were observed for the presence and price of any fruit or vegetable.

Analysis

Statistical analyses were conducted using SPSS v.27.³⁴ Descriptive statistics of frequencies for categorical variables or means with standard deviations for continuous variables were calculated. Composite scores for each venue section and subsection were calculated. A total composite score was calculated only for hospitals with all three venue sections by summation of all sections (minimum score −45, maximum score 173 points). Hospitals without GS were excluded from analysis of total composite scores. Differences between groups for hospital sizes, urbanization, and teaching status were analyzed for continuous dependent variables of scores and prices by independent samples t-test or one-way analysis of variance (ANOVA). Assumptions for normality and equal variances were assessed. Mann Whitney U was used to compare means when assumptions were not met. Categorical variables of hours of operation and available food options were explored by χ² or Fisher’s exact test as appropriate. All significance levels were set at P <0.05.

Results

Thirty-one hospital consumer food environments in SC were assessed (Table 1). Most hospitals were non-teaching (71%), general acute care hospitals (90.3%) in urban zip codes (71%) with 101–300 beds (35.5%); sizes ranged from 25 to 845 beds. All 31 hospitals had at least one cafeteria and VM. Three hospitals had no GS; six had coffee or snack shops that were observed in lieu of a GS.

Table 1.

Demographics for Hospitals in Sample and Composite Scores by Demographic Categories

Sample Characteristics (n=31)		Total Eligible SC Hospitals (N=83)	Sample Size	Composite Scorea n (mean±SD)	Cafeteria Scoreb mean±SD^	Vending Machine Scorec mean±SDe	Gift Shop Scored n (mean±SD)e
	Teaching
Teaching		17	9	9 (53.0±14.7)	36.1±10.8	14.1±6.0	9 (2.8±5.9)
Non-teaching		66	22	19 (43.1±14.3)	28.8±9.8	10.6±5.8	19 (3.0±2.8)
	Size
Small, 1–100 beds		41	9	7 (34.4±17.1)f	22.4±10.3g	10.6±6.8	3.0±6.0e
Medium, 101–300 beds		25	11	10 (48.4±10.3)	32.4±7.2	12.1±5.1	3.0±3.75e
Large, 301–500 beds		13	7	7 (46.6±11.6)	33.3±10.5	10.6±6.7	3.0±2.0e
Extra-large, >500 beds		4	4	4 (61.0±14.4)f	42.0±5.2g	14.5±6.2	2.5±16.5e
	Urbanization
Urban		54	22	21 (48.6±13.9)	33.0±9.3	12±12.0e	21 (3.0±6.0)e
Rural		29	9	7 (39.1±16.7)	25.9±12.2	8±6.0e	7 (4.0±4.0)e

^atotal composite score includes total scores for cafeteria, vending machine, & gift shops and excludes hospitals without gift shops (possible points range −45 to 173)

^bpossible points range −33 to 86

^cpossible points range −6 to 55

^dpossible points range −6 to 32

^enon-normally distributed results reported as median and interquartile range

^fp<0.05

^gp<0.01

Hospitals scored poorly in all venue sections and subsections. See Table 2 for HNES scores by venue section, subsections, and composite. Total composite HNES scores averaged 46.3±14.9 (HNES range −45 to 173). The highest total HNES score for an individual hospital was a 79. This high-scoring hospital had over 500 beds and was both an urban and teaching hospital. Composite HNES scores were compared between groups for urbanization, teaching status, and hospital size. Only differences by hospital size reached statistical significance. Small hospital composite scores were lower (34.4±17.1) than extra-large hospitals (61.0±14.4, p=0.02).

Table 2.

Hospital Nutrition Environment Scan for Cafeterias, Vending Machines, and Gift Shops (HNES) Section and Subsection Scores^a for Surveyed South Carolina Hospitals

HNES Venue Sections & Subsections	n	HNES Points Range	Mean Score in Sample (SD)	Lowest Score in Sample	Highest Score in Sample
Gift Shops
Media/Marketing	28	−3,15	0 (1.6)	−3	6
Access	28	0,6	2.6 (1.8)	0	6
Point of Purchase	28	−3,11	0.3 (2.5)	−3	4
Total Gift Shop Score	28	−6,32	2.9 (4.0)	−3	16
Vending Machine
Food	31	−3,27	5.6 (5.3)	0	17
Beverage	31	0,16	4.8 (2.3)	2	8
Facilitator/Barriers	31	−3,12	1.5 (1.5)	0	6
Total Vending Score	31	−6,55	11.6 (6.0)	4	23
Cafeteria
Facilitator/Barriers	31	−12,12	2.1 (2.5)	−3	9
Grab-and-Go	31	0,16	17.9 (5.2)	5	25
Menu Review	31	−9,26	7.4 (3.8)	1	13
Point-of-Purchase	31	−4,13	3.7 (3.6)	−3	11
Total Cafeteria Score	31	−33,86	30.9 (10.5)	11	49
Total Composite Score for Cafeteria, Vending Machine, & Gift Shops
All Sections	28	−45,173	46.3 (14.9)	21	79

^aHigher scores indicate a healthier food environment

The average cafeteria score was 30.9±10.5 (HNES range −33 to 86). The highest cafeteria score was 49, observed in a large, rural, teaching hospital. The lowest cafeteria score was 11 in a small, rural, non-teaching hospital. Comparisons of urbanization, teaching status, and hospital size, detected statistical significance only in hospital size. Small hospitals had a lower average cafeteria score than extra-large hospitals (22.4±10.3 vs. 42±5.2, p<0.01).

The average VM score was 11.6±6.0 (HNES range −6 to 55). VM scores ranged from a high of 23 in two urban hospitals- one of which was medium size and the other a large teaching hospital. The lowest score of 4 points was found in a large, urban, non-teaching hospital.

The average GS score was 2.9±4.0 (HNES range −6 to 32). GS scores ranged from a high of 16 points observed in an urban, extra-large, teaching hospital to a low of −3 points in two urban hospitals (one small, one extra-large teaching).

Access

Cafeterias and VM were publicly accessible at all 31 hospitals, with VM accessible 24/7. Cafeteria hours of operation varied by facility. All were open for breakfast and lunch during weekdays. Seventy-one percent (n=22) were open for weekday dinner but only 26% (n=8) were open late night (between 11pm to 2am). On weekends, cafeterias were closed in nine facilities (29%) and open for limited hours in 15 facilities (48%). Of cafeterias that offered service on weekends (n=22), six were closed for dinner (27%) and 15 were closed for late night (68%). Hours of operation by teaching status and hospital size varied significantly. Small hospital cafeterias were more often closed for late night on weekdays compared to large hospitals (82.6% vs. 17.4%, p<0.01). Teaching hospitals were more likely to be open late night on weekdays versus non-teaching hospitals (62.5% vs. 37.5%, p=0.03).

GS were open during breakfast and lunch hours in all hospitals (n=28). Seven GS (25%) were open early enough (6am to 7am) for night shift to access. Twenty GS (71%) stayed open until dinner time (after 4pm). All 28 GS were closed overnight, though 12 (43%) were open late enough for night shift to access. GS were open at least a limited number of hours on one weekend day in 17 hospitals (61%).

Availability

Most cafeterias offered at least one fruit (n=28, 90%), non-fried vegetable without sauce (n=26, 84%), healthy main entrée (n=20, 65%), healthy sandwich/wrap/burger (n=20, 65%), non-cream-based soup (n=21, 68%), and low-fat baked chips (n=24, 77%). Most cafeterias had a salad bar (n=26, 84%) and at least one low-fat or fat free salad dressing (n=20, 65%). Most cafeterias did not offer any whole grain side without sauce (n=23, 74%) or grab-and-go fresh cut fruits or vegetables (n=21, 68%). Only one rural hospital offered a whole grain side, and none offered a grab-and-go fruit or vegetable option. Grab-and-go fresh cut vegetables were not available in any of the teaching or hospitals with ≥300 beds.

While healthy options were available, unhealthy options constituted a large portion of the selection. Higher sugar cereals accounted for more than 50% of available cereals in 94% (n=29) of hospital cafeterias, and regular chips accounted for more than 50% of available chips in 100% (n=31). Similarly, less than 50% of bottled beverages and fountain sodas were a sugar-free option in 90% (bottles, n=28) and 84% (fountain, n=26) of cafeterias. Of items for sale at the point of purchase, most cafeterias sold unhealthy snacks and candies (n=22, 71%), 13 cafeterias (42%) had fruit, and none had vegetables.

Only three hospitals (10%) had any kind of fruit or vegetable in VM. Baked chips and healthy granola bars were available in 20 (65%) and 21 (68%) hospitals, while 100% of VM carried candy bars and regular chips. Ratios of available healthy to unhealthy foods were disproportional as nearly all hospital VM (n=30, 97%) had less than 25% of slots filled with healthy options.

Thirty-one hospital beverage VM carried diet sodas (100%), 28 had at least one slot for water (90%), and 17 VM had 100% juice (55%). Unsweetened tea was found in 7 VM (23%) and only three carried a low-fat milk (10%). Sugar-sweetened sodas were available in 29 hospital VM (94%) as were energy drinks in 13 hospitals (42%).

Most GS (n=24, 85.7%) sold only VM-like products such as candies, dry snacks, and cold bottled beverages, rather than grab-and-go items, hot foods, or hot beverages. Only six GS (21%) had a fruit or vegetable for sale.

Prices

Food and beverage prices varied in hospital cafeterias and VM (Table 3). VM in rural hospitals sold regular chips for 21 cents cheaper than urban hospitals (0.91±0.2 vs. 1.11±0.2, p=0.03). VM in rural hospitals sold juice drinks for seven cents/ounce more than urban hospitals (median/IQR: 0.19±0.1 vs. 0.12±0.1, p=0.045).

Table 3.

Food and Beverage Prices in Hospital Cafeterias and Vending Machines

	Number of hospitals where available	Mean price in US$ (SD)a	Minimum price in US$	Maximum price in US$
Cafeteria Items
Whole piece fruit (apple, orange, banana)	28	0.81 (0.2)	0.45	1.09
Vegetable side	29	1.37 (0.3)	0.95	2.09
Bag baked chips	23	1.03/oz (0.3)	0.70/oz	1.70/oz
Bag regular chips	28	0.85/oz (0.7,1.0)a	0.57/oz	2.58/oz
Low sugar cereal (<7g sugar/serving)	16	1.10/oz (0.4)	0.48/oz	2.17/oz
High sugar cereal (>7g sugar/serving)	22	0.84/oz (0.7,1.0)a	0.48/oz	3.99/oz
Salad bar	26	0.43/oz (0.1)	0.30/oz	0.69/oz
Grab-and-go package: fruit	6	0.54/oz (0.2)	0.26	0.76
Grab-and-go package: vegetable	3	0.76/oz (0.2)	0.55	0.86
Water (charge for cup)	15	0.11 (0.1)	0.05	0.40
20oz bottle diet beverage	29	1.66 (0.2)	1.25	2.13
20oz bottle sugar-sweetened beverage	28	1.67 (0.2)	1.25	2.13
Bottle 100% juice	29	0.15/oz (0.0)	0.10/oz	0.21/oz
Bottle juice drink	27	0.15/oz (0.0)	0.10/oz	0.21/oz
Vending Machine Items
Healthy granola bar	21	1.30 (0.35)	0.75	2.25
Candy bar	30	1.26 (0.22)	0.60	1.75
Bag regular chips	31	1.05 (0.25)	0.75	1.50
Bag baked chips	20	1.10 (0.23)	0.75	1.50
Fruit or vegetable	3	0.31/oz (0.11)	0.21/oz	0.43/oz
20oz bottle water	29	1.56 (0.22)	1.25	2.00
20oz bottle diet beverage	31	1.62 (0.18)	1.30	2.00
20oz bottle sugar-sweetened beverage	29	1.63 (0.19)	1.30	2.00
12oz bottle 100% juice	16	0.15/oz (0.04)	0.08/oz	0.25/oz
12oz bottle juice drink	17	0.14/oz (0.05)	0.08/oz	0.25/oz

^aNon-normally distributed results reported as median and interquartile range

Location

Most cafeterias were located on the first floor of the hospital (n=25, 81%), while nursing units were located on every floor, up to eight floors in this study. The closest fruit or vegetable option for sale was typically in the cafeteria (n=27).

Beverage and food VM were located adjacent to cafeterias in 29 hospitals (94%), and at other locations throughout the hospital in all 31 hospitals. Sixteen of the 31 hospitals (52%) housed VM on floors where nursing units were located. GS were located on the entrance floor in 25 hospitals with GS (89%).

Discussion

Findings from this study show that hospital consumer food environments do not promote healthy dietary choices for nurses. While most cafeterias offered some healthy foods and beverages, they were outnumbered by the many unhealthy options. For nurses wanting to purchase fruits/vegetables while at work, options were largely limited to cafeteria salad bars, which often had limited hours of operation, particularly on nights and weekends. In contrast, VM were located on or near nursing units with 24/7 access but carried few healthy options and no fruits/vegetables.

To facilitate availability of healthy options such as whole grain and low sodium foods, hospitals can include product nutritional requirements in procurement contracts with vendors.^35,36 For example, one SC hospital recently partnered with a food service management company to target nurses’ daily fruit and vegetable consumption through menu development.³⁷ By introducing healthy grab-and-go meals, fruit cups, and vegetable packs in cafeterias, nurses’ daily fruit/vegetable consumption increased over the pilot period.³⁷ Targeting point of sale with behavioral design strategies (e.g.; remove unhealthy items, add healthier items) could help as increased proportions, closer proximity, and conspicuous placement of healthy items have been shown to nudge consumers towards healthier choices.^{13–15,38,39}

VM procurement policies can be implemented to improve availability of healthy items.³⁶ Through partnership with VM companies, behavioral design strategies can be utilized by placing healthy items at eye level and adding labels identifying healthier options.³⁶ Another alternative to increase 24/7 access and availability is stocking cold VM or micro-markets with fruit/vegetable options. Two hospitals provided a badge-access, employee-only canteen that was accessible 24/7. These canteens were not observed for this study; however, they reportedly contained grab-and-go salads, sandwiches, wraps, fruits, and vegetables. Other innovative alternatives to the standard cafeteria operating hours (e.g., pre-orders, delivery) have demonstrated positive employee nutritional wellbeing results.⁴⁰

Hospital leadership support and organizational commitment to consumer food environments that educate and encourage healthy choices are necessary.³⁵ Adopting guidelines for healthier food service, like those from the CDC, could make hospital environments more health-promoting.^17,36 Hospital leadership could also enact policies that codify nutritional standards through workplace wellness programs, contractual stipulations, and purchasing agreements. Using cost-adjustment pricing strategies (e.g., increased cost for high-demand unhealthy foods, discounts for healthier items) can maintain financial sustainability while promoting healthier choices.^41,42 Finally, strategic guidance for implementation is available from the CDC for organizations committed to creating healthy hospital food environments for employees, patients, and visitors.^17,36

Limitations.

This cross-sectional study captured data during one visit at each hospital and may not reflect cafeteria menu diversity that may occur during a given week. Observations occurred before hospitals closed to the public and modified food service procedures (e.g., suspension of self-service options) due to the COVID-19 pandemic, and which changes will endure are still to be determined.

Several of the surveyed hospitals had additional retail venues on premises operated by restaurant franchises which contribute to the consumer food environment; these were not observed due to limitations of the HNES tool and because restaurant franchises have set menus with little opportunity for alterations. Furthermore, there are other HNES limitations, including the age of the tool and associated nutrition guidelines, and enumeration procedures which prevented equal comparisons between items. Some categorical sample sizes were small, yielding low power to detect differences between groups. However, some sample sizes represented up to 100% of population size (e.g., only four extra-large hospitals in SC). Finally, this study was conducted in SC, where Southern food cultural preferences may influence menu options. Traditional Southern cuisine often includes fried protein and vegetable or grain offerings, stewed/boiled vegetables cooked with fat and salt, rich desserts, and sugar-sweetened beverages.⁴³ Findings cannot be generalized to hospitals in regions with very different cultural food preferences or where food service guidelines are already in place.

So What?

What is already known about this topic?

Hospital nurses, the largest group of healthcare professionals, commonly report workplace food environments that pose barriers to healthy eating. In the few quantitative assessments of hospital consumer food environments that exist, none were conducted in the Southeast United States or focused on nurses’ workplace influences.

What does this article add?

This study provides detailed data on the hospital consumer food environment, with specific attention to environmental barriers relevant to nurses, including availability, access, prices, and locations of healthy foods within hospital cafeterias, vending machines, and gift shops across an entire Southeastern state.

What are the implications for health promotion and practice?

In hospitals, proportions of and access to healthy options need improvement to address the environmental barriers reported by nurses. Implementation of guidelines for institutional food service allows opportunity to ensure that most foods/beverages offered in hospitals meet dietary guidance. Tools based on behavioral design principles and food service guidelines, such as the HNES and CDC toolkit, can be used by hospitals to improve the healthfulness of their consumer food environments.