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

Hospital inpatients� experiences of access to food: aqualitative interview and observational study

Smriti Naithani BSc MSc,* Kevin Whelan BSc MSc PhD,� Jane Thomas BSc MMedSci,�Martin C Gulliford MA FRCP FFPH§ and Myfanwy Morgan BA MA PhD FFPH–

*Research Assistant, Division of Health and Social Care Research, Department of Public Health Sciences, �Lecturer, Nutritional

Sciences Division, �Senior Lecturer, Nutritional Sciences Division, §Professor, Division of Health and Social Care Research,

Department of Public Health Sciences and –Reader, Division of Health and Social Care Research, Department of Public Health

Sciences, King�s College London, London, UK

Correspondence

Ms Smriti Naithani

Department of Public Health Sciences

King�s College London

Capital House

42 Weston St

London

SE1 3QD

UK

E-mail: [email protected]

Accepted for publication

2 January 2008

Keywords: access to services, food

service, hospital, hunger, patient

experience, qualitative

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: organi-

zational 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 comfort-

able 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 behav-

iour 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.

doi: 10.1111/j.1369-7625.2008.00495.x

294 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd Health Expectations, 11, pp.294–303

Introduction

Undernutrition is common in hospital in-

patients, with a prevalence of between 13% and

40% reported in the UK1–3 and throughout the

world.4 Undernutrition is independently asso-

ciated with a number of negative clinical out-

comes, 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 Hospital6 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 bodies8 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 Plan10 and the Better Hospital

Food initiative.11

The role of the doctor is underlined in the

report Nutrition and Patients: a Doctors

Responsibility8, which emphasizes that doctors

should be �familiar with relevant aspects of

food service to their patients and the impor-

tance of dietary intake�. Recent surveys indicate

that overall, patients reported a positive expe-

rience 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 sat-

isfied 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 hospital13. 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 influenc-

ing their physical ability to eat and the quality

of meals.

Methods

Study design

A qualitative approach using semi-struc-

tured 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 hospi-

tals 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.

Access to food, S Naithani et al.

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd Health Expectations, 11, pp.294–303

295

Observations

Exploratory non-participant observations were

carried out on wards to understand the organi-

zation 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 cog-

nitive 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 con-

sulted). The study aim was to achieve a diverse

sample with respect to gender, ethnicity and age.

Interviews

Questions were open ended and explored per-

ceptions of food, perceived dietary requirements,

patients� eating experience during bedside meal-

times, impressions of the standard and accept-

ability of hospital food and food service, systems

for food delivery and arrangements for meal-

times, problems of hospital food and the role of

visitors in supplementing hospital food (Box 1).

Interviews were conducted at the patient�s bed-

side and were recorded using written notes with

the patients� consent.

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

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?



296

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 experi-

ences 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 con-

ducting 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).

Themajority of patients said theywere 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�, oftenqualified 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� percep-

tions 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 accept-

able 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,

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



297

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�tget 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�sbecause they serve dinner too early. That�swhen 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�tsleep 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�tenough information on the sheet so you can�t get aclear idea of what is in the food and in my case

whether it is suitable for me, suitable for a dia-

betic…. I get my wife to have a look at it and she�lltell 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. Observa-

tional 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 sup-

ported by a longstanding catering assistant.

Serving times

Over a third of patients (19 ⁄48) reported that

meals were served at times that were not con-

sistent 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



298

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) eitherskipped 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 inap-

propriate seating and trolley positioning result-

ing 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 des-

sertspoon. 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�vedropped something . . . sometimes they�ve forgot-

ten 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 indi-

cated 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



299

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 happyabout 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 identi-

fied 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 gotsome 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�reeating 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 inpa-

tients� satisfaction with hospital food.14,17

Patients� responses about food acceptability

were however often influenced by their low

expectations of hospital food and food provi-

sion, 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, andidentified organizational, physical, and envi-

ronmental 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 admis-

sion 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 avail-

able 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, manipu-

late utensils or to feed themselves, which was

particularly important if they were given insuf-

ficient time to finish eating or if needed help was

not provided. This corresponds with findings

from the 2006 Healthcare commission survey



300

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, organiza-

tional and environmental factors affecting the

quality of hospital meal times were widespread,

and included interruptions for medical or nurs-

ing 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 hospi-

tal 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 work-

ing within the wards. In some wards it appeared

more difficult to implement Protected Meal-

times, for example on surgical and acute wards

surgeons were seen consulting during mealtimes

and on the renal ward patient�s dialysis treat-

ment 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 com-

pared with short stay patients or that family and

friends provide food and assistance while eating.

Studies that have attempted to address prob-

lems 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 pro-

tected 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 wastage26,27 and it

is possible that they may have different impli-

cations for patients� experiences of food access,

choice and other aspects of patient care. A sec-

ond 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 limita-

tion 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



301

environmental barriers during mealtimes on

hospital wards and many elderly and post-surgi-

cal patients had physical difficulties in eating

while a more general difficulties was the unavail-

ability 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 andnutritional 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 forassistance. 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.

Acknowledgement

This research was supported by the Guy�s and St

Thomas� Charity.

Declarations

1. This 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.

References

1 McWhirter JP, Pennington CR. Incidence and

recognition of malnutrition in hospital. BMJ, 1994;

308: 945–948.

2 Kelly IE, Tessier S, Cahill A et al. Still hungry in

hospital: identifying malnutrition in acute hospital

admissions. QJM, 2000; 93: 93–98.

3 Edington J, Boorman J, Durrant ER et al. Prevalence

of malnutrition on admission to four hospitals in

England. Clinical Nutrition, 2000; 19: 191–195.

4 Council of Europe Committee of Experts on

Nutrition FSaCP. Food and Nutritional Care in

Hospitals: How to Prevent Under-Nutrition.

Strasbourg: Council of Europe Publishing, 2003.

5 Correia MI, Waitzberg DL. The impact of malnutri-

tion on morbidity, mortality, length of hospital stay

and costs evaluated through a multivariate model

analysis. Clinical Nutrition, 2003; 22: 235–239.

6 Association of Community Health Councils for

England and Wales. Hungry in Hospital? London:

CHC, 1997.

7 Age Concern. Hungry to be Heard. The Scandal of

Malnourished Older People in Hospital. London: Age

Concern, 2006.

8 Report of a working party of the Royal College of

Physicians. Nutrition and Patients. A doctor�sResponsibility. London: Royal College of Physicians,

2002.

9 Department of Health. Patient Focused Benchmarks

for Clinical Governance. London: NHS Modernisa-

tion Agency ⁄Department of Health, 2003.

10 Department of Health. The NHS Plan: A Plan for

Investment, A Plan for Reform. London: HMSO, 2000.

11 NHS Estates. Better Hospital Food. 2007. Source.

Available at: http://195.92.246.148/nhsestates/

better_hospital_food/bhf_content/introduction/

home.asp, accessed on 22 May 2007.

12 Department of Health. Acute Inpatient Survey:

National Overview 2001 ⁄ 02. London: HMSO, 2003.

Available at: http://www.dh.gov.uk/en/

Publicationsandstatistics/Publications/Publications

Statistics/DH_4066592, accessed on 22 May 2007.

13 Healthcare Commission. Inpatients: The Views of

Hospital Inpatients in England. Key findings

from the 2006 survey. Available at: http://

www.healthcarecommission.org.uk, accessed on 22

May 2007.

14 Gulliford M, Munoz JF, Morgan M et al. What does

�access to health care� mean? Journal of Health

Services Research & Policy, 2002; 7: 186–188.

15 Westergren A, Karlsson S, Anderson P, Ohlsson O,

Hallberg IR. Eating difficulties, need for assisted

eating, nutritional status and pressure ulcers in

patients admitted for stroke rehabilitation. Journal

of Clinical Nursing, 2001; 10: 257–269.

16 O�Hara PA, Harper DW, Kangas M, Dubeau J,

Borsutzky C, Lemire N. Taste, temperature, and

presentation predict satisfaction with foodservices in

a Canadian continuing-care hospital. Journal of the

American Dietetic Association, 1997; 97: 401–405.



302

17 Stanga Z, Zurfluh Y, Roselli M, Sterchi AB, Tanner

B, Knecht G. Hospital food: a survey of patients�perceptions. Clinical Nutrition, 2003; 22: 241–246.

18 Robinsion G, Goldstein M, Levine GM. Impact of

nutritional status on DRG length of stay. JPEN.

Journal of Parenteral and Enteral Nutrition, 1987; 11:

49–51.

19 Beth Horwell. Protected Mealtimes and Visiting

Hours, Elderly ward, YH, Audit Report 2006. York

Hospital NHS Trust, June 2006.

20 Commission for Patient and Public Involvement in

Health. Shaping Health. PPI Forums joining forces to

tackle NHS Food. Food Watch August–October 2006:

National Summary.

21 Savage J, Scott C Patients� Nutritional Care in Hos-

pital: An Ethnographic Study of Nurses� Role and

Patients� Experiences. London: RCN, 2005. Available

at: http://www.rcn.org.uk/downloads/research/insti-

tute/PatientsNutritionalCareInHospital.doc, accessed

22 May 2007.

22 Wade DT, Hewer RL. Motor loss and swallowing

difficulty after stroke: frequency, recovery and prog-

nosis. Acta Neurologica Scandinavica, 1987; 76: 50–

54.

23 Anderson MD. Malnutrition and length of stay – a

relationship? Henry Ford Hospital Medical Journal,

1985; 34: 190–193.

24 Wright L, Hickson M, Frost G. Eating together is

important: using a dining room in an acute elderly

medical ward increases energy intake. Journal of

Human Nutrition and Dietetics, 2006; 19: 23–26.

25 Das AK, McDougall T, Smithson JA, West RM.

Benefits of family mealtimes for nursing home resi-

dents: protecting mealtimes may similarly benefit el-

derly inpatients. BMJ, 2006; 332: 1334–1335.

26 Wilson A, Evans S, Frost G. A comparison of the

amount of food served and consumed according to

meal service system. Journal of Human Nutrition and

Dietetics, 2000; 13: 271–275.

27 Hickson M, Fearnley L, Thomas J, Evans S. Does a

new steam meal catering system meet patient

requirements in hospital? Journal of Human Nutrition

and Dietetics, 2007; 20: 476–485.



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