What do stakeholders consider the key issues affecting the quality of foodservice provision for long-stay patients?

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© 2006, The Authors

Journal compilation © 2006, Blackwell Publishing

Journal of Foodservice,

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, pp. 212–225

Blackwell Publishing IncMalden, USAFRIFoodservice Research International1524-8275Copyright 2006, Blackwell Publishing

2006

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5212225

Original Articles

Foodservice provision for long-stay patientsK. Walton et al.

Original article

What do stakeholders consider the key issues affecting the quality of foodservice provision for long-stay patients?

Karen Walton, Peter Williams and Linda Tapsell

Smart Foods Centre, University of Wollongong, Wollongong, New South Wales 2522, Australia

Abstract

This study aimed to elicit concerns of key stakeholders regarding foodserviceprovision for long-stay hospital patients. Seventeen focus groups and fourindividual interviews were conducted involving six stakeholder groups: die-titians, nutrition assistants, patients, nurses, foodservice assistants andfoodservice managers. Ninety-eight participants (20 male, 78 female) wererecruited from public and private hospitals in New South Wales, Australia.Each of the focus groups and individual interviews was conducted in ahospital setting where free and open discussions could be digitally recorded.Transcripts were prepared from the digital recordings and QSR Nvivo 2.0qualitative analysis software (QSR International, Melbourne, Australia) wasused to code the transcripts prior to content and thematic analysis. Themeswere identified by relative frequency in the discussion, number of issues raisedwithin each theme and the importance placed on the issues raised. Five majorthemes emerged from 37 discussion topics: the foodservice system, menuvariety, preparation to eat and feeding assistance, packaging and portion size.Participants were particularly concerned about the increased packaging offood products, perceived lack of meal set up and feeding assistance, limitedmenu variety especially when considering longer stay hospital inpatients, andthe increased use of cook-chill operations. These findings lend themselveswell to testing in a wider sphere via quantitative means in a proposed nationalsurvey. The results of this survey may produce a position on the main barriersto effective foodservice provision for long-stay patients in the Australiancontext, and enable identification of practical solutions.

Introduction

The ageing Australian population and theincreased need for health care services have influ-enced many changes to foodservice systems inan attempt to make them cost effective. Thesechanges have included the increasing use ofcook-chill systems in health services (Mibey &Williams 2002). Many other factors have influ-enced the variety of, and access to, food andbeverages available on hospital menus today,

including financial considerations, food safety ini-tiatives, a shortage of nurses (Kowanko

et al.

1999; Chang

et al.

2003), changes to foodservicedelivery systems (Mibey & Williams 2002;McClelland & Williams 2003) and the changingroles of nurses regarding foodservice and patientcare at mealtimes (Carr & Mitchell 1991;Kowanko 1997; Kelly 1999).

These challenges to foodservice delivery haveoccurred when patients’ expectations about qual-ity and service are increasing (DeLuco & Cremer

Correspondence:

A/Prof Peter Williams, Smart Foods Centre, Building 39, University of Wollongong, New South Wales 2522, Australia. Tel:

+

61 2 4221 4085; Fax:

+

61 2 4221 4844; E-mail: peter_ [email protected]

Keywords:

consumer satisfaction, focus groups, foodservice, hospitals, menus, qualitative research

Foodservice provision for long-stay patients

K. Walton et al.

© 2006, The AuthorsJournal compilation © 2006, Blackwell Publishing


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1990; Lau & Gregoire 1998; Chang

et al.

2003),while at the same time the risk of patient malnu-trition remains a key issue, especially for long-stay rehabilitation patients (Beck

et al.

2001).Patients are often admitted with multiple medicalproblems and may already be malnourished, orat an increased risk for malnutrition prior toadmission (Zador & Truswell 1987; Green1999).

Information about the nutritional status ofolder rehabilitation patients is limited, but severalstudies estimate the rate of malnutrition to bebetween 29–63% in such patients (Finestone

et al.

1996; Thomas

et al.

2002; Neumann

et al.

2005). The figures vary because of the assessmentmethod used and the type of patients studied. Arecent Australian study compared the nutritionalstatus of patients in acute and rehabilitationsettings using Subjective Global Assessment,and found much higher levels of malnutritionamongst the older, longer-stay patients: 7–14% ofacute care patients vs. 49% of rehabilitationpatients,

P

<

0.01 (Beck

et al.

2001).There is evidence that changes in food and

dietary practices can have a positive influence onthe nutritional status of inpatients. A recent UKstudy found that rates of malnutrition appearedto have reduced from 23.5% in 1998 to 19.1%in 2003, while rates of referral increased from56.5% in 1998 to 71.2% in 2003, as a result ofchanges in hospital nutrition care strategies(O’Flynn

et al.

2005).Research has also indicated that many food-

service managers are not satisfied with recentfoodservice changes (Mibey & Williams 2002).Another study reported that the change toplated foodservice systems and the reducedavailability of food items being available inward kitchens meant that much nursing controlhad been removed from main meal and snacktimes (Wilson & Lecko 2005). Nurses have alsobeen found to refer to competing agendas, dif-ficulty in prioritizing nutrition above otherdemands, lack of staff, time issues, budget cutsand inadequate training on nutrition as poten-tial issues that can also influence the feedingassistance and monitoring of intakes by nurses(Kowanko 1997; Chang

et al.

2003). Less qua-lified staff are often assigned to feed andassist patients, which may further devalue the

importance of mealtimes and patient feeding(Dickinson

et al.

2005).In 2004, people 65 years and over made up

13% of the general Australian population (ABS2005), but accounted for 32% of hospital sepa-rations and 51% of total bed days. The averagelength of stay (LOS) for inpatients (excluding dayonly) was 7.5 days, but 24% stay longer than 7days and 10% have a LOS of more than 14 days.The nutritional status of older people can deteri-orate as their hospital stay extends (McWhirter& Pennington 1994; Neumann

et al.

2005;Thorsdottir

et al.

2005), and in New South Wales(NSW), Australia, they have a much longer aver-age LOS as inpatients: 11.5 days for those over65 years vs. 5.2 days for younger patients (NSWDepartment of Health 2005).

Approaches to research about the views andperceptions of health service provision can vary,and may include focus groups, surveys and inter-views. Used alone or in combination with aquantitative survey, focus groups have started tobecome a more popular approach to customerservice review (Alspach 1997; Wensing & Elwyn2002; Abusabha & Woelfel 2003; Merkouris

et al.

2003). ‘The focus group interview worksbecause it taps into human tendencies. Attitudesand perceptions relating to concepts, products,services, or programs are developed in part byinteraction with other people’ (Krueger 1994).Restricting to one paradigm can result in limitedunderstanding of participants’ views (Fossey

et al.

2002). Fade (2003) suggests ‘Quantitative andqualitative approaches are both required if we areable to get a full understanding of the issues’. Thecombined method provides a clearer picture anddeeper understanding of people’s experiences andview (Conning

et al.

1997).The aim of this study, therefore, was to elicit

concerns of key stakeholders regarding food-service provision for long-stay hospital patientsusing focus groups methodology. Long-staypatients will refer to those who stay in a hospitallonger than 14 days. Specifically, the researchsought to examine opinions and attitudes of asample of dietitians, nutrition assistants, patients,nurses, foodservice assistants and foodservicemanagers regarding the current provision of food-service in a sample of NSW hospitals in order toidentify key issues that could be examined in a


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nationwide survey quantifying barriers to effec-tive foodservice provision for long-stay patientsand identifying practical solutions.

Methods

Study participants

The study employed focus group methodologyto obtain views from six different stakeholdergroups in the practice setting. While it may havebeen ideal to conduct separate groups for eachstakeholder type (Wallace 2005), the nature ofmany existing hospital networks meant that someof the groups contained a mix of stakeholders.Generally, groups consisted of one type of stake-holder only, but for logistical reasons a few mixedgroups were included (e.g. Group 13: three dieti-tians and one nutrition assistant; Group 15: sevenfoodservice assistants, one nutrition assistant andone foodservice manager).

Several different recruitment methods wereused to invite people to participate in a studyabout their opinions and attitudes regardingfoodservice provision for long-stay hospitalpatients. The hospital staff were contacted viapresentations at established meetings of dietitians,foodservice staff, nurses and nutrition assistants,as well as key contacts with dietitians and food-service managers, flyers at foodservice confer-ences and the ‘snowballing technique’ (Patton2002). Invitations for patients to participate wereextended by the nursing staff. Some participantspreferred to be individually interviewed for rea-sons of convenience or privacy. The participantsreceived no reward for their involvement. Thefunding for the study was provided by theSmart Foods Centre, University of Wollongong,Australia. The research was approved by theUniversity of Wollongong/Illawarra Area HealthService Human Research Ethics Committee inearly 2003.

Participant profile

Seventeen focus groups and four individual inter-views were conducted between September 2003and December 2004, which included 19 nurses,14 patients, 20 dietitians, 11 nutrition assistants,13 foodservice managers, 18 foodservice assis-

tants and 3 other health care staff (qualitymanagers and patient representatives). The 98participants included 20 males and 78 females,with the propensity of women considered appro-priate because they make up the majority of thestakeholder groups involved.

Conduct of focus groups and individual interviews

The focus groups were conducted by the samemoderator, who was also the chief investigator, at15 locations within the metropolitan and regionalareas of eastern NSW. The chief investigator waspresent at all sessions to obtain written consent,to moderate and to record the discussions. Allsessions began with the key question, ‘What doyou think about the meal service in hospitalstoday?’ In most cases, this led to a lengthy open-ended discussion about a range of foodservicetopics. Where required, the following set of stan-dard questions was referred to so as to encouragediscussion and the consideration of a range oftopics:• What do you think about the meal service inhospitals?• What do you think about the menu choices?(e.g. variety, choices, range of culturally specificdishes)• What about the accuracy of meal orders?• What do you think about the way choices areoffered and selected?(e.g. bulk vs. plated, time ahead of meal)• What about the serving sizes?• What about packaging and patient access?• What about assistance with feeding?• What about meal service times?• Location of eating meals?(e.g. dining room vs. bedside)• What about meal quality?(e.g. taste, temperature and appearance)• What sort of meals would you expect inhospital? What sort of meals would you like inhospital?• What about special diet requirements?• What about food safety initiatives?• What about monitoring?(e.g. intake and wastage)• Any communication issues?• How are any problems resolved?• What are the top three priorities?


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The questions were introduced utilizing an open-question format to invite discussion without pro-viding an opinion from the moderator (Krueger& Casey 2000). The moderator invited any fur-ther discussion about topics, reflected key pointsand invited less vocal participants to comment atvarious times. When it was evident that a pointhad been exhausted, the moderator would askabout another topic. On several occasions, themoderator needed to clarify a point, or ask forsome additional information when the group dis-cussion progressed without further questioningand covered a range of topics. At the completionof each session, the participants were asked if theyhad any further comments and were thanked fortheir participation. They were offered the optionof receiving the transcript and a summary of find-ings at a later time so they could review andclarify any points. Each session ran for approxi-mately 45 min.

Data analysis

All focus groups and individual interviews weredigitally recorded on two portable minidiscrecorders. All sessions were typed verbatim byone independent, experienced transcriber, withany details identifying the individual participantsor workplaces removed. Codes were used to iden-tify the individuals and sites involved in each tran-script. The chief investigator moderated all thediscussions and did the primary coding. She is anaccredited practising dietitian and PhD candidatewho had previously conducted focus groups whileworking as a quality manager and foodservicedietitian in the Illawarra Area Health Service. Thesupervising author and secondary coder is anaccredited practising dietitian and former hospitalfoodservice manager.

The accuracy of the transcriptions was checkedby reviewing several digital recordings against thetyped transcripts. The QSR Nvivo 2.0 qualitativeanalysis software was used to categorize all of thequotes from each of the transcripts. Each individ-ual transcript was coded in turn and a combina-tion of content and thematic analysis was used tolook for patterns in the data and match eachquotation to the most relevant topic (Rice & Ezzy1999; Patton 2002). Qualitative analysis was ini-tially carried out by the primary author. The ini-

tial coding framework was based around previousexperience in the study area, the literature reviewand standard questions format. The codingframework increased up to 43 topics during thecoding process so as not to limit the generationof ideas (Pope

et al.

2000). The assigned quota-tions and topics were then reviewed by the sec-ondary coder. Any discrepancy in a topic orquotation allocation was discussed and a consen-sus was reached before any changes were made.This process refined the topic number to 37, assix topics could be grouped or deleted. These 37topics were collectively grouped under five broadthemes. Both positive and negative aspects of eachtopic were considered (e.g. some participantsviewed portion sizes as too small, while othersthought them adequate). Exemplar quotes foreach topic were independently selected by the pri-mary coder and the secondary coder to illustratethe key study findings. A copy of the session tran-script and summary of themes was forwarded tothose participants who could be contacted afterthe study, so they had the opportunity to reviewand add any further comments. No significantchanges were recommended by the few partici-pants who provided feedback.

Quality assurance

The rigour of the research was reviewed using anevaluative framework taking account of credibil-ity, criticality, authenticity, integrity (Whittemore

et al.

2001; Fade 2003); triangulation (Patton2002); respondent validation, methods of datacollection and analysis, reflexivity, attention tonegative cases and fair dealing (Mays & Pope2000). The

credibility

of the research findings wasenhanced by the use of a varied sampling strategythat involved purposive, convenience recruitmentand ‘snowballing’ (Bowling 2002), utilising anindependent and experienced transcriber (Ereaut2002), providing a clear and transparent descrip-tion of the data analysis and coding framework(Mays & Pope 2000), and involving a secondcoder and the review of transcripts and summa-ries by many participants afterwards (Bowling2002; Fossey

et al.

2002). The review by actualstakeholder participants – referred to as ‘

respon-dent validation

’ – was also used as a way ofreducing potential errors in interpretation (Mays


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& Pope 2000). Previous experiences and back-grounds of the researchers were clearly stated tosatisfy any issues related to

reflexivity

(Mays &Pope 2000; Fossey

et al.

2002).

Criticality

wasaddressed by having both a primary and a sec-ondary coder involved in the data analysis toindependently review the quotations before fur-ther discussion and consensus. This was enhancedby the fact that many stakeholders also had theopportunity to review the findings and makeany additional comments.

Triangulation

was builtinto the study design through the use of differentdata sources (six different stakeholder groups)and the use of different methods (focus groupsand individual interviews) to enhance the com-prehensiveness of the study (Patton 2002). Thisassists in the discovery of patterns that generatean overall impression of the research area (Mays& Pope 2000). Digital recordings of all discus-sions and the use of exemplar quotes to illustratethe key points of each topic supported the

authen-ticity

of the research. The

integrity

was assuredby obtaining human research ethics approval. Theparticipant information sheet and consent formclearly explained the study and its aims, in addi-tion to highlighting that participants were free torefuse participation, or withdraw their consentat any time. Six different key stakeholder groupswere involved, and the summaries primarily rep-resent the broad views of the sessions to ensurefair dealing. However, consideration of ‘deviant’

or differing cases was necessary to allow consid-eration of all the data collected, no matter howoften some topics were mentioned (Mays & Pope2000; Pope

et al.

2000).

Results

Key themes

The five key themes and the 37 topics wereidentified, with those scoring more than 10 sepa-rate mentions noted in the illustrative quotes(Table 1). The most frequently discussed topics(in descending order) were portion size, prepara-tion to eat and feeding assistance, menu variety,packaging and foodservice system, with the firsttwo topics being referred to in every discussionsession. Saturation was reached after eight ses-sions, with no new topics identified in sessions 9–21 (Fig. 1). However, additional details and quo-tations about previously identified issues wereobtained in these later sessions.

The foodservice system

The foodservice system determines the types andamounts of menu choices offered to patients.Decisions on menu choices may be influenced bywhat retherms well in a cook-chill or cook-freezesystem, and how much time there is to preparefood in a cook-fresh system. While more options

Figure 1

Number of new topics discussed at each session.

0

5

10

15

20

25

30

1 F 2 F 3 F 4 NA 5 N 6 D 7 D 8 FA 9 D 10 Pt

Group number and key stakeholders present(Where F: Foodservice Manager, NA: Nutrition Assistant, N: Nurse,

D: Dietitian, FA: Foodservice Assistant and Pt: Patient)

Num

ber

of n

ew t

opic

s


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Table 1

Key themes, topics and exemplar quotes

Key themeTopics (Number of sessionstopic was discussed)

Exemplar quote for topics discussed in more than 10sessions (Key stakeholder type)

1. Foodservice 1.1 Portion size (

n

=

21) ‘Yes. Some of the oldies are put off by having large plates of food put in front of them. If they have something small they’ll tend to eat it’ (Foodservice assistant)

1.2 Packaging (

n

=

19) ‘I cannot for the life of me open, I’m alright with the butter, but when it comes to the jams and the honey and all that, the juices they have to open that for me. It’s ridiculous that you can’t open them because mostly this hospital is full of old people’ (Patient)

1.3 Foodservice system (

n

=

18) ‘Obviously a menu is planned according to what retherms most effectively and that limits your variety and that you do have a lot of wet dishes’ (Dietitian)

‘With cook-fresh we always felt we were rushing every mealtime to get things done but with cold plating you can plate whatever time of the day you want and we’ve got more choice on’ (Foodservice manager)

1.4 Mealtimes (

n

=

17) ‘I think it should [the evening meal] be later but at the same time maybe you should be looking at a more substantial snack if it’s going to be later or you have something more substantial after your meal’ (Dietitian)

1.5 Meal accuracy (

n

=

15) ‘Patients are disappointed if they don’t get what they ordered. Sometimes they order other items just in case they don’t get what they really want’ (Dietitian)

1.6 Temperature (

n

=

14) ‘I think technologically we really come a long way and it’s better’ (Foodservice manager)

1.7 Mid meals (

n

=

14) ‘And having high energy snacks for mid meals. I think that’s another thing that’s cut with budgets. Tea and coffee with biscuits isn’t really terribly nutritious’ (Dietitian)

1.8 Wastage (

n

=

12) ‘With elderly clients we do see in hospitals, is they get very upset with the wastage and if you do give them the ward size meals instead of an appropriate size for them, they do get very upset that they’re wasting food and they’re wasting money’ (Foodservice assistant)

1.9 Customization (

n

=

11) ‘And it’s not about food quality, its about the flexibility that we don’t have in it’ (Dietitian)

‘Basically the inflexibility and not being able to provide individuals with foods that they request at the time when they are really ill and the other thing related to that is a lot of a small number of our patients are long term and that can become an issue in actually meeting their nutrition needs if they don’t like the food or don’t find it because it’s repetitive’ (Dietitian)

1.10 Presentation (

n

=

11) ‘I’m thinking of texture modified meals more so. They’re the ones that I find least attractive. And they’re the people that need to eat them the most’ (Dietitian)

1.11 Extras (

n

=

11) ‘They cut down the extras list. When I first started here there used to be a big variety of different [extra foods available], they’ve cut it down to just about hardly anything’ (Nutrition assistant)

1.12 Taste (

n

=

9)1.13 Smell (

n

=

7)1.14 Texture (

n

=

7)1.15 Fortification (

n

=

6)1.16 Time allowed to eat (

n

=

6)1.17 Availability (

n

=

4)


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2. Menu 2.1 Menu variety (

n

=

19) ‘They come through in the morning and ask what you’d like for breakfast, lunch and tea. And you’ve got a choice of picking what you like. Not just thrown in front of you and say that’s it. You get to choose what you want to eat’ (Patient)

2.2 Special diets (

n

=

17) ‘And the choices, making sure there’s enough choices for the range of diets especially those high need individuals select from the main menu’ (Dietitian)

2.3 Menu selection methods(

n

=

16)‘Yeah, I think in a way and in my experience is quite limited

but often we have this menu and then you put in these diet codes and rather than giving them options, rather than just chopping things off, you combine a few diet codes and suddenly the person’s got one choice and that’s it’ (Dietitian)

2.4 Food preferences (

n

=

16) ‘We have a prevalence of wet dishes in the hospital. I know that that’s not (my) favourite. I’d prefer fish, eat, chicken that I have at home’ (Foodservice assistant)

2.5 Culture (

n

= 12) ‘I’ve noticed with a lot of the patients that are Greek or Italian the family brings in tea at night for them like spaghettis or lasagnes’ (Nurse)

2.6 Diet changes (n = 6)2.7 Foods brought in (n = 4)

3. Medicalcondition

3.1 Length of stay (n = 10) ‘The cycle is based on the length of stay. I know that [hospital X] has 1 week. It’s geared to the very acute’ (Dietitian)

3.2 Nutrition requirements(n = 6)

3.3 Appetite (n = 3)4. Ward

environment4.1 Preparation to eat and

feeding assistance (n = 21)‘The poor patient can’t sit there and eat it because she can’t

open it or he can’t open it and the nursing staff are busy showering or bathing somebody else, that meal is just going to sit there until the next hour’ ( Nurse)

4.2 Monitoring (n = 13) ‘And no one on that ward notices that that person hasn’t eaten. To me that’s very much a state of what’s happening. It used to be for example a nurses responsibility to feed the patients. That’s been eroded with their professionalism’ (Dietitian)

4.3 Dining environment (n = 11) ‘I think that has great advantages from the perspective of nursing being able to access people and supervise and support especially for rehab’ (Dietitian)

4.4 Socialisation (n = 4)5. Management 5.1 Patient and staff feedback

(n = 18)‘I know that from our survey perspectives that we get back

that their expectations are higher than they ever used to be’ (Foodservice manager)

5.2 Budget (n = 16) ‘I guess as things get more rigid because of cost, the ability to make changes at short notice is really limited in the ability to cater for individual requirements diminished in some way’ (Dietitian)

5.3 Food safety (n = 13) ‘The NSW Health document it sort of says to avoid all of these foods because of Listeria, and then it acknowledges that by doing this they don’t want to precipitate the issue of malnutrition so use your discretion’ (Dietitian)

5.4 Communication (n = 9)5.5 Supplements (n = 6)5.6 Improvements (n = 3)

Key themeTopics (Number of sessionstopic was discussed)

Exemplar quote for topics discussed in more than 10sessions (Key stakeholder type)

Table 1 Continued

Foodservice provision for long-stay patients K. Walton et al.

© 2006, The AuthorsJournal compilation © 2006, Blackwell Publishing Journal of Foodservice, 17, pp. 212–225

219

may be available with cook-chill and cook-freezesystems, some types of dishes may be limited (e.g.grills, fried dishes and boiled eggs) because oftheir poorer quality after reheating (Light &Walker 1990).

The participants generally reported a betterperception of the cook-fresh system and identifiedbetter levels of flexibility or customisation, witha working kitchen still available to prepare itemsat short notice for special diet or very ill patients.Many staff lamented the loss of their productionfacilities when they became receival kitchens, asthey perceived a decline in the level of customerservice. Conversely, cook-fresh operations weresometimes viewed as more staggered in their dailyactivities, such that mealtimes were a rush. Itwould appear that this system sometimes limitsthe evening meal options to mainly ‘light meals’(perhaps one hot main, soup, sandwiches anddesserts) because cooks were not always retainedfor the afternoon shift. This finding is supportedby other research that reported 81% of NSWhospitals using a cook-chill system, comparedwith 47.5% using a cook-fresh system (P < 0.01),offered more than one hot choice at the eveningmeal (McClelland & Williams 2003).

Bulk trolleys are rarely used to serve meals inAustralian hospitals (Mibey & Williams 2002),but several groups discussed the advantages anddisadvantages of bulk hot service and selectionvs. plated systems. For example, one dietitiannoted:

I’ve seen the bulk in action at the maternityward and it means that you get a greater vari-ety of choice. You can sort of more or lesschoose what you feel like on the day ratherthan having to decide the day before what youwant to eat. That’s a good option.

Some stakeholders identified the lack of hot, bulkfoodservices as a potential influence on actualintakes and wastage, which is supported by otherresearch (Shatenstein & Ferland 2000; Wilsonet al. 2001). The type of foodservice system usedwas also linked to many of the other topics iden-tified, including the texture, presentation andsmell of the food, as one nurse indicated, ‘I thinkwe can also present it a lot better. Cook-chill isdefinitely no inspirational food’.

Portion sizes delivered through the system

The portion size of meals was discussed by theparticipants in every session. The commentsvaried depending on the size and the type of food-service system, the options currently available andthe main types of patients in their hospitals. Somecommented that there was sometimes not a choiceof size, and that there should be; others thoughtthe standard portion was too large, while somethought they were too small at times. One dieti-tian noted:

There is not enough flexibility. We’ve got thecook-chill service system so our trays are verylimited and our plates are one standard size sothere’s no flexibility. We can’t have large sizeserves or small size serves so and it’s limited onwhat we can fit on the trays so, yeah, they’resort of good for some people but not forothers.

Many referred to the need for a small option,particularly for elderly patients who can be over-whelmed by well-meaning staff providing largerportions. It was regularly noted that olderpatients do not like waste. However, othersreferred to the needs of young patients and mater-nity patients who often have large appetites andmay not be satisfied by a standard portion. It wascommonly agreed that a choice of portion size,the availability of extras and the fortification ofnormal meal items were required to meet patientneeds.

Packaging within the foodservice system

Many menu items are now in a prepackagedformat for numerous reasons, including qualityimprovement, portion control, budget and foodsafety. Previous research has indicated that theaverage meal tray may contain between 5 and 19items at each meal depending on what the patientselects (Wilton et al. 2004). This certainly addsto the challenge of food access, particularly forelderly and disabled patients. One foodserviceassistant noted:

I consider myself fairly dexterous and ablebodied and some of those straws in the pack-ets, they’re not easy to get out at all. So whenyou have aged people with compromised



220

vision and dexterity and coordination, it’sshocking.

It also increases the time that may be requiredby staff to open packages before assisting patientswith setting up and feeding. The level of packag-ing may also impact on the presentation of thetray and the amount of waste generated.

The menu

A key issue for many was the nutritional ade-quacy and number of choices available on themenu, particularly for long-stay patients andpatients requiring therapeutic diets. The trendwithin Australian hospitals has been to offer acombined menu that has options that cater tomost therapeutic diets (Mibey & Williams 2002).

Many dietitian participants were concernedthat patients on a combination of therapeuticdiets may have minimal choice offered to them,as one stated:

I think the general menu and the way it’s struc-tured at the moment meets the needs of, youknow, those short stay people fine. I don’tthink there’s any issues with how they managebut it’s these more complicated, more complexpeople with major nutritional issues that Ialways find it very difficult.

Many foodservice managers, dietitians, food-service assistants, nursing and nutrition assistantstaff felt that menus do not cater in the same waythat they used to, even for patients on full diets.The limited options for condiments between mealsnacks and hot breakfasts were highlighted, suchas this comment by a dietitian:

I guess the longer cycle you have the morecostly it is with different ingredients that youhave to store and then training people to cookthe different dishes and then having the dietvariations on the menu. So I think also menucycle length has been reduced. So there’s notthe variety there used to be.

Some felt variety was reduced mainly becauseof budgetary constraints and the fact that food-service is treated as a hotel service, rather thanbeing acknowledged as part of holistic medicalcare, issues which has previously been highlighted

by numerous researchers (Kowanko 1997; Coun-cil of Europe 2002). More than 20 years ago,Wood et al. (1985) discussed the perceived lowpriority of nutrition in medical care and high-lighted the need to improve attitudes and mana-gerial support so as to improve the nutritionintakes of patients. As one nurse put it:

We seem to have an attitude that this foodservice is basically not core business thereforewe should not be putting money into it if it’snot making money, and I think that’s a tragedy.It’s a change since I started nursing in the ethosof running a hospital.

This issue also links with the consideration ofmenu selection methods, which forms a compo-nent of the broad menu theme. There has been asignificant change to shorter menu cycles (lessthan 14 days) and an increased use of bedsidecomputerized menu entry systems, although mostmenus are still paper based (Mibey & Williams2002; McClelland & Williams 2003; Patch et al.2003).

The patient’s medical condition

Consideration of individual nutrition require-ments is closely related to the discussion aboutscreening and assessment of high-risk patients toensure that their nutritional needs are met. Mon-itoring is a related topic that was also identifiedby the stakeholders. Only when it is identifiedthat patients are not eating adequately can indi-vidual strategies be put in place to enhance theirintakes (Gibbs-Ward & Keller 2005; Sydner &Fjellström 2005).

Nutrition requirements

Patients on therapeutic diets need careful consid-eration to ensure that menu variety is adequate tomeet their requirements. Issues of customisation,menu variety, monitoring and fortification are allclosely related to the aim of meeting nutritionrequirements. One foodservice manager com-mented that she was concerned about intakes ofpatients consuming special diets:

Particularly the speech pathology patientsbecause that comes into your elderly. Regu-



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larly, nothing is touched, nothing at all. Whichis a huge cost to all these tetra packs andgoodness knows what else. So we’ve got toaddress it and try and do it better by whatevermeans it takes.

Wright et al. (2005) recently reported signifi-cantly smaller intakes of energy and protein byolder patients requiring texture modified diets,compared with those on normal textured diets.

Preparation to eat and feeding assistance

Older patients often need more assistance andencouragement with meals, particularly as moreitems are prepackaged. This is happening at atime when registered nurses are busier than everand the role of feeding is sometimes delegated toother staff (Kowanko et al. 1999; Chang et al.2003), as can be seen from the comments of die-titians and nutrition assistants:

The bottom line is that it is an assistant nursingfunction rather than a nursing function. That’show they do it in nursing homes. Because thetrained nurse is basically glued to the drugtrolley. (Dietitian)

I think it’s a fairly universal problem. Whenworking as a nutrition assistant I didn’t feelthat my morning was complete until I had gonearound and buttered several toasts and youknow open sugar and made cups of tea forpatients and you just follow the meal trolleyaround and assist the nursing staff in thatregard. (Nutrition assistant)

Making foods easier for people to eat is amajor thing, whether it’s from actually sittinga person close enough for them to reach it,whether it’s opened for them, with the patientsitting upright, if they need feeding assistance(Dietitian)

This issue was raised during every session, andall stakeholder types viewed it as an issue of keyimportance to improve the dietary intakes ofpatients. Some participants, including some of thepatients, felt this service was adequately offered,while many felt it was an area of priority forongoing improvement, which ideally would bepartnered with efficient monitoring procedures.

Some stakeholders, such as this dietitian, talkedof the possibility of patients eating in diningrooms and the value of greater socialisation anda more usual eating environment:

It’s a very social event. A lot of people actuallyseem to eat quite well when they’re sittingthere talking and picking, rather than sitting ina hospital environment. It’s not like sitting ina bed.

This area is complex to research, but there is someevidence suggesting that a dining room environ-ment and the consequent social interaction canimprove dietary intakes (Edwards & Hartwell2004).

Obtaining patient and staff feedback

Obtaining regular patient and staff feedback isimperative to understanding how the foodserviceunit is performing. Stakeholders talked of con-ducting surveys, speaking with patients abouttheir perceptions on the different foodservicetypes, as well as possible influences on quality;however, there was recognition of a need toimprove quality improvement processes, as can beseen in this comment from a dietitian:

I think the frustration from a diet tech perspec-tive is that the wards ring us when it’s reallyan issue of likes and dislikes, or you knowthe patient’s not happy with the quality of hisfood. I can’t change it, I can’t fix it and Icertainly offer the facility to pass on their com-plaints. Most patients don’t take that up whichis frustrating because I don’t think from a foodservice perspective you can improve it unlessyou know.

Key stakeholder differences

The differing opinions of some stakeholdersabout the topics were found to be related to thedifferences in their experience and backgrounds,such as whether they had experienced cook-freshor cook-chill foodservice systems, if their hospi-tals had fortified food options, and how goodpatient and staff communication networks wereat their workplaces.



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Many common themes ran throughout the ses-sions; however, some of the topics were particu-larly an issue for certain stakeholder groups.

PatientsThe patients were generally happy with mostaspects of the foodservice. Their main negativecomments were regarding the level of packagingand the texture of some meats and vegetableswithin some facilities. They did not have as manycomplaints as other stakeholders. On average,they were also older than the other stakeholders,and it may be that older patients are less likelyto complain than younger staff working in thefacilities.

NursesKey issues for nurses related to the perceived lackof menu variety in some settings, negative opin-ions about the cook-chill system, the amount ofpackaging, and the taste, texture and lack ofaroma with some foodservice systems.

Foodservice managers and foodservice assistantsThese staff were especially worried about thewastage of nutritional supplements and the influ-ence of their tightened budgets on actual patientintakes. This was related to their genuine concernfor the inadequate feeding assistance available,lack of monitoring of actual patient intakes andlimited menu options available.

Dietitians and nutrition assistantsIssues of special concern for these nutrition staffrelated to the inability to meet some specialdietary needs, a lack of customisation, inadequatevariety, lack of feeding assistance and theincreased use of packaged products. They werekeen for food fortification to be routinely utilisedand extra menu choices to be available for long-stay patients and those with complex dietaryneeds.

Discussion

The findings of this study are consistent withthose of other researchers who have explored sat-isfaction with hospital foodservices, particularlyregarding the quality and technical aspects forpatients. However, the issues regarding packaging

appear to have been only reported recently(Watters et al. 2003). Most studies primarilyrelate to the perceptions of inpatients and nurses.The current study represents the views and atti-tudes of six key stakeholder groups; thus, manyof the current findings consider many broadertopics and are not always as complimentary assome of the studies reporting only patients’ views.

DeLuco & Cremer (1990) reviewed the percep-tions of dietary services and hospital food viatelephone interviews with a sample of 223 adultpatients in Ohio. The majority of participantsreported the hospital meals as nutritious (94%),appearing and tasting fresh, the cold foods werea suitable temperature, and there were enoughmenu options to choose a healthy and fulfillingmeal (82%). Fewer participants (61%) thoughtthe meals tasted good, were appropriately hot,looked and smelt good, and were suitably tender,while seasoning of meals was viewed as adequateby only 32% of the participants.

Dubé et al. (1994) and Lau & Gregoire (1998)reported on questionnaires with inpatientsregarding ratings of foodservice quality inCanadian and US hospitals. Food quality was thebest predictor of the overall satisfaction of inpa-tients, but other issues such as interpersonal careaspects of meal delivery (e.g. courtesy and assis-tance with meal tray), customisation and the atti-tude of the staff who deliver the meals were alsoimportant.

Watters et al. (2003) reviewed the perceptionsof an American hospital foodservice via focusgroups with postdischarge patients and nurses,and individual interviews at meal rounds withinpatients. The findings indicated that patientswere more satisfied with the foodservices than thenurses. While food quality was identified as thepriority issue, service was also important. Satis-faction with portion size varied, as did choicesavailable and appropriateness of foods offered.The nurses highlighted issues relating to the traylayout, waiting times for replacement meals, con-tainers that were often difficult to open and thelack of extra food items available at all times inward areas.

The barriers to nutrient intakes by long-stayhospital patients are many and varied. However,key issues for further consideration regardinginterventions relate to portion size, preparation to



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eat and feeding assistance, menu variety, packag-ing and foodservice system. Several of these issuesare interrelated (e.g. foodservice system, portionsize and packaging), as outlined in Table 1.

Given the general level of agreement on keyissues uncovered in this qualitative study andthose in the published literature, it seems likelythat the key findings are relevant and able to begeneralized to the other parts of Australia, andperhaps internationally, particularly as the popu-lation ages. However, it should also be high-lighted that the size, budget and the structure offood, nutrition and nursing services can alsoimpact on the dietary intakes of patients. Thus,while some sites identified practices that aresuccessful, it is important that hospital size andorganizational factors are always consideredwhen considering interventions to addressbarriers.

Patient satisfaction or dissatisfaction is a com-plicated phenomenon that is linked to expecta-tions, state of health, personal characteristics, inaddition to health system characteristics (Fordet al. 1997). Measuring the quality of an intangi-ble product or service, such as the quality of thefoodservice or medical care provided, is alwayschallenging (Ford et al. 1997; Ramirez-Valdivia& Crowe 1997; Lim & Tang 2000; Torres & Guo2004).

This research applied focus group methodologyto a sample of stakeholders in the hospital systemof NSW, Australia. The quantitative approach,using surveys or questionnaires, appears to havehistorically been the most common method used,probably because of its familiarity, ease of admin-istration, reach, distance from the interviewee andlow-time costs (Conning et al. 1997). However,surveys or questionnaires are sometimes criticisedfor their concentration on ‘hotel-style’ aspects ofcare, their ‘blandness’ and ‘tendency to produceundifferentiated positive responses’ (Evason &Whittington 1997). Most surveys do not allow anexploration of complex issues or a discussionabout opportunities for further improvements.

In contrast, focus group methodology, appliedin the research reported here, has the advantagesof allowing open-ended questions and deeperinvestigation of participants’ responses (Dreachslinet al. 1999). They elicit more complete and honestresponses (Evason & Whittington 1997) and are

‘rich in data’ (Grbich 1999). Other benefitsinclude: the ability to probe and seek further clar-ification of a point, the possible use of interpreterswith a group of non-English-speaking people andthe ability to discuss a topic with specific groups.They can also be used to test topics for questionsin an accompanying survey, or to further expandand explore the categorized findings from a com-pleted survey and literature review (Ford et al.1997; Bolch 1999).

The disadvantages of focus groups mayinclude: small numbers that will not showstatistical significance and the sample of partici-pants may not be representative (Evason &Whittington 1997). The participants may not beindependent of each other, and have beendescribed as, ‘Complex, often complicated mosa-ics of history, experience, motivation, and inter-ests’. It is suggested that focus groups, like othermethods, ‘Provide one window on these mosaics’(Hollander 2004).

The range of participants involved in this studyallowed for a comprehensive understanding of thecurrent foodservices provided to patients, and afull discussion on priority interventions. Thesefindings lend themselves well to testing in a widersphere via quantitative means in a proposednational survey. The results of this survey mayproduce a position on the main barriers to effec-tive foodservice provision for long-stay patientsin the Australian context, and enable identifica-tion of practical solutions.

Conclusion

The use of 17 focus groups and four individualinterviews has enabled the identification of 37topics and five broad themes regarding food-service provision in NSW hospitals. While therewas much agreement about the topics and keythemes, some stakeholders had specific concernsand some topics had both positive and negativeperspectives. The perspective often depended onthe foodservice system used and the size of thefacility. It is evident that there are many possiblebarriers to dietary intakes, and some possiblesolutions can be identified. These views will beused to plan a national questionnaire that willattempt to quantify these barriers and prioritisepractical solutions.



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Acknowledgements

The authors would like to thank all the partici-pants in this study and the independent tran-scriber, Ms. Lyn Politis.

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Documents

What do stakeholders consider the key issues affecting the quality of foodservice provision for long-stay patients?