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We eat to live and be healthy, but food is not just fuel; every anniversary, celebration, high day and holy day has its accompanying special meal. We share meals as time to enjoy being together, to mark kinship and friendship ties, to confirm shared identities and what we hold in common. No matter how eclectic our taste may be, what we eat is a marker of our social identities – this White Western woman may enjoy trialling bush tucker but it won’t be my staple diet. At the same time, the way in which we eat is equally revealing. The etiquette of eating varies across cultures but every society has commonly held criteria of social acceptability. Adults feed themselves and do so in ways that demonstrate their mastery of complex skills in complicated settings: to spray food as you speak, dribble it down the chin or splatter it is regarded with distaste and denigration. Such behaviour marks loss of control, and control over one's actions is a mark of maturity and adulthood.

Martinsen et al. (2008) have focused their attention on the situation faced by those who lose this control, and live with this as a permanent feature. They ask the question, what is it like to have to be fed, to be dependent on others to get every morsel of every meal to your mouth? They have addressed this by engaging with a group of knowing informants, 16 people with high cervical spinal cord injury resulting in paralysis from the level of the upper limbs and who, with current levels of medical knowledge, will never regain this function. Their initial plan to conduct the study through interviews broadened to include observation of an assisted meal at some time-point following the initial interview. This allowed better understanding of the situation, with the opportunity for more detailed exploration in the following interview. It perhaps reflects the quality of relationships established in the first interviews that, despite flagging presence of others in the meal situation as potential sources of self-consciousness and embarrassment for interviewees, participants consented to this.

The combination of interviews and observations yielded unique insights on this situation, with important messages for all those involved with providing feeding assistance, not just to those for whom this is a permanent situation but also the wider group who experience this for limited periods. Such people are reliant on others for life-support: not the highly technological skills required to maintain life with the aid of ventilators and inotropic drugs, but skills that are none the less technical for that. Skills required in this situation must maintain not just physiological life but also psychological health and well-being. This is in tune with Bowers (1988) notion of ‘preservative care’, based on recognition of the need to preserve the cared-for person’s sense of self. Key to this was preservation of control within the situation, by subtle signs and commands perceived and responded to by carers, by minimizing anything that might draw attention, choreographing the activity to appear as effortless and normal as any other meal. For this extreme group, feeding dependence was part and parcel of a wider dependency, but even for them, having to ask and signal for support was unwelcome. Finch and Mason (1993) point out that people generally see the situation of having to ask for help as one to avoid if possible. Where it is needed, it is therefore more satisfactory to have assistance offered before it has to be requested, entailing sensitive as well as skilled intervention.

If these conditions are fulfilled, many of the social and psychological imperatives of this situation will have been successfully addressed. Yet, there still remains consideration of the sensual value of food, of taking the management of the situation to a level in which participants can simply enjoy their food, without needing to consciously monitor their eating process. This requires expert practice from those delivering assisted feeding, not mere competence.

Nurses’ and carers’ roles in this are to develop the necessary skills to be able to respond appropriately and with sensitivity. Martinsen et al. noted that routines established in the hospital became the basis for the way participants initially constructed their meals, and sometimes for years after the injury. Hence, these skills are needed across the spectrum of acute to continuing care. Sadly, all too often such skills are lacking, and assisted feeding is delivered by those with no or minimal training, and handed on to carers in the same way. This study flags the importance of this area of skilled intervention, describing it as an opportunity to ‘combine knowledge with authentic human involvement’– and really make a difference to patient/client experience.

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