There is nothing like personal experience to interest you in a research study. I read this paper (Xia & McCutcheon 2006) while making daily visits to a hospital. If I had not been interested in the subject beforehand, visiting a patient heightened my curiosity about the business of eating and drinking in health or residential settings. I am sure I am not alone in seeing how food and drink are handled says much about a hospital's culture and care. In our review (Manthorpe and Watson 2003), we highlighted concerns about the quality and quantity of food and drink in hospital settings for older people with dementia and the ways in which their families felt assured, or otherwise, that the rest of their relative's care was being well-handled.
This paper avoids a blaming approach, although at times a little criticism surfaces. While the authors discuss a comparative case design, what will stand out for me are the pictures they paint. Being given a urine bottle while eating, talking about bowel movements while having your lunch, the ways in which a doctor's arrival can interrupt a meal and what a cold meal, left at the bedside, looks and tastes like 45 minutes after it has been delivered. Powerful illustrations: powerful evidence.
This study asks the question: who does what? It sensibly adopted an observational method, sensible because, as the authors found, patients seemed very happy and were perhaps reluctant to voice any criticisms. In my view any study replicating this approach might constructively seek relatives’ views or speak to individuals after they have been discharged from hospital. A key question is whether patients have fairly low expectations of hospital food, or are feeling generally apathetic or even depressed, or whether they do fear repercussions if they complain. Perhaps, as the study suggests, what is behind the paradox of patients’ views (admittedly only four were interviewed) is that they too find the process of mealtimes to be complex and it is indeed unclear who does what.
As the authors observed, who does what is not a simple matter of recording the activity of nursing staff. Patients’ abilities or disabilities govern much of the mealtime experience. This includes their own views on whether eating well will help with recovery and might relate to problems with cognition as much as disability that makes the tasks difficult without assistance. Other eating establishments do not generally have these problems, although hospitals may seek to mimic domestic or, more comparably, communal eating venues, such as canteens or fast-food outlets, with some element of restaurant service. This matter of roles then becomes important: are kitchen staff ‘waitresses’ or do they have a further role in domestic service? Are nurses responsible for the ‘transmission’ of food or drink, or simply their monitoring? Do the normal rules of mealtimes apply (lack of interruption, delicacies) in hospital or does acquiring a patient status mean that what was taboo is now suspended? The sociology of food is a rather grand-sounding term but these insights have much to offer. As with the sociology of the body (Twigg 2000) the seemingly commonplace is as girded by rules and power as other social systems.
For me the interest of this paper is not to go over role boundaries and demarcations, but to move to thinking about skills. What are the skills needed to help sick and often disabled people to eat and drink? How can these be learned and practiced? What are the barriers to exercising these skills and how can staff themselves engineer such system change? In some ways the hospital described in this paper was addressing these issues. It had identified that nursing staff could not exercise their skills because they were on break. The study found that nurses were using their skills to record fluid intake but could not record food intake, as they did not see what the patient left on the plate. Kitchen staff did not have the skill to record this (unlikely) or there was no system in which they could do so.
Nurses, however, were using their skills of encouragement and motivation, if time allowed. High levels of illness and disability on hospital wards are common, however, and these skills have to be applied individually. Mealtimes, of course, in communal environments tend to arrive en bloc. What can be performed to square the circle of providing individually tailored support to high numbers of individuals? Skills that are needed are in system (re) design.
The authors make a series of constructive recommendations. They acknowledge that changes in nurses’ own mealtimes have not been proven as leading to better patient outcomes, but that further study might be warranted. They suggest trials of greater number of meals and more snacking, with smaller portions. Like many studies, they also call for more education and training to improve nurses’ attitudes and perceptions. I was not so convinced by this point, as it seemed to me that the authors had located good evidence of nurses’ understanding of the importance of food and their role in providing assistance at a number of levels. These skills were exercised but it may be that the training and education need to concentrate on problem solving. Involving the kitchen or serving staff would be constructive in this activity, as presumably it is disheartening for them to see so much food left to get cold and to remain uneaten. What skills do they have that can be used? Where do their responsibilities lie? If opening the food is the main type of assistance offered what might ease this for patients? Who is responsible for telling the kitchen that noodles seem difficult for many patients, that blended food can look unappetizing and that portions are too big for many of them? What skills are necessary to change this model of catering when resources are limited, demand is high and distances from bedside to kitchen are so great?
Domestic science is a term not generally used in the UK any more. This article suggests that the term might usefully be reinvented (as terms often are). Xia and McCutcheon have succeeded admirably in describing and analysing what is literally under our nose in hospital.