Hospital meals are existential asylums to hospitalized people with a neurological disease: A phenomenological–hermeneutical explorative study of the meaningfulness of mealtimes

Abstract Aim Hospital meals are challenging for neurological patients. Patients struggle with both physical eating disabilities and social issues during mealtimes. The aim of this study was to examine the meaningfulness of the phenomenon of hospital meals for hospitalized patients with a neurological disease. Design Interviews (N = 23) with neurological patients were analysed and interpreted to gain in‐depth comprehensive knowledge of the phenomenon of hospital mealtimes. Method Data were analysed and interpreted in a three‐phased process using a phenomenological–hermeneutic approach inspired by Paul Ricouer. Results Four themes were identified: (a) A lonely ride together with others; (b) Letting the chaotic setting fade into the background; (c) Mechanical activity with great personal significance; and (d) Humanizing the setting when eating in the hospital. Mealtimes were supporting existential moments to patients. Offering a calm mealtime setting was experienced by the patients as an asylum where uplifting and comforting feelings were raised.

Patients with neurological diseases constitute one of the largest groups experiencing eating disabilities. Kumlien & Axelsson (2002) showed that patients who have had a stroke have an especially high number of eating disabilities; more than 80% of these patients in nursing homes were assessed to have some kind of dependence when eating. Many inpatients with neurological diseases experience more than one eating disability (Westergren et al., 2001). These eating disabilities often cause a lack of participation in meals with relatives or in meals with other/fellow patients.
However, for patients admitted to hospital, it can be difficult to decide whether mealtimes should be private or whether the meals should be shared with other fellow patients (Sidenvall, Fjellstrom, & Ek, 1996, Manthorpe & Watson 2003. Hence, conventions, habits and involvement of other people tend to form the basis of mastering eating situations in patients hospitalized with a neurological disease (Martinsen & Norlyk, 2012;Medin et al., 2011). Having conversations and socializing during mealtimes address some of the main issues regarding malnutrition among patients suffering from a neurological disease.
There is a growing interest in the patients' experiences of mealtimes in hospitals to improve the existing hospital mealtime situation.
Several studies have explored hospital mealtime experiences using various methods of collecting empirical data (Holst, Mortensen, Jacobsen, & Rasmussen, 2010;Lassen, Kruse, & Bjerrum, 2005;Naithani, Whelan, Thomas, Gulliford, & Morgan, 2008;Ottrey, Porter, Huggins, & Palermo, 2018). However, research on the neurological context of patients' experiences of hospital mealtimes is sparse. Moreover, existing research mainly focuses on patients' experiences with eating difficulties, whereas the practical element of the mealtime situation and its relational and aesthetic importance have not received similar attention. Life with eating difficulties is a complex phenomenon where the social dimension of mealtimes is particularly challenged; hence, patients suffering from neurological diseases experienced mealtimes as a disgusting, uncomfortable long-term experience that depended on help from others and causing them to feel embarrassment (Medin et al., 2011, Carlsson, Ehrenberg, & Ehnfors, 2004. In addition, altered physical and social appearance is related to difficulties preparing and transporting food to the mouth, as are swallowing deficits (Perry, & McLaren, 2004).
Moreover, studies have demonstrated that the long-term mealtime experiences of patients suffering from a neurological disease involve existential issues because the eating disability causes them feelings of being abandoned and struggling with loss, which make them strive towards a normal life (Perry, Hamilton, Williams, & Jones, 2013, Carlsson, Ehrenberg, & Ehnfors, 2004

| PURP OS E
To explore how the phenomenon of mealtimes is meaningful to hospitalized patients with a neurological disease.

| ME THOD
This study is a qualitative study that gives in-depth and comprehensive analysis of the phenomenon of hospital mealtimes based on data from earlier studies Beck et al., 2016;. This study has a phenomenological-hermeneutic approach inspired by the French philosopher Ricouer (1973Ricouer ( , 1979Ricouer ( , 1984. According to Ricouer, analysis and interpretation can be considered as an endless hermeneutic spiral, providing new insight into a phenomenon (1984). Thus, this study offers an in-depth analysis and contributes to a comprehensive understanding of the phenomenon of hospital mealtimes and thus adds to the existing findings focused on patients' experiences of hospital meals. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong, Sainsbury, & Craig, 2007).

| Participants
A total of 23 inpatients with a neurological disease participated in interviews regarding their experiences of hospital mealtimes . The participants were introduced to the aim of the study when they were approached face-to-face by the first author (MB). All of the invited patients accepted to participate. The number of participants was considered to give insight and a "richly textured understanding" of how patients assign meaning to the mealtime activity before and after an intervention changing mealtime settings (Kvale & Brinkmann, 2009). The participants had different neurological diagnoses including migraine, Guillain-Barre syndrome, stroke and multiple sclerosis. Some patients were totally dependent on caregivers, while others varied between needing full assistance during meals and being able to eat by themselves. The participants varied in age, diagnoses, days of admission and eating disabilities.
The participants were selected based on an assumption of being most likely to contribute to the conversation with information-rich data. Patients with severe cognitive deficits, expressive aphasia and dementia were excluded. Further characteristics of participants are illustrated in Table 1.

| Data collection
According to Ricoeur, the possibility of analysis and interpretation is endless (Ricouer, 1979). This paper offers an in-depth analysis and comprehensive understanding of the primary data investigating the phenomenon of mealtimes in a Danish neurological department in 2015. The data material consisted of large amounts of transcriptions, and the previous analysis reported in  a&b) was far from exhaustive. Therefore, the authors returned to the material to get new insights. To achieve a nuanced understanding of patients' experiences of meals in a neurological department, participants were interviewed individually (Brinkmann, 2013;Kvale & Brinkmann, 2009).
The interviewer (MB) is experienced in interviewing; however, a semi-structured interview guide was used to ensure that the relevant questions related to the phenomenon were posed (Kvale & Brinkmann, 2009). The interviewer memorized the interview guide and strived to make the interview seem like a conversation.
The interviews started with an open question such as, "Tell me a little about yourself. What is your story in relation to this place (the hospital)?" Attention and responsiveness to the patients were expressed by asking relevant follow-up questions to allow the patients to elaborate on all of the dimensions to their stories (Fog, 2007). The interviews were conducted at the hospital department in a suitable room and lasted between 45-60 min. The interviews were recorded, listened to and transcribed afterwards.

| Ethical considerations
Written and verbal information about the study was given to all participants, and informed consent was obtained. Participants were informed that their names and other personal information would be anonymized to maintain confidentiality. They were reminded that they could withdraw from the study at any time without any consequences for their treatment and care in the department. This study was approved by the Danish Data Protection Agency and performed

| Analysis and interpretation
Data analysis and interpretation were inspired by Ricoeur (,1973, 1979), and the aim was to obtain new knowledge about the phenomenon of hospital meals based on patient's experiences when hospitalized with a neurological disease. Three methodological phases were used during the analysis and interpretation. The data are presented more systematically in the paper than it was actually performed, due to the dialectical movement (Ricouer, 1979).
The analysis was based on a naïve reading (phase 1), where the text was read and reread to gain an intuitive understanding of the material. Through the structural analysis (phase 2), the text was structured into meaningful units. Thus, it became possible to visibly identify what the text was about and central themes.
A rich description of the meaning units was considered crucial as they included important arguments for validating the impression derived from the naïve reading and a credible way to start interpretation of data. During the comprehensive understanding and discussion (phase 3), theoretical perspectives and relevant empirical research were included to give new insights and interpretation of the data.

| Naïve reading
The naïve reading phase provided the overall impression that hospitalization increased the significance of mealtimes to patients.
Being hospitalized with a neurological disease was an existential experience in patients' everyday lives that they found difficult to embrace. Mealtimes represented a familiar and recognizable activity. The naïve reading indicated that comfort and well-being were embedded in the mealtime activity. Comfort and well-being were, however, dependent on how the way healthcare professionals managed the high-paced environment and workload during mealtimes.

| A lonely ride together with others
Patients described how the neurological disease was a life-changing event and followed by many negative thoughts and feelings. Some of the aspects of living a life with a neurological disease were described like this: To me, the disease meant that I had a swelling in the brain, which meant that I could not speak or remember some words. I have been sad, because I am afraid.
You get a bit frightened and you are snapped out of it. This means that you do not want to see anyone because they should not see how I have looked (P18).
Existential issues in particular were embedded in the mealtime activity because eating in the hospital was described as a lonely ride.

| Letting the chaotic setting fade into the background
The mealtime setting was described as a fast-paced environment; some patients compared the eating environment to a railway station. Patients also elaborated on how mealtimes could be experienced as dedicated activities with only one purpose: nurturing.
However, patients explained how they often experienced being disturbed while eating, which is a complete contrast to the main aim of the meal. During the interviews, it was noted that peace and quiet was difficult to achieve during mealtimes. However, when peace and quiet was achieved, it revitalized the patients' actions related to the meal. For example, the patients made their bed and cleaned up their room and-in this way-prepared themselves for the meal.

| Mechanical activity with great personal significance
Well-being was based on many sensory impressions experienced in the hospital by patients. Therefore, the impressions from the

| Humanizing the setting when eating in the hospital
In addition to the importance of having a relationship with fellow patients, conversations with staff during mealtimes were perceived as key activity to generate a positive experience. The conversations could be rather simple and had a common polite nature, such as talking about how many kids the staff members had or what they would do after their shift was over. However, despite the superficial nature of these conversations, they became important elements to make the mealtime activity a pleasant experience for patients because they acknowledged the patients' need to get to know the staff. Getting to know caregivers as people and not just as professionals was comforting to patients because it influenced their feelings of safety during their hospitalization.
Furthermore, it was identified that the information that staff shared with their patients helped to make the relation between patients and staff equal, as the "white coat" serving the meal to the patients became personalized. The mealtime was an activity where the relationship between the patients and staff members could be strengthened (or weakened) depending on the interaction during mealtimes. A man elaborates: I have been here for a long time and I know the first name of most of them (the nurses). Well, it is nice just to feel like you are a part of them. Then, they come by, say "hello" and so on and you get to know people across the shifts (P12).
Getting closer to staff through the meal activities meant that patients felt more like humans in their "role" as patients. In this way, the purpose of the meal was changed. The activity was no longer about nutrition but rather about human nourishment because the mealtime became an existential experience of life with a neurological disease.
The mealtime was identified as a way to legitimize the patients' needs to be vulnerable because the patients, especially during the mealtime activity, were more receptive to the support and care they received while eating, establishing an uplifting and comforting experience. A patient illustrates this feeling by saying: The meal to me can be very relaxed. Mealtimes is like a moment in everything-even for those sitting and feeding you. They can also sit, relax, talk a little and get to know the patients. It is such a good way to get in touch and create a relationship. You also need to have that relationship with them (the nurses?). Now I know all the names of the nurses and their children.
When they just sit and have a chat with you, it becomes a matter of not only being fed, but also a matter of having a positive experience (P5).

| Comprehensive understanding and discussion
Based on the findings of this study, it can be argued that mealtimes form the basis for creating a community among humans and deinstitutionalize the mealtime activity. Studies exploring in the meaning of the phenomenon of mealtimes in people's everyday lives identify mealtimes as important social events with family and friends and as an essential part of human social life (Holm & Kristensen, 2012).
From the beginning of life, food has been associated with relationships with others. Thus, eating habits are recognized as a part of our identity and role in society (Holm & Kristensen, 2012). Our study illustrated how mealtimes had the potential to make the relationships between strangers more intimate. Although mealtimes were shared with other patients and not relatives, mealtimes created a community among patients, which countered the patients' feelings of mealtimes as being a "lonely ride." Our study showed that patients experienced a feeling of togetherness with others through the mealtime activity, which can be explained by the pause that the mealtime activity represented.

| Study limitations
We collected data in only one department at one hospital.
Nevertheless, it can be argued that our findings have some generalizability and transferability and may be relevant to other departments with patients suffering from comparable medical diseases.
Generalizability should be seen in relation to the typical features of the phenomenon that has been described by this phenomenological-hermeneutic study (Polit & Beck, 2010). This study may be strengthened by including healthcare staffs' perspectives on the mealtime phenomenon to shed light on the importance of the professionals' mealtime actions for hospitalized patients. Including patients with dysphagia, nasogastric feeding and PEG feeding may also strengthen the study since these groups of patients have severe eating disabilities. Their perspectives could unfold the phenomenon of mealtimes in new ways, hence adding further variation in relation to the recruitment of participants (Malterud, 2011).

| CON CLUS ION
The phenomenon of mealtimes was significant to hospitalized patients with a neurological disease because mealtimes supported patients existentially during hospitalization with a neurological disease.
A peaceful eating hospital environment was identified as crucial.
Offering a calm mealtime setting allowed the patients to experience an asylum where supporting, uplifting and comforting feelings were raised. Patients were able to be attuned to their surroundings and to be in touch with their senses, which they considered meaningful and promoting well-being. Patients' mealtime experiences, however, depended on how the staff members orchestrated the activity and whether they included both a human and an aesthetic approach when serving meals to the patients. This meant that patients strived for a more personal and equal relationship with the healthcare professionals to ensure a positive experience during their hospitalization.

| RELE VAN CE TO CLINI C AL PR AC TI CE
This study highlights that patients are existentially challenged during mealtimes in hospitals. Patients suffering from a neurological disease assign great importance to their surroundings during mealtimes and experience calm and appealing environments as an existential way to support life with a neurological disease. When building new hospitals or renovating existing, it is important to consider patient-centred mealtime areas as environments that make existential care possible. Additionally, healthcare professionals need to consider that a mealtime means much more than food on the plate to patients and that it in fact is an important aspect of their care.

ACK N OWLED G EM ENTS
We would like to acknowledge the patients and the caregivers, who participated generously and positively to support this study.

E TH I C A L A PPROVA L
The study was approved by the Danish Data Supervisory Committee by Region Zeeland (REG-16-2013).

CO N FLI C T O F I NTE R E S T
None declared.