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Maturitas 97 (2017) 613

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Maturitas
journal homepage: www.elsevier.com/locate/maturitas

I dont eat when Im sick: Older peoples food and mealtime


experiences in hospital
Kelti Hope a , Maree Ferguson b,c , Dianne P. Reidlinger d , Ekta Agarwal a,b,d,e,
a
School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Australia
b
Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Australia
c
School of Human Movement Studies, The University of Queensland, Brisbane, Australia
d
Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
e
Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Inadequate dietary intake is a common problem amongst older acute-care patients and
Received 12 July 2016 has been identied as an independent risk factor for in-hospital mortality. This study aimed to explore
Received in revised form 2 December 2016 whether food and mealtime experiences contribute to inadequate dietary intake in older people during
Accepted 9 December 2016
hospitalisation.
Methods: This was a qualitative phenomenological study, data for which were collected using semi-
Keywords:
structured interviews over a three-week period. During this time, 26 patients aged 65 years or more,
Malnutrition
admitted to medical and surgical wards in a tertiary acute-care hospital, were asked to participate if they
Food intake
Older
were observed to eat less than half of the meal offered at lunch. Participants provided their perspectives
Hospitals on food and mealtimes in hospital. Responses were recorded as hand-written notes, which were agreed
Qualitative research with the interviewee, and analysed thematically using the framework method.
Results: Twenty-ve older people were interviewed across six wards. Two main themes, validating cir-
cumstances and hospital systems, were identied. Each theme had several sub-themes. The sub-themes
within validating circumstances included expectations in hospital, prioritising medical treatment,
being inactive, and feeling down. Those within hospital systems were accommodating inconvenience,
inexible systems, and motivating encouragement.
Conclusion: Inadequate dietary intake by older hospital patients is complex and inuenced by a range
of barriers. Multilevel and multidisciplinary interventions based on a shared understanding of food and
nutrition as an important component of hospital care are essential to improve dietary intake and reduce
the risk of adverse clinical outcomes. Improving awareness of the importance of food for recovery amongst
hospitalised older people and healthcare staff is a priority.
2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction occupy at least 40% of hospital beds [35] making them signicant
users of healthcare services.
In 2010 an estimated 524 million people, or eight percent of Several multicentre studies have reported that malnutrition is
the worlds population, were aged 65 years or older [1]. By 2050 prevalent in 2360% of older patients admitted in acute care hospi-
this number is projected to triple to 1.5 billion equating to 16% tals, with an estimated 40% at nutritional risk [610]. Malnutrition
of the worlds population [1]. Increased longevity has been syn- is associated with poor clinical outcomes including prolonged
onymous with an increase in prevalence of chronic diseases and length of stay (LOS), frequent readmissions and increased risk of
multi-morbidities, and has resulted in a rapidly increasing demand mortality [6,11,12]. Although the aetiology of malnutrition in older
for health care services [2]. Reports indicate older adults currently acute care patients is complex and multifactorial [13,14], inad-
equate dietary intake during hospitalisation and post-discharge
can exacerbate malnutrition [6,15,16]. Despite published literature
indicating that patients are generally satised with the overall qual-
ity of food provided in hospitals [1719], inadequate food intake is
Corresponding author at: Faculty of Health Sciences and Medicine, Level 2,
frequently reported in the older hospital population [6,11,2022].
Building 18, Bond Institute of Health and Sport, Bond University, Qld 4229, Australia.
E-mail address: eagarwal@bond.edu.au (E. Agarwal). Poor dietary intake during hospitalisation has been independently

http://dx.doi.org/10.1016/j.maturitas.2016.12.001
0378-5122/ 2016 Elsevier Ireland Ltd. All rights reserved.
K. Hope et al. / Maturitas 97 (2017) 613 7

associated with increased morbidity [15,16], prolonged LOS [6,15], meal and dessert respectively). Patients consume their meals in
and increased risk of in-hospital mortality [11,16]. their rooms.
A large number of studies have evaluated barriers to food intake
during hospitalisation through objective measures such as patient 2.4. Participants
questionnaires [18,23,24] and review of patient characteristics
from medical charts [22,25]. Some studies have explored views Participants were purposively sampled from 12 medical and
of healthcare staff on the reasons for poor food intake in older surgical wards in the departments of orthopaedics, oncology, gas-
hospital patients [26,27]. Whilst these approaches are useful for trointestinal, internal medicine, respiratory diseases, and urology.
obtaining insight into reasons for poor intake from healthcare staff At the time of data collection, the hospital was in the process
and patients perspectives, qualitative methodologies are likely to of piloting assisted and protected mealtimes in some wards. The
provide a deeper insight into the patient experience to help iden- wards selected for recruitment were not part of the pilot project and
tify the reasons why older people may have a poor food intake in therefore considered suitable for the aim of the present research.
hospital [28]. Few qualitative studies have explored the patient Inclusion criteria were: (1) age 65 years; (2) observed food
perspective regarding food and mealtimes in hospital [17,29,30]. intake of fty per cent or less of food provided at a lunch meal;
These studies focussed on patients experiences with food access (3) LOS 2 days at the time of mealtime observation; and (4)
[17], nutritional issues [29], food sensory quality [30] and meal- provision of informed verbal consent. Participants with an LOS
time experiences [31] during hospitalisation. However, to the best of 2 days were selected to ensure that they were receiving
of our knowledge, perspectives regarding reasons for poor food meals that they had self-selected. Demographic data including age,
intake have not previously been sought from older people who weight, and days since admission, were collected from partici-
eat poorly during hospitalisation. Therefore, the aim of the current pants medical chart. Potential participants were identied by one
study was to explore the food and mealtime experiences and per- researcher (KH, a nal year nutrition and dietetics student). The
ceptions of hospitalised older people with poor food intake during researcher observed potential participants lunchtime meal trays
their admission. after the trays were collected by foodservice staff and assessed
intake compared to what was ordered as indicated in the meal
slip accompanying each food tray. Potential participants were then
2. Methods approached to participate in the interview if they met the inclu-
sion criteria. People were excluded from the study if they (1) were
2.1. Study design diagnosed with a terminal or critical illness or disordered eating;
(2) had cognitive impairment as recorded in the medical chart; (3)
A qualitative phenomenological study design was used in order were admitted in an intensive care/high dependency unit, rehabil-
to gain insight into the lived mealtime experiences and perspec- itation, long-stay or sub-acute wards; (4) were receiving clear/full
tives of older hospital patients. Semi-structured interviews using uid diets, only enteral/parental nutrition, texture modied diets
open-ended questions were undertaken with hospitalised older and/or thickened uids; or (5) were nil-by-mouth.
people, to understand their mealtime experiences and to explore None of the researchers were directly involved with providing
the reasons for poor dietary intake during their hospital admission. nutritional care to the hospital patients. One of the researchers (MF)
Interviews were chosen as the most appropriate method to answer was employed at the hospital at the time of data collection, in a
the research question, which was concerned with the experience non-clinical role. The researcher conducting the interviews did not
and perceptions of food and mealtimes by individuals in hospital, offer any nutritional advice but instead referred participants to the
and as the most practical method for data collection at the hospi- ward dietitian (not involved in the study) for nutritional support if
tal bedside. Rigour in the design and reporting of the study is based required.
on the RATS framework (Relevance of study question, Appropriate-
ness of qualitative method, Transparency of procedures, Soundness 2.5. Data collection
of interpretive approach) [32].
An initial interview guide was developed based on relevant liter-
2.2. Setting ature [17,18,22,23,29,30]; and drawing on the clinical knowledge
and experiences of three researchers (KH: student dietitian; EA,
This study was conducted in a 750-bed metropolitan tertiary MF: Accredited Practising Dietitians). Several drafts were produced
teaching acute care hospital located in Brisbane, Australia. and discussed until the researchers were satised with the con-
tent and phrasing of the questions and prompts posed. The initial
interview guide was used in three pilot interviews with patients
2.3. Hospital food service who did not meet the criteria for inclusion in the study, result-
ing in minor changes to the wording of questions in order to elicit
The hospital predominantly uses a cook-chill plated delivery the most relevant responses from participants. After the rst two
system with some items prepared fresh (such as poached eggs, interviews were conducted, it was noted that both participants had
sandwiches and salads). Breakfast, lunch and dinner are served referred to the lack of concern about food intake by nursing staff,
by foodservice staff commencing at 7 a.m., 11:45 a.m., and 5p.m. so an additional question was added to the nal interview schedule
respectively. Patients on diet codes requiring specied mid-meals (Appendix A).
are delivered by nutrition assistants in the morning and afternoon Each interview lasted approximately 30 min and was completed
and by foodservice staff for supper. Each morning patients order at the participants bedside. The researcher (KH) introduced her-
their dinner for that evening, along with breakfast and lunch for self as a research student, explained the study and obtained verbal
the following day. Depending on the ward, patients can either order consent from the participants. Questions were then posed using
their meals by making selections on a paper menu order form, or open ended language and, in line with the semi-structured nature
verbally with a nutrition assistant using an electronic menu order- of the interviews, varied in the actual phrasing and order of ques-
ing program. Patients admitted after the morning menu rounds tions posed with each participant. Responses were recorded using
receive default meals suitable to their diet code (e.g. default lunch hand written notes, rather than with an audio recording device,
and dinner meals for full diet are sandwiches and dessert, and hot in an effort to overcome the practicalities of the ward environment
8 K. Hope et al. / Maturitas 97 (2017) 613

which had a lot of background noise and was not conducive to clear Table 1
Characteristics of participants (N = 25).
audio recording. Participants provided consent for their answers
to be recorded in condensed form. The response for each ques- Patient characteristics Results
tion was written down by the interviewer as the participant spoke, Females/Males 21 /4
and claried before moving on to the next question. Attempts were Age in years (range) 6598
made to record the specic expressions, words and phrases used Days since admission (range) 220
by the participant in their response to questions. The written notes Diet Type
High Protein- High Energy/Standard 16 /9
for each question were repeated back to the participant to ensure
Ward type
joint agreement on the specic statements attributed to them. Internal Medicine 6
Interviews were conducted over a three-week period after which Orthopaedic 6
data collection ceased, due to time and resource constraints of the Gastrointestinal (medical and surgery) 8
Respiratory 3
research team.
Oncology/Haematology 2
Urology/Vascular 2
2.6. Data analyses

At the conclusion of each day of data collection, interview that poor food intake might be normal and not as high a priority as
responses from the hand-written notes were typed and de- the medical treatment. Four sub themes were relevant: expecta-
identied (using pseudonyms where necessary), and converted to tions in hospital, prioritising medical treatment, being inactive
electronic format to facilitate immersion in the data and initial and feeling low.
coding. The hand written notes were analysed thematically using
the framework method [33]. An initial coding framework matrix 3.1.1. Expectations in hospital
was developed by one researcher (KH), who then coded partic- Participants believed that their poor appetite and intake whilst
ipants responses line by line using the coding framework, with in hospital was to be expected given the circumstances. Many
additional codes added to the framework where the data did not felt that their appetite would get back to normal when they went
otherwise t within the framework. Codes for several days inter- home. They described various reasons for not eating well, including
views were reviewed and discussed periodically by other members being sick and their admission to hospital in the rst place.
of the research team (EA, MF). Patterns identied through the cod-
ing process were collated in a spreadsheet using a matrix of codes I dont eat when Im sick. I dont think many people do when theyre
and participants to enable a comparison between interviews and not feeling well. (Female, 83 years)
also within interviews. Interim sub themes and themes were devel-
Similarly, medications and treatment were blamed for reducing
oped by one researcher (KH) that represented the experiences and
appetite and subsequent intake. Participants described experienc-
perceptions of participants in relation to the research question;
ing nausea, gastrointestinal pain, reux, stomatitis, diarrhoea and
these were reviewed, and discussed between three researchers.
constipation, (viewed as nutrition impact symptoms (NIS) by the
Finally, an electronic and paper based audit of the coding in the
researchers) while in hospital.
matrix spreadsheet was undertaken by a fourth researcher (DR:
Accredited Practising Dietitian), and the themes and sub-themes Ive got a lot of nausea. The smell of food makes me feel nauseous.
were revised. Attempts were made to ensure that divergent views I constantly feel nausea. I feel like I want to vomit all the time, but
and experiences were represented within the themes. Further dis- dont. (Female, 79 years)
cussions between all four researchers resulted in renement of
However, despite meeting the inclusion criteria of poor intake,
themes until a consensus was reached. Representative quotes were
appetite was seen as relative for some including one participant
selected and agreed for each theme and sub-theme; quotes were
who described hers as good after fasting for procedures.
selected to capture the key perspectives of participants within the
theme and to capture divergent views between participants within
3.1.2. Prioritising medical treatment
the same theme.
Participants believed food was not a priority during hospitali-
2.7. Ethics approval sation instead prioritised medical treatments which they believed
were more important than food
The study was approved by the Metro South Human Research I dont know about the food, but I know the treatment theyre
Ethics Committee and the Queensland University of Technology giving me is helping me. I have an infection and theyre giving me
Human Research Ethics Committee. Verbal informed consent was medicine to make it better. I dont think food has anything to do
obtained from each participant before commencing the interview. with it. (Male, 75 years).
However, this was not universal and others also strongly
3. Results
expressed their view that it was important to eat all food provided
and saw food as part of the treatment in hospital.
Twenty-ve of the 26 patients approached to participate in
the study provided consent. Table 1 outlines demographic char- Yes, food is important to help you get better in hospital. It feeds
acteristics of participants. There were two main themes developed you, makes you stronger. (Female, 69 years).
during the analysis, Validating circumstances and Hospital sys-
tems. Each had several sub-themes, relating to the perspectives 3.1.3. Being inactive
and experiences of older people which may contribute to their poor The hospital environment was seen by participants as one where
food intake in hospital. their activity was limited and didnt reect normal day-to-day
activities. Many described activity only as it related to hospital
3.1. Validating circumstances treatment, such as physiotherapy sessions.

This theme captured participants rationalising of their poor More exercise would help to improve my appetite. Once Im
food intake during their admission. The prevalent perception was unattached to so many tubes. (Female, 80 years)
K. Hope et al. / Maturitas 97 (2017) 613 9

If you did walk around the wards, it would be better as far as 3.2.2. Inexible systems
the bowels are concerned . . . constipation is a bit of a problem. Some participants perceived that the inexibility of the food
(Female, 85 years) service and wider systems within the wards had impacted on their
ability to eat. These included advance ordering of meals only to nd
Many participants saw lack of activity as validating their poor
it was not what they wanted when it arrived; feeling pressured to
intake and contributing to other issues impacting their appetite
order food they did not want; large meal size; meal timings and
such as constipation. Conversely, some denied any connection with
menu options not to their preference.
appetite.
They ask me what I want, this or that. I feel I have to say yes to
I do go for a walk with Richard [physio], hes a lovely fellow to go
some things to satisfy them. But the only thing I want to eat is the
walking with. I go once a day. Im not feeling an improved appetite
jelly. Sometimes I might try one sandwich . . . only if I feel like it. But
from this. (Female, 80 years)
the rest will go. The rest of the tray will get taken away. (Female,
65 years)
3.1.4. Feeling down
Participants described feeling depressed as a result of their Some of the food is nice, but its far too much . . . Just looking at
condition and being in hospital, and described the impact this had this [menu order form] puts me off the food. Reduces my appetite.
on their food intake (Female, 83 years).

Im quite depressed at the moment. When you get like that you If I did have a hot meal here, by the time I got halfway through, it
dont feel like eating much. (Male, 69 years) would be cold. (Female, 83 years).

Whilst many did not elaborate, others talked about missing What I wouldnt mind would be a bit of bread. Some bread and
home cooking and not seeing friends and family as contributing butter is something I would be enjoying. (Female, 80 years)
to their low mood.
3.2.3. Motivating encouragement
Im so used to my home cooking, not used to all this packaged and
Participants described being encouraged to eat by family
processed food they serve here. Prefer the fresh food. (Female, 80
members and visitors who provided assistance and verbal encour-
years)
agement, which motivated them to improve their food intake.

3.2. Hospital systems I only ate most of the dinner last night because my daughter was
here and she told me to eat it- it will build up your strength- or
This theme captured the view that practices in hospital resulted something. She cut up the meat for me in small pieces, it was good.
in participants poor food intake. Three sub-themes were relevant: She said I want to see that plate nice and clean. It helped having
accommodating inconvenience, inexible systems and motivat- my daughter there encouraging me to eat. (Female, 85 years).
ing encouragement. Some also noted that visitors frequently bought in food includ-
ing fruit and hamburgers that were described as more appetising,
3.2.1. Accommodating inconvenience and noted this as a motivator to eat more than they otherwise might
Participants described how they felt obliged to accommodate have. However, the attitude of nursing staff was also seen as impact-
inconveniences due to being in hospital. This included the hospi- ing on their motivation to eat. Several participants expressed that
tal environment in general being not conducive to eating, and the nurses did not seem concerned if all the food was not consumed,
affecting appetite and intake. They talked of mealtime interrup- and did not monitor how much food they had eaten, thus reducing
tions, from both doctors and nurses which they took as part of the the perceived importance of food intake.
environment, and did not feel able to challenge.
The nurses dont even see the plate. The tray gets taken away and
Sometimes of an evening they [the meals] sort of come just as the the nurses dont know what youve eaten. They dont care if I dont
nurses want to do something. Some of the nurses are good and will eat the food. (Female, 92 years).
wait until youve nished. But some of the nurses . . . once they put
Although encouragement was considered important by many,
a respirator mask on me while my soup was sitting there. I couldnt
some participants also expressed that it was unlikely to change
eat it. It was cold by the time I got to it. (Female, 78 years)
their intake regardless either because they were used to not eat-
Many described not wanting to eat quickly because of their ing much food at home anyway or did not like the taste of the food
illness symptoms such as not wanting to vomit so I go slowly. provided. Participants believed they were eating plenty of food
However, the schedule of mealtimes meant they felt rushed; felt and enough to meet their nutritional requirements which did not
the need to help the staff that collected the trays or worried that motivate them to eat more. A number of participants only ordered
they would still have the previous meals tray when the next meal the amount of food they felt they were able to consume, mainly to
was delivered. avoid wasting food.

I felt a little rushed today to get the dessert nished before the I also have this terrible problem with waste. I hate waste. Part of
guy came to collect the tray. If the tray is left if causes all sorts of that plays on my brain a bit when I do leave the food. I think how
problems. . .. (Female, 67 years) terrible, with all the people starving around the world. But even
that doesnt encourage me to eat all the food. (Female, 65 years).
Participants also reported practicalities of the environment that
they felt obliged to compensate for, including their concern they
would be unable to access the toilet in time and the anxiety that 4. Discussion
ensued, resulting in reduced food intake.
This study found that older people saw the reasons for their
Eating makes me get diarrhoea. I get worried. There are four beds poor intake in hospital as due to their current circumstances,
and only one toilet. I worry I cant use the toilet if someone is using and described experiences which highlighted a mismatch between
it. Also, I cant walk quickly . . . might not get to the toilet in time. the hospital patients needs and inexible hospital systems. Being
(Female, 65 years) unwell, and the hospital admission itself, were seen as legiti-
10 K. Hope et al. / Maturitas 97 (2017) 613

mate reasons for not eating well and also impacted on activity of appetite or not hungry was also reported as the main reason
levels and feeling down. Older people described an obligation to for reduced intake by hospital patients [11,16,18,22]. A number of
accommodate the inconvenience associated with the systems and interventions may be appropriate for addressing poor appetite in
inexibility of the hospital environment, which affected their eat- older hospital patients. Food fortication has shown to increase
ing. They described the positive effect of encouragement by family energy and protein intake by up to 25% with a reduced portion size
and visitors which improved their food intake. of meal [51] and may be suitable for older people whose appetite
The current study highlighted that older peoples food intake is affected by large portion sizes. A pilot study examining the effec-
was inuenced by their own understanding that poor appetite was tiveness of medical nutrition therapy in acute care patients eating
an expected outcome of being in hospital. Older people were also poorly during hospitalisation found that simple strategies such as
of the opinion that dietary interventions were less valuable than allowing patients the opportunity to self-select meals off the menu
medical treatment, and therefore did not perceive eating poorly resulted in signicantly improved intake, thereby not requiring
as a problem. It has been proposed that hospitalised older people further nutritional interventions [52]. Selective mid-meal trolleys
characteristically have overly positive self-perception and affect containing a variety of high energy and/or high protein snacks and
optimisation, and limited knowledge or insight regarding nutri- commercial drinks have demonstrated increased nutritional intake,
tional requirements [34,35]. Given the body of evidence linking improved dietary satisfaction and greater self-reported quality
nutritional adequacy with improved patient outcomes [36,37], it of life [53,54]. Considering that approximately half the hospital
is imperative for all healthcare professionals to improve older patients are not offered snacks in-between meals [6], the oppor-
peoples knowledge and awareness regarding the importance of tunity to self-select nutritious snacks spontaneously at the point of
nutrition during hospitalisation. Bell et al. found that a multi- consumption may result in signicant improvement in nutritional
disciplinary and multimodal model of nutrition care resulted in intake in older hospital patients.
signicant improvements in nutrition-related outcomes in older We believe this to be the rst qualitative study where older
people with hip fractures [38]. The model of nutrition care included people with poor food intake had the opportunity to provide their
strategies such as physicians promoting nutrition as medicine, perspectives of barriers to adequate food intake during hospitali-
enhanced food service system and promoting nutrition-related sation. One limitation of this study is the exclusion of patients with
knowledge and awareness amongst staff and patients themselves cognitive impairment and those on texture modied diets, who
[38]. This nding indicates that similar interventions should be are well documented to have some of the poorest food intake lev-
trialled in other older inpatient populations. els of acute care hospital patients [6,55,56]. These patients may
Existing literature recognises that loneliness and isolation con- have had additional perspectives of mealtime experiences in hos-
tribute towards depression in some acute patients, especially those pital, in addition to those identied by this study. Finally, all four
in the side rooms of wards [31]. Depression has been associated researchers were from the discipline of dietetics (including one stu-
with causing loss of appetite, reduced food intake, and uninten- dent dietitian and three Accredited Practising Dietitians), which is
tional weight loss in older persons [14]. Participants in this study likely to have impacted on study design, data collection and data
acknowledged that encouragement from visitors at mealtimes analysis decisions. Additional rigour could have been achieved by
resulted in improved consumption of food. Visits from family mem- the inclusion of a researcher from a different professional back-
bers and friends should be encouraged during mealtimes to provide ground, for example nursing. Despite this, the results are still
older people the opportunity to socialise and receive companion- applicable to the practice of dietitians and other health profession-
ship, have a home-like environment, and potentially also receive als, and the themes developed have highlighted several barriers to
assistance and encouragement with food. food and nutrition in hospital which may be useful for improving
An interesting nding from this study was that older people food intake for older people in hospital.
reportedly reduced their food intake to limit their visits to the toi-
let. There is evidence to suggest that hospital patients often reduce
5. Conclusion
their uid intake to avoid using the bedpan due to the associated
loss of privacy and dignity [39]. It is possible that this perceived
The current study demonstrates the complexity of inadequate
loss of privacy and dignity also impacts patients desire to consume
intake for older patients in the acute care setting. Both, patient- and
adequate quantities of food. To the best of our knowledge, this is the
organisation-related barriers contributed to reduced food intake.
rst study to identify older peoples anxiety regarding toilet visits
Therefore, the design and implementation of multilevel interven-
inuencing the quantity of food they consume during hospitalisa-
tions that improve food intake is crucial. Barriers to food intake
tion. Further investigation into this issue as a potential barrier to
and older patients perceptions should be routinely evaluated as
food intake is warranted.
malnutrition and poor food intake are common in this population
Another striking nding from this study was that meal trays
[6] and not without adverse consequences [11,16]. Food awareness
were reportedly cleared before participants had nished consum-
needs to be improved as a matter of priority in all stakeholders,
ing all the food they wanted to eat. Observational studies show that
including older patients themselves and healthcare providers [57].
on average, older patients can take approximately 20 min to con-
Implementation studies that inuence the current nutrition culture
sume a meal, with some patients taking 5575 min [40,41]. It is
are required to showcase not only the process of implementation
likely that older hospital patients are hesitant to request nursing
but also the benets older hospital patients stand to gain from them.
staff for assistance and thereby take longer to self-feed. Further,
medication rounds, showering time, reviews by doctors and allied
health staff members, diagnostic tests and procedures, have also Contributors
been recognised as interrupting patients at meal times [6,4246].
Protected mealtimes allow for patients and staff members on the KH contributed to the study design, collected, analysed and
wards to concentrate only on activities related to food consump- interpreted the data, and contributed to the manuscript revision.
tion, and although challenging to implement in a busy hospital MF contributed to the study design, reviewed the quantitative
ward environment [47,48] evaluations of this strategy appear to and qualitative data analyses, and contributed to the manuscript
be promising [49,50]. revision.
Poor appetite was a commonly reported reason for not consum- DPR analysed and interpreted the data, and contributed to the
ing all the offered food and supports existing literature where a loss manuscript revision.
K. Hope et al. / Maturitas 97 (2017) 613 11

EA conceptualised the study, contributed to the study design, Funding


compiled the ethics applications, reviewed the quantitative and
qualitative data analyses, reviewed the quantitative and qualitative This research did not receive any specic grant from funding
data analyses, and compiled the original manuscript. agencies in the public, commercial, or not-for-prot sectors.
All authors approved the nal manuscript.
Ethical approval
Conict of interest
The study was approved by the Metro South Human Research
The authors declare that they have no conict of interest. Ethics Committee and the Queensland University of Technology
Human Research Ethics Committee. Verbal informed consent was
obtained from each participant before commencing the interview.

Provenance and peer review

This article has undergone peer review.

Appendix A. Semi-structured interview questions.

Appetite Please describe your current appetite.


Has there been a change in appetite since being in hospital? Similar or different to at home/usual? Why do you think this is?

% Intake How much of the last meal served (lunch) did you eat? None, 25, 50, 75 or 100%.
Has this changed over the past couple of days? increased/decreased.
How does this compare to how much you usually eat at home? eating more, the same or less. Why do you think this is?

Reasons for not eating Why did you not eat all your meal today?
all the offered meal Explain the reasons why you didnt eat all the food provided to you today.
Tell me what things have stopped you from eating more of your meal today.
What happened? How did you feel? Is this usual for you?

Missed meal Have you ever missed a meal during your stay in hospital? If yes, why- procedure, asleep, no assistance available, meal placed out
of reach?
If you missed a meal, were you offered any food later? Did you ask for food? If not, why didnt you ask for any food?

Menu choice available Do you like the range of food offered for meals?
What have you liked, what havent you liked?
Do you get to choose the types of foods you like to eat?
What wouldve you preferred to have received?
Does the food in hospital differ to what you normally eat? If so, how?
What types of food would you like to eat in hospital if you had the choice?
What types of food do you like to eat when you are not feeling well?

Size of meal offered How would you describe the quantity of the meals? Too big, too small, just right.
Would you prefer a smaller serve of your meal? If so, which items would you like less of?
Would you prefer a larger serve of your meal? If so, which items would you like more of?

Problems with Do you like how and when you order your meals in hospital? If not, how, and when would you prefer to order your meals in
ordering food hospital?
Have you ever experienced any problems with ordering your food? Not receiving what youve ordered.
When your meals arrive, do you ever not want what youve ordered? Or wish that you had ordered something different?
Does your appetite change between ordering a meal and receiving the meal?

Visitors Do you have visitors in hospital?


Do visitors bring you food in hospital? What have they brought? Why?
Do your visitors come during meal times?
Do your visitors encourage you to eat at meal times?

Assistance with meals Do you require assistance eating your meal? If so, what type of assistance do you require help with reaching, cutting food?
Have you ever been asked if you would like assistance with eating your meal?
If not, do you ever ask the nurse for assistance with eating your meal? If not, why not?

Timing of Meals Are the meal times suitable for you? Would you prefer food to be delivered earlier or later?
Do you have enough time to eat your meal?

Hunger during hospital Have you ever felt hungry during your stay in hospital? If yes, when did you feel hungry between breakfast and lunch, between
stay lunch and dinner, overnight, before breakfast?
When you do feel hungry, is there any food available for you to eat? If not, do you ask the nurses for food? If not, why?
Do you feel comfortable asking for food? If not, why?

Access to food Would you like to have access to extra food items between meals?
What extra food items would you like to have access to? When would you like to have access to these food items?
12 K. Hope et al. / Maturitas 97 (2017) 613

Meal interruptions Do you have enough time to eat all your meal? If not, why?
Have you ever been interrupted during meal times? If yes, how noise, clearing trays, other patients, procedures?
Did the interruption affect how much of your meal you ate? If so, how?
If there were no interruptions, do you think you would eat more food?

Nutrition Impact Do you experience any bloating, nausea, abdominal pain? Does this affect how much you eat? If so, how? How often does this
Symptoms happen?
Do you have difculties with chewing or swallowing your food? If so, have you told the staff about your difculties? If not, why
not? If so, what have the staff done to help you?

Importance of Food in Do you think it is important to try and eat most of the food provided to you in hospital?
Hospital Do you try to eat even if you dont feel like it?
Do you think food plays a role in helping you get better? If so, how?
Tell me your thoughts about the role of food in hospital.

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