Nutrition & Dietetics 2008; 65: 222–228 DOI: 10.1111/j.1747-0080.2008.00249.

ORIGINAL RESEARCH

Is there adequate feeding assistance for the

hospitalised elderly who are unable to feed
themselves?
Mei F. TSANG
Food Service Department, Royal North Shore Hospital, Sydney, New South Wales, Australia

Abstract
Objective: To observe patients at meal times in order to determine the type and amount of feeding assistance
required by hospitalised elderly patients and the adequacy of assistance nursing staff provide to patients.
Methods: The study was an observational study. Patients admitted to the ward were observed over a one-week
period encompassing all meals (breakfast, lunch, dinner and snacks) served on a 14-day menu cycle.
Subjects: A total of 46 hospitalised elderly patients with mean age 86.5 ⫾ 4.8 years admitted to the ward.
Setting: The study was undertaken in a general teaching hospital geriatric ward in Sydney.
Results: A high percentage of patients required some assistance with feeding at meals (70%, n = 32). The partially
dependent patients had their needs basically fulfilled by ward staff. However, of the nine totally dependent patients,
three were observed lacking any assistance (33%). The amount of assistance time from nursing staff was found
shorter than that from non-nursing staff, 123 and 137 minutes, respectively. Nursing assistants were the main
providers of assisted eating in the ward. However, little attention and time were given to that task by registered
nurses.
Discussion: Provision of assisted eating by nursing staff presents many problems. More than 40% of hospital food
was wasted and patients’ recommended intakes for preserving health were not met. Hospital feeding policies and
staff arrangements therefore need reviewing.
Conclusions: Although assisting patients who are unable to feed themselves is a time-consuming process, it is a
vital and necessary part of nursing care.

Key words: aged, food intake, hospitalised, nutrition, nutritional status, malnutrition.

INTRODUCTION One possible reason for malnutrition in

Nutritional deficits in hospitalised
elderly patients
Poor nutritional intake and undernourishment has been
documented in as many as 61% of hospitalised elderly
patients.1 A study completed in Concord Hospital, Sydney in
2002 showed that 30% of elderly patients were malnour-
ished and 42% were at risk of malnutrition.2 Other studies
also indicate that 42–56% of elderly patients maintain nutri-
ent intakes less than their basal metabolic rate while hospi-
talised.1,3 One report, ‘Hospital food as treatment’, found
energy and protein intakes among the elderly of between
30% and 75% of those recommended.4
M.F. Tsang, MND, Student Dietitian
Correspondence: M.F. Tsang, formerly, Food Service Department,
Royal North Shore Hospital, Pacific Hwy, St Leonards, NSW 2065,
Australia. Email: iristmf@hotmail.com
Accepted November 2007
hospitalised elderly patients
Several studies indicate that elderly patients are at particular
risk of malnutrition because of high food wastage.5,6 The lack
of attention paid to nutrition by health professionals has
exacerbated the problem.5,7 One important report, ‘Hungry
in Hospital 1997’, pointed out that even patients with good
appetites were not getting sufficient nourishment because of
inadequate eating assistance.7 The need for assisted eating
(assisted feeding) is defined as needing help from another
person to be able to eat.8 In the United States, the Healthcare
Financing Administration requires health professionals to
address feeding problems as part of nutrition care.9 Two
important measures, the Feeding Assistant Program 200310
and the Healthcare Financing Administration’s Minimum
Data Set—Version 2.0 (Nursing Home Resident Assessment
and Care Screening), were introduced to provide protocols
for nutrition care in elderly people.9 In recent years, in some
Australian hospitals, to free nurses for more specialised
duties and for economic reasons, the task of serving food has

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 Feeding elderly hospital patients

been allocated to nursing aides.5 Moreover, there are no The levels of feeding assistance required by patients at
universally accepted feeding protocols or nutrition screening meals were observed and classified into three types: total
tools in Australia.11 independence, partial dependence and total dependence.
For each patient included in the study, the amount and type
of food eaten were visually measured and recorded by a
Aims trained dietitian in quartiles (0, 25%, 50%, 75% or 100%) of
The aims of the present study are to: (i) observe patients at the amount served. It has been shown that the results
mealtimes in order to determine the amount of assistance obtained from visual estimation compare well with the
needed by each patient and the time taken to provide this weighed method (r = 0.89, P < 0.0001).12 All oral intake was
assistance; (ii) investigate whether patients receive enough recorded, including any food that was brought in for
eating assistance at mealtimes; and (iii) analyse the amount patients, and food charts were checked at least every
of food waste by observing how much food is left on the 12 hours. The adequacy of eating assistance provided was
patient’s tray. assessed by observing the following: (i) patients’ eating
behaviours; (ii) types of eating assistance required by the
patients and the percentage of patients receiving the feeding
METHODS assistance; (iii) the amount of time staff spent assisting the
patient to eat and who provided the assistance; (iv) the
The study was an observational study and it was carried out
number of caregivers providing assistance per meal; (v)
in a general teaching hospital in Sydney. The researcher was
the amount of time patients required to finish their meals;
granted permission from the hospital food service depart-
and (vi) tray access time and meal duration.
ment to visit the geriatric ward at mealtimes as a hospital
In addition, the medical charts were studied. The follow-
food quality improvement activity. Ethical approval to
ing data were collected on all patients in the study if
conduct this research was from Northern Sydney and
possible: (i) demographic data; (ii) anthropometric data.
Central Coast Health Human Research Ethics Committee,
including weight within the previous four months, height
Sydney.
and body mass index; and (iii) health history, such as
All patients admitted to the ward were considered for
medical diagnoses, length of hospital stay, medication and
inclusion in the study. A total of 67 patients was admitted to
physical capability.
the 25-bed geriatric ward in the research period. Of these, 21
patients were excluded because of: (i) receiving palliative
care; (ii) nil by mouth for more than three days; and (iii) Statistical analysis
tube feeding. This left a total of 46 patients (19 male and 27 The statistical methods used in the present study were means
female) admitted for periods ranging from three days to over and standard deviations.
seven days who were observed over a one-week period,
encompassing all meals (breakfast, lunch, dinner and RESULTS
snacks) served on a 14-day menu cycle. Demographic char-
acteristics of the patients are shown in Table 1. The levels of feeding assistance required
Fourteen patients required no assistance from staff at meal-
times. They were predominately younger than 75 years of
Table 1 Demographic characteristics of patients in the age and physically independent.
study Twenty-three patients required partial assistance at meals
and they had their needs basically fulfilled by ward staff. The
Number of patients
most common type of assistance provided to these patients
(n = 46)
was physical guidance.
Age (mean ⫾ standard 86.5 ⫾ 4.8 Nine patients required full assistance for eating at meal-
deviation) (years) times. Six of these patients received assistance ranging from
Gender tray set-up to total feeding. They were predominately over
Male 19 (41.3%) 80 years of age, female, on multiple drugs with long hospital
Ethnicity stay. Three of the nine patients did not receive any help from
European 42 (91.3%) caregivers with eating. Table 2 sets out the results.
Other 4 (8.7%) Eleven patients displayed different eating behaviours
Native language depending on time of day (Table 3), but are grouped accord-
English 41 (89.1%) ing to their most common behaviours.
Other language 5 (10.9%)
Average length of stay (days) 5.3
Physical capability Three main types of feeding behaviours
Total independence 16 (34.8%) presented at meals
Partial dependence 19 (41.3%)
The bed capacity of the ward was 25 patients. The average
Total dependence 11 (23.9%)
number of patients taking breakfast, lunch and dinner per

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M.F. Tsang

Table 2 The predominant levels of feeding assistance required by patients at meals and the degree of assistance received
Types of feeding Number of patients % of patients receiving the
behaviour Description (n = 46) required eating assistance
Total independence Patient requires no assistance from 30% (n = 14) 0% (n = 0)
nursing staff after receiving tray.
Partial dependence Self-feeding is demonstrated but requires help 50% (n = 23) 87% (n = 20)
with tasks.
This includes patients who try to eat
independently, patients who response to verbal
instruction and patients who need physical
guidance such as tray setup and positioning.
Total dependence An inability to self-feed was demonstrated. 20% (n = 9) 66.7% (n = 6)
Patient required intensive levels of physical
assistance and/or verbal guidance to be
able to eat.
Definitions of the three types of feeding: Ott F, Readman T, Backman C. Mealtimes of the institutionalised elderly: a quality of life issue.
CJOT 1991; 58: 7–16.

Table 3 Patients classified by actual levels of feeding assistance

Feeding behaviours
Total independence Partial dependence Total dependence
Number of patients (n = 46) 30% (n = 14) 50% (n = 23) 20% (n = 9)
Total independence for all three meals 21.4% (n = 10) 0 0
Both total independence and partial dependence for meals 8.6% (n = 4) 6.5% (n = 3) 0
Partial dependence for all three meals 0 39.1% (n = 18) 0
Both partial dependence and total dependence for meals 0 4.4% (n = 2) 4.4% (n = 2)
Total dependence for all three meals 0 0 15.6% (n = 7)

120% Figure 1 Three main types of feeding

behaviours presented at breakfast,
lunch and dinner.
Percentage of feeding behaviour

14% 10% 15%

90%

55%
60% 50%
59%

Total
Dependence
30%
Partial
Independence
27% 35% 35%
Total
Independence
0%
Breakfast Lunch Dinner

day was 22, 21 and 21, respectively. It should be noted that
admissions and discharges meant that patient numbers
varied daily. Figure 1 shows the percentage of patients dem-
onstrating the three main types of feeding behaviours at
breakfast, lunch and dinner times. Breakfast was the busiest
time in the day for staff as it had the lowest percentage of
totally independent patients compared with lunch and
dinner.
Lunch time was the least busy meal. At lunch time, there
were only 10% totally dependent patients and up to 35% of
the patients were totally independent in eating.
Although there was usually help from relatives, the
evening mealtime was very difficult as there was a smaller
number of nursing staff with a higher percentage of
totally dependent patients (15%). Table 4 shows that the
time needed for assisting totally dependent patients was

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 Feeding elderly hospital patients

Table 4 The amount of time provided for eating assistance per day by category of feeding behaviours (minutes)
TAT(a) Assistance time per Length of meal time taken
Feeding behaviours Breakfast Lunch Dinner Ratio(b) patient per meal by patient per meal
Total independence 0 0 0 0 0 18.2
Partial dependence 48 54 42 144 (69.7:74.3) 4 20.3
Total dependence 47 35 34 116 (53.3:62.7) 14.5 24.9
Total 95 89 76 260 (123:137)
(a)
Total amount of assistance time per day provided by nursing staff and non-nursing staff (minutes).
(b)
Ratio of the amount of assistance time from nursing staff to the amount of assistance time from non-nursing staff (minutes).

Figure 2 The amount of time staff 18

16.7
spent assisting each patient to eat at 15.7
mealtimes (min/patient/meal). Assistance time (min) 15

12
10.8

Total
6
4.5 independence
3.7 3.8 Partial
3 dependence

0 0 0 Total
dependence
0
Breakfast Lunch Dinner

nearly four times longer than for the partially dependent
patients.
The amount of time staff spent assisting
patients to eat at mealtimes
The average numbers of patients who were totally indepen-
dent, partially dependent and totally dependent at mealtimes
were 7, 12 and 3 per meal, respectively. Figure 2 shows the
average assistance time provided for patients in each of the
three behaviour types per meal.
number of these totally dependent patients did not receive
any assistance from nursing staff for eating. This caused the
high food wastage rate. Those with the lowest food wastage
were the totally independent patients (average 15.4%). All
three groups of patients had their lowest food wastage at
breakfast (average 33.1%).
DISCUSSION
The present findings suggest that inadequate eating assis-
tance is a significant problem for hospitalised elderly
patients.

Different groups of staff provided eating Responsibility for feeding in hospital

assistance in the ward
The amount of assistance time varied between different
groups of staff (Table 5). Nurse assistants (ANs) were the
main providers of eating assistance in the ward. They spent
a total of 85 minutes per day on eating assistance. A total of
123-minute assistance time was provided by nursing staff:
registered nurses (RNs), enrolled nurses (ENs) and trainee
enrolled nurses (TENs). The amount of time from RNs was
found to be the shortest across all three meals.
Food wastage
Totally dependent patients were found to have the highest
food wastage across the three meals (average 77.6%). A
In the study, 23 patients required partial assistance at meals
and their needs were basically fulfilled by ward staff. Nursing
staff mainly spent their time assisting partially dependent
patients, while paraprofessional staff, such as ANs, spent
more time feeding totally dependent patients. The amount of
time required for full eating assistance was 25 minutes in
contrast to partial eating assistance which was four minutes.
The larger the number of totally dependent patients, the
longer the amount of time required for eating assistance. As
the role of RNs in the ward is to assess, monitor and detect
patients’ medical illness, not surprisingly the amount of time
they spent feeding patients was found to be short across all
three meals. Among the nursing staff, ENs appropriately
spent the longest time per day assisting patients to eat,

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M.F. Tsang

Table 5 The amount of time staff provided for eating assistance

Assistance time (minutes/meal) Total assistance time
Group Ratio(a) Feeding behaviours Breakfast Lunch Dinner (minutes/day)
Registered nurse 1:4 Total dependence 1.7 5.3 7.1 14.1
Partial dependence 3.3 4.9 6.7 14.9
Total 5 10.2 13.8 29
Enrolled nurse 1:2 Total dependence 12.9 9 2 23.9
Partial dependence 15.6 12.7 3.9 32.1
Total 28.5 21.7 5.9 56
Trainee enrolled 1:1 Total dependence 10.1 1.1 4 15.3
nurse Partial dependence 11.6 2.9 8.3 22.7
Total 21.7 4 12.3 38
Nurse assistant 1:2 Total dependence 22 14.2 12.1 48.5
Partial dependence 14 15.7 6.5 36.5
Total 36 29.9 18.6 85
Relative 3:3.5 (lunch and Total dependence 0 5.4 7.7 13.1
dinner) Partial dependence 0 15 12.9 27.9
Total 0 20.4 20.6 41
Volunteer 1:1 Total dependence 0 0.4 0.7 1.1
Partial dependence 2.6 2.6 3.7 8.9
Total 2.6 3 4.4 10
Dietary aide Provided partial Total dependence 0 0 0 0
assistance occasionally Partial dependence 0.9 0.1 0 1
Total 0.9 0.1 0 1
(a)
Ratio of number of individuals involved in feeding to number of individuals on duty.

followed by TENs. However, assistance from TENs cannot be
relied on because they are not part of the permanent ward
workforce.
Non-nursing staff, such as ANs, played important roles in
eating assistance. They were the main ones assisting both
totally dependent and partially dependent patients in the
ward. However, ANs are not as skilled to deal with elderly
patients as RNs and ENs.5 Feeding elderly patients needs
training, experience and medical knowledge for the danger
signs.5 The best compromise would be for RNs to closely
supervise ANs.5
A significant amount of assistance was given by relatives
visiting patients at lunch and dinner times as they were well
aware that nursing staff did not have enough time to feed
patients properly and adequately. No assistance was given by
relatives at breakfast time because of restrictions on hospital
visiting hours. As a significant amount of assistance was given
by relatives at dinner time, the amount of assistance time from
ENs, TENs and ANs was significantly lower at those times.
Nursing staff regarded relatives as an important source of help
in eating assistance. Overall, it is suggested that the inconsis-
tency of responsibility for feeding in hospital contributed to
the problem of food wastage in elderly patients.
Staff arrangements for eating assistance
There were various reasons that required nursing staff to
spend more time on assisting eating at breakfast compared
with lunch and dinner: (i) the average number of patients
joining meals was highest at breakfast; (ii) relatives were
unable to provide eating assistance at breakfast time; (iii)
breakfast needed to be finished before doctors’ rounds in the
morning; and (iv) assisting patients to have breakfast offered
nursing staff an opportunity to observe patients’ condition
before doctors’ rounds.
Dinner was another difficult time for nursing staff to
provide assistance, as there were fewer nursing staff on duty.
Furthermore, staff and patient meal times clashed.
As lunch time was the least busy meal, the ward combined
afternoon tea with lunch, serving patients at 12:20 p.m. This
was partly because of a time clash with nurse duty handover,
which was normally at 3:00 p.m. Moreover, the ward had a
high patient turnover rate, so patient activities, such as dis-
charge and bed movements, were most likely to take place
after lunch time. This practice caused an increase of food
wastage and put patients’ nutritional needs at risk.
It was found that a high proportion of patients had a
medical background of dementia (41%, n = 19). Some of the
patients with dementia seemed to exhibit the ‘sundowning’
phenomenon.13 Patients exhibiting the ‘sundowning’ phe-
nomenon often show increased agitation, restlessness and
confusion in late afternoon, evening or night, which may
cause such patients to change their eating behaviours as the
day progressed.13 As patients’ needs for eating assistance
varied based on their medical and cognitive condition and
because of the high patient turnover rate, it was difficult for
nursing staff to predict the exact number of ‘sundowning’
patient would be in the ward at any one time, which con-
tributed to the inability of prearranging adequate workforce
for eating assistance.

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Inadequate eating assistance provided to
totally dependent patients
Totally dependent patients were found to have the highest
food wastage across the three meals, particularly dinner
(wastage at dinner 87.8%). Totally dependent patients
required a longer time to eat as a high proportion of them
(78%) were found to have eating problems, such as dysph-
agia, cognitive and functional impairments. However, the
average amount of assistance time each totally dependent
patient was given at dinner was 10.8 minutes which is not
much time even for a healthy person to eat dinner.
10.8 minutes is also far shorter than the time recommended
by National Nursing Minimum Data Set (20 minutes).9
When these patients were fully assisted at dinner, the time
taken was observed to be 25 minutes.
A further difficulty was that, a scheduled time was set by
the food service department for the food carts to be returned
to the kitchen after each meal. Feeling pressured to finish
feeding in a limited time caused the staff to become impa-
tient with patients who ate slowly. Some nursing staff mixed
patients’ solid food into a liquid or discontinued feeding
patients when there was still food on the plate, without an
indication from the patients that they did not want to eat
more.
Furthermore, three out of nine totally dependent patients
were observed did not receive any assistance at mealtimes.
Shortage of nursing staff was not the reason for this as the
nurse/patient ratio was adequate, ranging from 3.0 to 3.1
patients per nurse during the day shift (7:00 a.m. to
3:00 p.m.) and 3.5 patients per nurse during the evening
shift (3:00 p.m. to 11:00 p.m.). It fulfilled the recommenda-
tion from the Australian Nursing Federation that staffing
levels for an acute aged care unit should be 5 nurses to every
20 patients.14 Instead, some possible reasons for the patients
not being fed were observed. First, some patients fell asleep
during mealtime. Second, some patients refused meals
because of poor appetite, physical illness and tiredness. A
further difficulty was the hospital’s food service policy. Any
change of diet order had to be done at least one hour before
meal serving time. Some patients did not have their meals
because of delays in updating the doctor’s dietary prescrip-
tions after medical procedures. Furthermore, diet orders
were occasionally incorrect. Mixing up patients’ diet orders
often happened in the ward as it was difficult to keep track.
High mealtime wastage
A Nottingham study of plate waste found that 42% of hos-
pital food was wasted.15 The present finding is consistent
with the present study that food wastage was high across the
three meals (42.9% on average). The highest food wastage
was found at lunch (average 48.5%). The present study
suggests the following reasons: (i) inappropriate hour of
meal service: it was too early for the patients to have lunch at
12:20 p.m. as they had just finished morning tea at
10:30 a.m.; (ii) inappropriate meal arrangements: afternoon
tea was combined with lunch to serve to patients at
© 2008 The Author
Journal compilation © 2008 Dietitians Association of Australia
Feeding elderly hospital patients
12:20 p.m. This contributed to patients being overwhelmed
with food; (iii) the ward served a large quantity of food at
lunch time, a great proportion of which was wasted; and (iv)
RNs were unable to supervise and spend time assisting
patients to eat as they were required to hand out medication
during lunch time.
All three levels of eating behaviour: total independence,
partial dependence and total dependence, had their lowest
wastage at breakfast (6.8%, 30.1% and 62.5%, respectively).
Patients consumed significantly more calories and refused
foods and fluids less often in the morning as there having
been a longer period of time since the last meal (dinner): all
the meals were served over a period of 10 hours, from
8:00 a.m. to 6:00 p.m. In addition, many patients did not eat
supper or drink their supper drink as they had already
prepared themselves for bed and they did not want to have
to toilet themselves during the night.
Possible solutions to provide
adequate eating assistance for the
hospitalised elderly
The present study indicated that the current hospital feeding
policy is not well designed to meet the nutritional needs of
the sick elderly. Some proposed solutions are as follow:
1 As nutrition therapy is currently not often formally
prescribed,16–18 guidelines and instructions regarding
nutritional screening and assessment are recommended.
They can be simple checklists included in the nursing
assessment to identify patients at risk.
2 A multidisciplinary Nutrition Committee could be
appointed by all the major Australian hospitals to set
standards for the delivery of food services and nutritional
assessments.19
3 Ensuring adequate staffing levels at mealtimes: ideally the
nurse/patient ratio would be 1 nurse : 1 totally dependent
patient and 1 nurse : 3–4 partially dependent patients.
Nurse dinner meal breaks and medication hand-out times
should be arranged so that maximum available staff is on
the ward during patient meal times.
4 To focus staff resources optimally. Nursing staff should
target first those who eat less than 50% of most meals as
they are at the highest risk of undernutrition.19
5 A flyer to be given to patients’ relatives on admission
could be developed. The flyers should outline the impor-
tance of good nutrition and encourage relatives to assist
patients to eat.
6 Ward staff can be facilitated to focus on nutritional care by
regular ward meetings and discussion.
7 Regular quality monitoring activities are necessary to
ensure that eating assistance is being provided
consistently.
Proposed solutions specific to North Shore Hospital
include:
1 As many patients do not eat supper or drink their supper
drink, moving the hot supper drink to be included with
the evening meal would be an appropriate step to reduce
the burden of feeding for available staff.
227
M.F. Tsang
2 Rearranging the schedule of afternoon tea: afternoon tea
could be served between lunch and dinner at 3:00 p.m. in
order to eliminate patients being overwhelmed with food,
thus decreasing the lunch time food wastage.
Limitations of the study
As there was only one observer on the ward in the present
study, more patients may have received assistance and the
assistance required may have been greater than has been
noted. Moreover, as this was a small sample research design,
and the study period was relatively short, only covering
seven days’ meals, it may not be representative of the usual
level of assistance required by patients. Consequently, the
study results should be applied cautiously to elderly patients
in similar situations.
CONCLUSION
Nurses are currently responsible for feeding patients but
cannot meet the demands. The present study has demon-
strated that patient feeding needs are complex and varied
and that nurses caring for such patients on a daily basis are
in a potentially ideal position to assess and evaluate nutri-
tional care.
ACKNOWLEDGEMENTS
I gratefully acknowledge Dianne H Volker for her time and
advice on writing this paper. My thanks also go to Peter
Petocz for his contribution towards statistical analysis and to
Tracey Ronald, Fifi Spechler, Alison Baldwin and the Royal
North Shore Hospital food service department for their
cooperation and help. Without their assistance, the present
study would not have been possible.
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