To Örebro University

Mealtimes are an important part of the hospital stay for patients and have significance for the patients' recovery and treatment as well as for their overall experience of their hospital stay. However, more knowledge is needed to understand the activities performed for the benefit of the patients and what the staff experience and describe to be meaningful or challenging when serving patients their meals. This study investigates the notion of hospitality in understanding the everyday activity of serving meals to older adult patients. The study is based on 20 semi-structured interviews with assistant nurses, registered nurses, and meal hosts at two hospitals in Sweden. Through thematic analysis, four themes were identified that capture the everyday activities of serving meals to older adult patients from the staff's perspectives: Managing the patient's best interest, Managing time, Managing the food service frame and Managing the meal environment. The findings suggest that hospitality is performed when these are managed, and that hospitality therefore is performed in negotiation with and within the given organisational frames in the hospitals. When these frames are stretched, the staff do more than is expected and carry out a caring and knowing performance that complements the already person-centred care approach in place. Essentially, the staff find that when having time, but also when taking time with the patients during the mealtime, they are able to increase the patients' food intake and create positive mealtime moments, hence emphasising the need for studying welcoming organisational structures that can enable the staff to perform hospitable mealtimes for the older adult patients.

The increasing age of populations throughout the world means that healthcare services are faced with new challenges, not least regarding the provision of food during hospital stay. There is a lack of knowledge of how hospital mealtimes are experienced by older patients, and so the aim of this article was to review current knowledge regarding mealtimes in hospitals from the perspectives of older patients. A literature search was performed using seven databases: PubMed, Web of Science, Scopus, Sociological Abstracts, SweMed+, ASSIA and CINAHL with no limits regarding publication date. The inclusion criteria were peer‐reviewed articles in English or Swedish that used qualitative methods to examine older patients’ (>65 years) mealtime experiences. The Five Aspect Meal Model (FAMM) served as a framework for understanding the complexity behind a mealtime experience. Qualitative content analysis was used as a guide when analysing the material. The search produced 415 studies, 14 of which were included in the review. The findings generated three main themes for understanding how older patients experience mealtimes while in hospital: (1) the food and the food service, (2) mealtime assistance and commensality during mealtimes and (3) the importance of retaining one’s independence. The review also clearly indicated a shortage of studies that solely focus on older patients’ experiences of their mealtime. More research is therefore needed to be fully able to understand the complex task of providing meals in hospitals.

Hospitality is a social phenomenon expressing relationships between a host and a guest. This relationship can be seen in its most extreme form within a hospital setting, where the guest is a patient staying within an establishment where the core activity is not to provide the patient with food and drinks but to treat medical conditions. The aim of this study is therefore to explore how hospitality was performed by nursing staff and meal hosts in the dining room environments at four hospital wards and to explore the specific role of the room and its artefacts in facilitating or hindering acts of hospitality. In total, twenty non-participating observations were conducted across four wards within two Swedish hospitals. The dramaturgical theory proposed by Goffman was used as theoretical lens. Field notes were analysed in accordance with qualitative content analyses and yielded two overarching themes: (1) Hospitality and hospitableness through acts of caring and (2) The dining room environment’s potential to promote or hinder acts of hospitality. The findings suggest that the dining room environment facilitated timely service for the patients when the materiality within the room followed the principles of mise en place and included the constant presence of a staff member. This is seen as an important finding in relation to what needs to be addressed when planning hospital dining room environments and to the patients’ ability to consume a meal within a frame that acknowledges and assists the patients during their meals.

The overall aim of this thesis was to explore how the notion of hospitality could be used as a perspective to understand the meal provision within a hospital frame. Of interest was how patients (>65 years of age) experience their mealtimes together with perspectives from the ones serving the meals. This is motivated by older adult patients being more affected by malnutrition and having more challenges during mealtimes than other patient groups. Previous research has identified the importance of assistance during mealtimes and the implications that staff can have for patients’ food intakes. However, few studies have been found that focus on older adult patients’ own experiences of meal provision from a qualitative approach, nor studies that have focused on the practical doings by the staff.

The thesis is grounded in an interpretive perspective viewing social reality as constructed and experienced in relation to how one interacts with other subjects as well as objects, by applying the theory of symbolic interactionism together with Goffman’s dramaturgical theory. In addition, the FAMM was used to understand the entirety of the meal experience, and the person-centred care approach to understand the study setting of interest.

The fieldwork was conducted across four wards at two Swedish public hospitals, and interviews were conducted at three of these wards. In total, 20 mealtime observations together with 11 interviews with patients and 20 interviews with staff in different categories were conducted. The wards differed in relation to the dining room environment, the role of the meal host and how the meal service was conducted.

The overall findings reflect these differences by suggesting that the meal provision needs to be understood as a balancing act, where the staff perform in front of the patients in relation to the hospitability provided by the organisational host. The patients experienced hospitality through being acknowledged and recognised together with unexpected moments of hospitality. In turn, the staff were found to be knowing and caring in their performances towards the patients as well as showing professional knowledge when reading between the lines and offering what not always was voiced.

The findings identify a need by the staff to be able to have more time with the patients, having the ability to perform a meal service in a timely manner as well as the ability to navigate within the organisational frames. Demonstrating the need for, as well as the presence of, the “ity” factor in hospital meals.

Eating and sharing meals are essential parts of everyday life and expressed through tradition and culture. This everyday expression of who we are is argued to be taken away from us during hospitalization. Few studies have qualitatively explored hospitalized older patients experiences with their mealtimes. This is a perspective that could increase the understanding of how to provide enhanced dining experiences during time of illness for this malnutrition prune age group. The study objective was therefore to explore older patients’ (> 65 years) mealtime experiences during hospital stay with an emphasis towards the social interactions taking place before, during and after their meals. Eleven semi structured interviews were conducted and analysed through the lens of hospitality and the dramaturgical theory outlined by Goffman. The preliminary results indicate that the patients experience hospitality through materiality (e.g. the menu), commensality (with fellow patients and staff) an d individuality (the possibility to make own meal choices) but also inhospitality through conformity (not expressing their wishes or conforming to the situation) and locality (e.g. being lonely in ther oom). The patients are seen to reinforce the role of the non-complaining patient as well as not being a burden. The understanding of these kinds of role making and role taking by the patients is important to recognize within healthcare to be able to ensure that the mealtime and the meal service is provided with a person- centered approach together with the recognition that hospitality can bring fourth the practical doings in how to perform during meal service.

In order to understand the provision of meals to older patients in hospitals, the notion of hospitality is interesting. Previous research has found that even if adequate nutrition is provided the food served to the patients is not always consumed (Agarwal et al. 2013). Therefore, it is essential to also highlight aspects related to how and where the meals areserved, as well as the interaction between the staff and the patients.

The overall aim of this study was to explore how nursing staff and meal-hosts approached the mealtime for older patients and what aspects impacted on how the meals were served to the patients.

Method: Twenty mealtimes was observed across four wards within two hospitals in Sweden that had nursing staff serving meals on wards with a dayroom (2 wards) and meal-host serving meals on the wards with a dining room (2 wards). The objectives of the observations was to observe how the staff served the meals to the patients with as special focus on the hospitality approaches provided and the overall dining area. The Five Aspect Meal Model (Gustafsson, Öström, Johansson & Mossberg, 2006; Edwards & Gustafsson, 2008) and the notion of hospitality (Lashley, 2000; Telfer, 2000) serves as main frameworks. Moreover, Goffman’s dramaturgical theory (Goffman, 2014) is used to understand the scenery observed during the mealtimes.

Preliminary findings: Two overall themes were identified in the initial analyses, 1) atmosphere in the dining area; 2) and serving style and hospitality approaches.

The overall atmosphere differed between the two dining areas which impacted on how the patients were approached during mealtimes. The observations disclosed several encounters were the atmosphere in the dining area in the wards with meal-hosts serving were perceived as a regular restaurant with patients approached and asked what they would like to eat and drink in relation to the menu that was available. It was also observed in several occasions that the meal-host sat down next to the patients and helped the patients to choose a dish from the menu, asking if they were satisfied with the meal or if they needed anything else. The meal-host constant presence in the dining room contributed to a positive atmosphere as well as opportunities for the patients to get direct assistance. In the wards with nursing staff serving the food in the dayroom the patients were not as frequently out for lunch or dinner and several observations disclosed that no patients were taken to dine outside the own room. However, when the patients were out the hospitality approaches differed. Most often the patients were nicely talked and attended to in the moment of providing the meal tray and when the tray was taken away. However, the time between service and closing of the meal the patients was most often left unattended for. The atmosphere was most often sensed as “heavy” and silent. It was observed that the nursing staff not always thought of turning the lights on in the dayroom contributing to a less positive atmosphere. The staff was observed to just passing by the dayroom without visiting the dayroom to ask if the meal was of satisfaction or overall seeing the patients.

The serving style and hospitality approaches differed in some aspects between meal-hosts and nursing staff at the observed wards. The nursing staff was observed on all wards, including the wards with meal-host serving the meals, to be more hands-on and talking closer with the patients, which also disclosed different caring roles during mealtimes. If patients wanted anything else, a hand was often seen to be touched upon the patient or confirmed the wish by talking near and close to the patient. The meal-host was observed to both display a near service style with taking orders by sitting next to the patient or squatting to be on the same level as the patient, and, in some occasions, take orders as in restaurants with the help of a note pad standing next to the table.

Conclusion: The preliminary findings of this study indicate that a constant presence of a meal-host or nursing staff would be beneficial for both the overall atmosphere in the dining area as well as for patients getting timely assistance. However, further analyses are needed to fully understand and report the findings of this study.