Download Hungry in hospital, well-fed in prison? A comparative analysis of

Walden University
ScholarWorks
School of Management Publications
College of Management and Technology
9-2013
Hungry in hospital, well-fed in prison? A
comparative analysis of food service systems
Nick Johns
Walden University, [email protected]
John Edwards
Heather Hartwell
Follow this and additional works at: http://scholarworks.waldenu.edu/sm_pubs
Part of the Life Sciences Commons, and the Medicine and Health Sciences Commons
This Article is brought to you for free and open access by the College of Management and Technology at ScholarWorks. It has been accepted for
inclusion in School of Management Publications by an authorized administrator of ScholarWorks. For more information, please contact
[email protected].
Appetite 68 (2013) 45–50
Contents lists available at SciVerse ScienceDirect
Appetite
journal homepage: www.elsevier.com/locate/appet
Research report
Hungry in hospital, well-fed in prison? A comparative analysis of food
service systems q
Nick Johns a,⇑, John S.A. Edwards b, Heather J. Hartwell b
a
b
School of Management, College of Management and Technology, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA
Foodservice and Applied Nutrition Research Group, Bournemouth University, Poole, Dorset, BH12 5BB England, United Kingdom
a r t i c l e
i n f o
Article history:
Received 20 September 2012
Received in revised form 3 April 2013
Accepted 5 April 2013
Available online 18 April 2013
Keywords:
Food service systems
Prisons
Hospitals
Patient nutrition
Prisoner nutrition
Institutional catering
a b s t r a c t
Meals served in prisons and hospitals are produced in similar ways and have similar characteristics, yet
hospital patients are often at risk of being undernourished, while prisoners typically are not. This article
examines field notes collected during nutritional studies of prison and hospital food service, which confirmed the difference in nutrient intake claimed by other authors. A comparison of food service processes
and systems showed that the production of meals and the quality leaving the kitchen was similar in both
types of institution. However, the delivery and service system was found to be much less coherent in hospital than in prison. Transport and service of hospital food were subject to delays and disruptions from a
number of sources, including poor communication and the demands of medical professionals. These
meant that meals reached hospital patients in a poorer, less appetising condition than those received
by prisoners. The findings are discussed in the light of previous work and in terms of hospital food service
practice.
Crown Copyright Ó 2013 Published by Elsevier Ltd. All rights reserved.
Introduction
Published evidence (Edwards, Edwards, & Reeve, 2001; Edwards, Hartwell, Reeve, & Schafheitle, 2007; Hartwell, Edwards, &
Beavis, 2007; Hartwell, Edwards, & Symonds, 2006) suggests that
prisoners’ food intake is more adequate for their needs than that
of hospital patients, but little is known of the background or causes
underlying this phenomenon. This paper examines and compares
factors which may be influencing the food intake of prisoners
and hospital patients.
The prison system’s custodial responsibility requires that inmates receive a diet sufficient to maintain them, while its public
responsibility means that this must be done on a minimal budget.
Therefore in most countries, the quality of the prison diet, which
might otherwise succumb to budgetary pressures, is controlled
through national legislation (Brisman, 2008), for example in the
UK it comes under the Prison Service Order 5000, which interprets
the UK Department of Health’s dietary reference values (DRVs) into
q
Ethical Approval and Acknowledgements: Approval from the Acute Care Hospital
Research Governance and the Dorset Research Ethics Committee (DREC) was
obtained for the research in hospital. Ethical approval for the prison research was
granted by the Head of the Prison Service and the management team of each prison
concerned, and full support was given by each food service department. The
research design and protocol for both studies were also approved by the University
Ethics Committee.
⇑ Corresponding author.
E-mail address: [email protected] (N. Johns).
practical food terms (Blades, 2001). In 2000 UK prisons moved
from a ‘‘ration scale’’ system, where prisoners were given set
meals, to a menu system offering a range of choice at every meal.
Prisoners in most European and US prisons can purchase supplementary food items from internal shops, but for security reasons,
they cannot receive food brought in from outside.
Prisoners tend to look forward to mealtimes, which punctuate
the daily routine with ‘‘high points’’ of varied activity (Valentine
& Longstaff, 1998). However, the food and service express the penal experience, through bland monotonous quality, rigid timing
and contrast with what prisoners would normally eat at home
(Brisman, 2008; Smith, 2002) and for these reasons, most inmates
express dissatisfaction with prison food (Dodd & Hunter, 1991;
HMSO/OPCS, 1994; Smith, 2002; Ugelvik, 2011). Many consider
that their diet changes on entering prison (HMSO/OPCS, 1994)
and that they get too many calories for too little exercise (Valentine & Longstaff, 1998). The management of prison catering is
important for maintaining morale, minimising disruption and
avoiding riots, since collecting food from the prison service counter
provides an opportunity for contact between inmates and a potential focus for trouble (Brisman, 2008; Valentine & Longstaff, 1998).
Hospitals generally have no custodial duty towards their patients, and medical treatment dominates the concept of care. As
with prisons the catering budget is under public scrutiny and food
and nutrition are subject to national guidelines, which focus on
nutritional quality and on the food delivery system (Hartwell & Edwards, 2003; Mahoney, Zulli, & Walton, 2009; Porter & Cant, 2009).
0195-6663/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.appet.2013.04.006
46
N. Johns et al. / Appetite 68 (2013) 45–50
Many hospitals, including those in non-Western countries offer a
range of menu choices (Jessri et al., 2011; Porter & Cant, 2009).
On the other hand, the service and consumption of food often conflicts with medical rounds, diagnostics and treatments, and it is
sometimes considered to hinder the institution’s ‘‘proper’’ business
of treatment (Hickson, Connolly, & Whelan, 2011; Jessri et al.,
2011). Like prisoners, hospital patients look forward to meal times,
since they mark the passage of time, and conversations with (nonmedical) food service staff offer a brief escape from medical matters (Johns, Hartwell, & Morgan, 2010). Despite this, the quality,
timing and delivery of hospital meals tend to accentuate patients’
awareness of their absence from home (Johns et al., 2010) and as in
prison, food is frequently a cause for complaint and dissatisfaction
(Johns et al., 2010). Unlike prisoners, patients can receive food
brought in from outside by friends and relatives. Hospitals also
have shops that sell food items, but the scope is limited, since facilities are rarely available for patients to heat their own food (Hickson et al., 2011; Jessri et al., 2011; Johns et al., 2010).
Various studies have reported inadequate intake of energy and
macronutrients, especially carbohydrates, among hospital patients,
although dietary protein and most micronutrients tend to be adequate (Barker, Gout, & Crowe, 2011; Gallagher-Allred, Voss, Finn, &
McCamish, 1996). Often patients’ nutrition is poor on arrival and
those most undernourished on admission tend to show the greatest rate weight loss during their hospitalisation (McWhirter & Pennington, 1994). Inadequate nutrition may lengthen patients’
hospital stay by 50%, an average of 6 days, and triple mortality
rates (European Nutrition for Health Alliance, 2008). Jeejeebhoy
(2003) notes that hospital under-nutrition is not generally caused
by disease-related factors and concludes that it must be due to low
food intake.
In contrast, Edwards, Edwards, and Reeve (2001), Edwards,
Hartwell, Reeve, and Schafheitle (2007) report that the prison diet
generally provides adequate amounts of energy, protein and most
micronutrients. They found minor deficiencies in vitamin D, zinc,
selenium, manganese and iodine, and sodium levels exceeded
maximum recommendations, findings that are also consistent with
studies in the UK and USA by Lester et al. (2003) Eves and Gesch
(2003) and Collins and Thompson (2012). In addition to desirable
nutrients, prison diets tend to contain higher than recommended
levels of cholesterol, sodium, and sugar (Collins & Thompson,
2012; Edwards et al., 2001, 2007). Thus whilst prison diets cannot
be unreservedly described as ‘‘healthy’’, prisoners appear to receive
adequate energy, an appropriate balance of macronutrients and a
reasonable intake of most micronutrients.
Prison and hospital catering are generally designated ‘‘institutional food’’, a term which has not been clearly defined in the academic literature. The following outline provides the elements of a
definition for the present discussion. Institutions generally have
some other motivation than feeding their population, which tends
to be expressed in the food, the service and the situation in which
the food is eaten. The quantity and quality of institutional food is
under strict Governmental control, yet recipients tend to perceive
the food as bland in taste, texture and temperature and the service
as ill-timed and perfunctory, no matter how grateful they are to receive it. The quality of institutional food generally expresses the
dominant national culture, and may not be entirely appropriate
for minority groups (Valentine & Longstaff, 1998). Although one
would hesitate to claim these features of institutional food as universal, they have been reported for hospitals, prisons and other
institutions in countries as diverse as Norway (Ugelvik, 2011)
and Iran (Jessri et al., 2011).
Above all (and despite reflecting the national culture) institutional food is always perceived as differentiating the institution
from normal life. The recipients of hospital and prison food are
‘unwilling customers’, often anxious, frightened or disoriented at
being removed from the emotional security of home. They are surrounded by uniformed, empowered staff in an alien environment
where meal times are imposed and the choice of food is often made
well before consumption takes place, and there is generally also a
loss of privacy. Given the similarity of food provision in the two situations (Ugelvik, 2011, reports that the prison he studied in Norway received its food from the local hospital kitchen), it is
surprising that prisoners are substantially better nourished than
hospital patients.
Other differences influencing the nutritional needs of hospital
patients and prisoners include typical length of stay and nutritional status upon arrival. In prison the length of stay may be
months or years, while in most European hospitals it now averages
between 5 and 10 days (Beck et al., 2001; Johansen et al., 2004);
thus the function of food provision is different. In hospital, longterm maintenance is generally not required, but patients must receive enough food to maximise their rate of recovery and redress
poor nutrition that occurred before the hospital stay. Food service
in prison is essentially concerned with long-term maintenance.
The nutritional status of new prisoners has not been reported,
but long-term exposure to prison catering presumably has a normalising effect. In all types of institution there is a humanitarian
requirement to provide food in a condition that recipients consider
edible and appetising.
The food service system, including ordering, transport, service
and the environment where the food is eaten plays an important
part in the meal experience and therefore has a significant influence upon food intake (Reilly, Hull, Albert, Waller, & Bringardener, 1987). Allison (1999) notes that effective ordering of hospital
food may depend upon the clarity of the menu, the language in
which it is written and the system by which orders are collected
from patients and communicated to the kitchen. Menu choice
and portion control may be inappropriate for patient needs
(Rush & Moloney, 1998). For instance smaller, more energydense portions may produce greater calorie intake in older patients, who may be deterred by larger portions of carbohydrate-rich food (Stephen, Beigg, Elliott, Macdonald, & Allison,
1997). Transporting and holding institutional meals can render
the temperature, texture and colour less attractive, by cooling,
warming or drying the food (Hartwell et al., 2007; O’Hara
et al., 1997). The service of hospital meals may reduce acceptability through poor presentation, or may make the food less
accessible, if it is wrapped or placed outside the reach of the patient (Corish & Kennedy, 2000). The timing of meals may be too
rigid, or spread over too long a period, and other aspects of service may be inflexible, for instance there may be no access to
snacks and no allowance made for patients returning to the
ward after tests or treatments (Jessri et al., 2011; McGlone, Dickerson, & Davies, 1995; Millar, 1998).
The service and consumption of food may be affected by disruptions due to ward rounds or emergencies, by the ward atmosphere,
which depends on the level of activity of nurses and other staff
(Corish & Kennedy, 2000) and by the medical conditions and
behaviour of other patients (Cardello, Bell, & Kramer, 1996). Hickson et al. (2011) examined the effect of protecting mealtimes from
medical rounds and other disruptions, finding that although patients valued the protected time their food intake did not increase.
Edwards and Hartwell (2004) report that food intake was the same
whether patients ate sitting alone by the bed or sitting in bed, but
increased by 20% if patients ate together in a group. Food intake is
also affected by diseases and medications, which may suppress
appetite, cause nausea or distort sensory perception of food. Ethnic
background may limit menu choice and reduce food acceptability,
and handicapped patients’ ability to feed themselves may be compromised by the way food is served or by a lack of available assistance (Corish & Kennedy, 2000). Older patients may be unable to
47
N. Johns et al. / Appetite 68 (2013) 45–50
Table 1
Mean nutrient intake in hospital and prison.
Nutrient
Unit
Energy
kcal
MJ
g
%
%
mg
lg
mg
Protein
Total Fat
Carbohydrate
Ascorbic acid
Calciferol
Calcium
a
b
c
d
Hospital male dieta
Prison male dietb
Mean
SD
Mean
SD
1184
5.0
50.3
34
49
64
2.0
521
331
1.4
13.5
3042
12.80
104.6
35.3
51
93.3
2.7
938
87
0.37
7.4
29.0
0.6
126
13.8
1.5
52
Recommendationsc
2550
10.6
55.5
35
50
40
10
700
Hospital female dieta
Prison female dietb
Mean
SD
Mean
SD
1134
4.8
45.1
37
47
75
1.7
479
252
1.0
13
3007
12.64
98.1
39.2
48.1
132.8
2.6
1377
471
1.96
5.2
23
0.7
127
28.8
0.0
308
Recommendationsd
1940
8.1
45
35
50
40
10
700
Hartwell et al. (2013)
Edwards et al. (2007).
Males 19–59 years.
Females 19–50 years; Department of Health (1991).
navigate menus or may be daunted by food presentation or portion
sizes (Johns et al., 2010; Stephen et al., 1997).
Food wastage in the UK National Health Service varies between
17% and 67% and is estimated to cost £155 million per annum (Williams & Walton, 2011; Allison, 2003). Measurements of 60–70 g
per person per meal compare unfavourably with school and hotel
food catering where wastage is in the range 30–40 g (Hong & Kirk,
1995). A study by Frakes, Arjmandi, and Halling (1986) found that
starchy foods and vegetables made up a substantial proportion of
the waste food in a US hospital. Wastage rates are inversely proportional to food acceptability and therefore hospitals with higher
rates of wastage are less likely to be meeting patients’ nutritional
needs (Hong & Kirk, 1995).
Hartwell et al. (2007) have shown that the way hospital food is
transported and served affects its temperature and organoleptic
quality at the point of service. Thus in principle the way food is transported and served in hospitals and prisons may be responsible for
differences in its quality and acceptability at its destination, and
hence for the amount that is eaten. However, there has been no
study to test this proposition. The present article compares prison
and hospital food service systems in institutions where the nutritional intake of occupants was already known. These were the four
prisons studied by Edwards et al. (2007) and a hospital study undertaken in 2011 from which data have not as yet been published.
Nutritional data from these studies are shown in Table 1.
The prison figures in the table are comparable with those from
studies by other authors (Edwards et al., 2001; Eves & Gesch, 2003;
Lester et al., 2003; Collins & Thompson, 2012). The hospital figures
may be compared with mean intakes of 1713 kcal/day and 81 g/
day reported by Gariballa and Forster (2008) and of 1448 kcal/
day reported by Edwards and Hartwell (2004). Nutritional intake
at these institutions are thus broadly typical of prisons and hospitals, respectively. Besides these nutritional data the research team
gathered information about the way food was produced, transported and served and about the quality of the food leaving the
kitchen and arriving at its destination in the prisons and the hospital. This article compares and contrasts these observations in the
two types of institution.
Method
Data for the prison study described were gathered in 2007. Four
closed male prisons (category A, B and C 2) and two closed female prisons, sampled as described by Edwards et al. (2007)
formed the basis for the prison part of the study. The 2-day visits
were conducted as follows. On the first day, researchers explained
the rationale and purpose of the study, made themselves familiar
with the layout and operating practices, and observed service of
the evening meal. The following day, they observed breakfast service and the preparation, transport and service of the midday and
evening meals. Detailed field notes were made during observation
and at least eight inmates and five warders per prison were interviewed on an opportunity sampling basis.
The hospital study was conducted in 2011, in a hospital that
was convenient in terms of travel, liaison and ethical clearance.
Researchers (the same individuals who had conducted the prison
study) used a very similar approach to that employed in the prisons, observing the preparation, transport and service of meals for
three consecutive days and making field notes. They also interviewed ten food service staff, eight medical staff and ten patients,
sampled on an opportunistic basis. Throughout both the studies
ethical guidelines were followed strictly, and stakeholders in the
institutions were consulted frequently for direction, suggestions
and data. Researchers liaised regularly during the data collection
phase and referred to each others’ notes in order to reassure themselves that saturation of data had been achieved.
Field notes were typed and comments transcribed from recorders and notes. Data from the six prisons were reviewed by the research team and amalgamated, and the process by which food was
produced, transported and served was pieced together in group
discussion. Several drafts were required in order to ensure that
everyone’s observations were taken into account, and to identify
the main features of the food provision systems. The prison data
were examined again before the hospital study in order to co-ordinate the data collection process. The hospital data were gathered in
a very similar way to those at the prisons, except that temperatures of foods were measured with a probe immediately prior to
consumption. When the hospital data had been gathered and analysed (including delineating the food production/service process),
the team met several times to compare and contrast the two sets
of findings. Following this analysis and discussion, schemes of
the food service processes in the two types of institution were
drawn up in a set of draft results forming the basis of this article.
The fact that the research team was experienced in this kind of
study brought advantages in analysing the food service systems,
but also introduced a possibility of bias, in terms of the theoretical
frame of reference and of preconceptions about the data. In order
to minimise these effects, another researcher who was not part
of the data gathering team was asked to review the raw data and
the draft findings. Points emerging from this review were discussed in detail with the team before finalising the results.
Results
The food was produced centrally in both types of institution and
transported some distance on trolleys to cell wings (in prison) or
48
N. Johns et al. / Appetite 68 (2013) 45–50
wards (in hospital) where it was served. Detailed observations
were as follows.
Prison
Breakfast, a pack containing cereal, bread, jam, spread, sugar
and milk, was issued on demand, either in the morning or the
evening before. A beverage pack, containing tea (but no coffee), sugar and coffee whitener was also available. Packs were also provided for special dietary requirements, including vegans,
vegetarians, diabetics, and Mormons. Midday and evening menus
offered five items from which prisoners could choose, approximately 3 days in advance.
Meals were prepared in a central kitchen by prisoners, supervised either by warders or by civilian food service staff. Staffing
levels were relatively high for this sort of operation, probably because the prisoners provided ‘‘free’’ labour. The equipment was
modern and well-maintained and included brat pans and combiovens, and the kitchen was clean and well-organised. Food purchasing was centralised, but in three of the prisons purchases were
supplemented with food from prison farms and gardens. About
£1.80 was allowed per prisoner per day for meals and beverages.
The temperature, colour and other sensory qualities of the food
were noted by researchers as it left the kitchen, immediately prior
to mealtimes. It was loaded into heated trolleys and taken by
warders to service counters in the prison wings, a process that typically took 10–15 min. Here a warder called out the names of queuing prisoners, who came up to collect their pre-ordered main
course and dessert at the counter, where they could also augment
their meal with fruit, bread (white and wholemeal), spreads and
condiments. The whole service process took 20–30 min. Male prisoners received their meals on their wing and ate them in their cells,
but female prisoners collected their meals from a central service
counter and ate them in a dining room. Plate waste averaged less
than 7% across the six prisons but it was not possible to weigh food
left at the counters after service, which was noted as almost nil.
Hospital
The hospital provided food for both medical and surgical patients, offering vegetarian, vegan and ethnic meals as well as medically indicated diets, e.g. for diabetic and renal patients. Four
different menus were used on a two-weekly cycle throughout
the year. Ward staff collected orders from the patients in the afternoon or evening for the following day. This meant that if a patient
was transferred or discharged, the newcomer to that bed received
the meal ordered by the previous incumbent. Ward staff consolidated patients’ requests into bulk orders, or, in some circumstances, placed a bulk order for the ward without consulting
patients. Bulk orders were telephoned to the kitchen, where they
were communicated through a computer database to the food
preparation staff. Kitchens were as clean and well-organised, but
not as well-staffed as in the prisons, and the kitchen equipment
was older, although efficient and well maintained. About £2.20
was allowed for meals and beverages, specified as three and seven
respectively per patient per day. Bulk foods were purchased centrally, while fresh produce was mostly procured locally.
Patients received a continental-style breakfast between 07.00
and 08.00 h in the morning, which tended to be the busiest time
on the wards, and was often disrupted by medical rounds. Lunches
and evening meals were prepared in a central kitchen several
hours ahead of meal times, for instance lunch preparation commenced at 07.00 h for service at 12.30. Upon leaving the kitchen
foods were at appropriate temperatures and the sensory quality
was comparable with that observed in the prisons. Food was
loaded into heated trolleys on bulk trays transported by porters
to ward corridors, a process that could take up to 45 min, and
plugged into a power supply. The trolleys might wait another half
hour here before it was convenient for ward staff to move them
onto the wards and again plug them into a power supply. They
then waited for up to an hour on the ward for hand-over (change
of nursing shift), or for medical rounds to finish. Finally they were
wheeled to individual bays by health care assistants or ward hostesses. Patients’ pre-ordered main meals and desserts were placed
together on bedside tables by health care assistants or ward hostesses. Alternatively nurses would serve the food in addition to their
other duties. Patients who needed to be fed were attended to after
the other patients had been served, which could take 50 min for
the whole ward. During the many delays, observers noted that
the hot food often cooled and cold food became tepid in the ambient ward temperature. The food would also dry and discolour,
especially if it was left open with a large surface area, e.g. spread
out on serving dishes. Plate waste was measured at an average of
5.9%; trolley waste at 20.5%. The resulting total wastage rate was
26.4%, significantly higher than in the prisons. Published UK standards for hospital catering are 10% for plate waste and 12% for unserved bulk trolley waste (Department of Health, 1996).
Comparison
Compared with the prison, the hospital food service process
was fragmentary and ill-coordinated, with poor communication
between kitchen, transport, service and patients. The different
groups participating in the process included catering staff, porters,
nursing and auxiliary staff, between whom there was no coherent
cooperation. The resulting in delays and disruptions were exacerbated by ward rounds, tests and treatments. The busiest time on
the ward was breakfast, when patients were constantly interrupted whilst consuming their food. Ward staff had difficulty communicating with caterers and dieticians, and doctors relied on
nurses to communicate nutritional concerns about patients, a process which could be disrupted by shift-work patterns, heavy workloads and short-staffing. There was also evidence of tension
between ward hostesses and medical staff, who frequently had different task priorities.
In the prison system, food tended to arrive hot and comparatively fresh and it could be consumed immediately, without distractions. In contrast, keeping food hot in hospital was a
challenge even with heated trolleys that could be plugged into a
power supply. The problem was not with the trolleys, which were
quite capable of maintaining heat integrity, but with delays in the
transport and service practices described above. Operators tended
to put all the food on display as soon as it arrived on the ward, but
serving all the patients took a long time, during which the food was
unheated and uncovered and hence deteriorated still more.
Discussion
Observations showed that food left the kitchens in a similar
state reasonable sensory (and nutritional) quality at both types
of institution. However the quality of the food reaching recipients
in hospital was much less satisfactory than that in the prisons in
terms of temperature, texture and appearance, and food wastage
was also substantially higher. The food service system in hospital
was subject to many more delays and disruptions than that in
the prisons, and as a result the food quality deteriorated, as has
also been reported elsewhere (Hartwell & Edwards, 2003; Hartwell
et al., 2007; Jessri et al., 2011). This occurred despite a higher budget allocation for hospital catering.
In prisons no disruption of mealtimes was observed, but in hospitals there were many medical rounds, tests and treatments, espe-
N. Johns et al. / Appetite 68 (2013) 45–50
cially at breakfast time. These disruptions spoiled the food by
delaying transport and service. They also made conditions less satisfactory for its consumption, although this was probably the lesser
effect, since Hickson et al. (2011) found no significant improvement in the food intake of patients whose lunchtimes were protected from (most) medical disruptions. On the other hand the
present study showed that medical disruptions were most significant at breakfast, rather than at lunchtime. In the male prisons and
the hospital, meals were taken alone in cells, or in bed respectively.
Eating alone has been shown to reduce the amount of food consumed (Edwards & Hartwell, 2004). This did not seem to affect
the food intake of prisoners, but it should be considered a factor
in hospitals, where eating in company could be relatively easily
achieved and might increase food intake.
Food provision in prisons and hospitals is under severe budgetary constraints, and takes, at best, second place to the institutions’
primary objectives. In both situations it is hampered by the number of stakeholders, the individual requirements of inmates/patients and the logistical complications of kitchens and service
points, sometimes located at considerable distances from prison
wings and hospital wards. However, these common factors do
not prevent prisons providing their inmates with adequate nutrition, while hospitals often fail in this regard. This study showed
that clinical considerations tend to take precedence over food service. This might be appropriate in hospitals specialising in acute
conditions, but food should have a higher priority in rehabilitation
and in elective surgery, and should generally be considered an
integral part of treatment.
The qualitative methodology employed in this study brought
with it a number of potential shortcomings, which need to be taken
into account. Most significantly, the data came from two separate
studies, conducted 4 years apart. The same researchers were involved and very similar methodology was used, but evolution in
the observation techniques used and the questions asked, inevitably occurred as the researchers became more familiar with the
study. However, evolution undoubtedly also occurred during the
repetitive studying of six prisons, and this did not produce notable
differences in the data. On the other hand the situation in the prisons may have changed, perhaps for the worse, during the 4-year
delay. Food temperatures were measured in the hospital study,
but not in the prisons. However, as in the hospital, food was assessed visually at the point of service and prisoners asked to comment on the food did not mention temperature as a problem.
Trolley waste was measured as well as plate waste In the hospital
study, but in the prisons the amount of waste at the service counters was so small that it could not be practically measured.
The ethos of the research and its underlying assumptions presented other limitations. Since observations focused upon food service systems, no other potential source of difference was sought,
but nor were concerns raised by interviewees about issues other
than the food and the service. Interviews and observations are
notoriously prone to subjectivity, and the research team sought
to minimise this by regular discussions of method and data and
by ensuring that every viewpoint was considered. Analysis was
mainly based on delineating the food service systems and in order
to minimise this potential source of error, a colleague who had not
been on the data collection team reviewed the results and discussed salient issues with team members.
The sensory characteristics of hospital food and the physical
environment in which it is eaten are isolated considerations within
a larger problem, the need for an integrated system. Providing direct, individualised and total nutritional care requires careful
orchestration and control, which in turn requires collaboration
and co-operation. At present hospitals do not have central co-ordinators who can control the entire process from kitchen to consumption, but this is common in prisons. The lack of priority
49
afforded to hospital food provision, compared with medical treatment obscures its importance to patients’ recovery and well-being.
This stands in contrast with prison meals, which tend to be accepted by inmates and prison staff as part of the punishment and
are demonstrably fit for purpose in most nutritional terms.
Conclusion
In both scenarios, food was organised centrally and transported
to a remote location for service. Meals were prepared by practically
qualified individuals, supervised appropriately, using appropriate
equipment and food preparation techniques, and food leaving
kitchens in both institutions had adequate nutritional and sensory
quality. However, in prison the system was managed more effectively, transport was rapid and food quality was maintained up
to the point of service. In hospital, the system was less effective,
and delays in the delivery of meals meant that the sensory quality
of food reaching patients was poor. The demands of ward rounds,
tests and treatments compounded delays, compromised the environment in which the food was eaten and meant that individuals’
food requirements might be missed or forgotten. Many of these issues can be traced back to a general perception that nutritional intake is incidental to clinical concerns, and is therefore approached
as an ‘‘afterthought’’. Appropriate nutrition is a fundamental human right and the management of hospital food service could learn
much from its counterpart in the prison system.
References
Allison, S. P. (1999). Hospital food as treatment. A report by a working party of the
british association of parenteral and enteral nutrition (BAPEN). Maidenhead.
British association for parenteral and enteral nutrition.
Allison, S. P. (2003). Hospital food as treatment. Clinical Nutrition, 22, 113–114.
Barker, L. A., Gout, B. S., & Crowe, T. C. (2011). Hospital malnutrition. Prevalence,
identification and impact on patients and the healthcare system. Internal Journal
of Environmental Research into Public Health, 8, 514–527.
Beck, A. M., Mikkelsen, B. E., Ovesen, L., Balkn, U. N., Fürst, P., Hasunen, K., et al.
(2001). Food and nutritional care in hospitals. How to prevent undernutrition.
Report and guidelines from the Council of Europe. Clinical Nutrition, 20(5),
455–460.
Blades, M. (2001). Food and nutrition in the prison service. Prison Service Journal,
134, 46–48.
Brisman, A. (2008). Fair fare? Food as contested terrain in US Prisons and Jails.
Georgetown Journal on Poverty Law and Policy, 15(1), 49–93.
Cardello, A. V., Bell, R., & Kramer, M. (1996). Attitudes of consumers toward military
and other institutional foods. Food Quality and Preference, 7, 7–20.
Collins, S. A., & Thompson, S. H. (2012). What are we feeding our inmates? Journal of
Correctional Health Care, 18(3), 210–218.
Corish, C. A., & Kennedy, N. P. (2000). Protein-energy undernutrition in hospital inpatients. British Journal of Nutrition, 83(6), 575–591.
Department of Health (1991). Dietary reference values for food energy and nutrients
for the United Kingdom. London: HMSO.
Department of Health (1996). Hospital catering, delivering a quality service. London:
HMSO.
Dodd, T., & Hunter, P. (1991). The national prison survey. London: HMSO.
Edwards, J. S. A., Edwards, A., & Reeve, W. G. (2001). The nutritional content of male
prisoners’ diet in the UK. Food Service Technology, 1(1), 25–33.
Edwards, J. S. A., & Hartwell, H. (2004). A comparison of energy intake between
eating positions in a NHS hospital. A pilot study. Appetite, 43, 323–325.
Edwards, J. S. A., Hartwell, H., Reeve, W. G., & Schafheitle, J. (2007). The diet of
prisoners in England. British Food Journal, 109(3), 216–232.
European Nutrition for Health Alliance (2008). European Nutrition for Health
Alliance launches campaign to highlight the challenge of Malnutrition in
society. <http://www.european-nutrition.org>. Accessed 21.09.12.
Eves, A., & Gesch, B. (2003). Food provision and the nutritional implications of food
choices made by young adult males, in a young offenders’ institution. Journal of
Human Nutrition and Dietetics, 16(3), 167–179.
Frakes, E. M., Arjmandi, B. H., & Halling, J. F. (1986). Plate waste in a hospital cookfreeze production system. Journal of the American Dietetic Association, 86(7),
941–942.
Gallagher-Allred, C. R., Voss, A. C., Finn, S. C., & McCamish, M. A. (1996).
Malnutrition and clinical outcomes. The case for medical nutrition therapy.
Journal of the American Dietetic Association, 96(4), 361–369.
Gariballa, S. E., & Forster, S. J. (2008). Dietary intake of older patients in hospital and
at home. The validity of patient kept food diaries. Journal of Nutrition, Health and
Aging, 12(2), 102–106.
50
N. Johns et al. / Appetite 68 (2013) 45–50
Hartwell, H., & Edwards, J. S. A. (2003). Comparative analysis of ‘plated’ and ‘bulk
trolley’ hospital food service systems. Food Service Technology, 3(3/4), 133–142.
Hartwell, H., Edwards, J. S. A., & Beavis, J. (2007). Plate versus bulk trolley food
service in a hospital. Comparison of patients’ satisfaction. Nutrition, 23,
211–218.
Hartwell, H., Edwards, J. S. A., & Symonds, C. (2006). Food service in hospital.
Development of a theoretical model for patient experience and satisfaction
using one hospital in the UK NHS as a case study. Journal of Food Service, 17,
226–238.
Hickson, M., Connolly, A., & Whelan, K. (2011). Impact of protected mealtimes on
ward mealtime environment, patient experience and nutrient intake in
hospitalised patients. Journal of Human Nutrition and Dietetics, 24(4), 370–374.
HMSO/OPCS (1994). Survey of the physical health of prisoners. London: HMSO.
Hong, W., & Kirk, D. (1995). The assessment of labour productivity and its
influencing variables in 12 conventional hospital food service systems in the
UK. International Journal of Hospitality Management, 14(1), 53–66.
Jeejeebhoy, K. N. (2003). Hospital malnutrition. Is it a disease or lack of food?
Clinical Nutrition, 22(3), 219–220.
Jessri, M., Mirmiran, P., Jessri, M., Johns, N., Amiri, P., Barfmal, N., et al. (2011). A
qualitative difference. Patients’ views of hospital food service in Iran. Appetite,
57(2), 530–533.
Johansen, N., Kondrup, J., Plum, L. M., Bak, L., Nørregaard, P., Lauesen, N., et al.
(2004). Effect of nutritional support on clinical outcome in patients at
nutritional risk. Clinical Nutrition, 23(4), 539–550.
Johns, N., Hartwell, H., & Morgan, M. (2010). Improving the provision of meals in
hospital. The patients’ viewpoint. Appetite, 54(1), 181–185.
Lester, C., Hamilton-Kirkwood, L., & Jones, N. K. (2003). Health indicators in a prison
population: Asking prisoners. Health Education Journal, 62(4), 341.
Mahoney, S., Zulli, A., & Walton, K. (2009). Patient Satisfaction and energy intakes
are enhanced by point of service meal provision. Nutrition and Dietetics, 66,
212–220.
McGlone, P. C., Dickerson, J. W. T., & Davies, G. J. (1995). A caterer’s perception of
feeding patients in hospital. Proceedings of the Nutrition Society of London, 55(2),
195A.
McWhirter, J. P., & Pennington, C. R. (1994). Incidence and recognition of
malnutrition in hospital. British Medical Journal, 308, 945–948.
Millar, B. (1998). Dying for a good meal? Health Service Journal, 108(5601), 24–27.
O’Hara, P. A., Harper, D. W., Kangas, M., Dubeau, J., Borsutzky, C., & Lemire, N.
(1997). Taste, temperature, and presentation predict satisfaction with
foodservices in a Canadian continuing-care hospital. Journal of the American
Dietetic Association, 97(4), 401–405.
Porter, J., & Cant, R. (2009). Exploring hospital patients’ satisfaction with cook-chill
food service systems. A preliminary study using a validated questionnaire.
Journal of Food Service, 20(2), 81–89.
Reilly, J. J., Jr., Hull, S. F., Albert, N., Waller, A., & Bringardener, S. (1987). Economic
impact of malnutrition. A model system for hospitalised patients. Journal of
Parenteral and Enteral Nutrition, 12(4), 372–376.
Rush, F., & Moloney, M. (1998). Patient satisfaction, nutrient content and actual
intake of food served in two Dublin teaching hospitals. Proceedings of the
Nutrition Society, 57(4), 166A.
Smith, C. (2002). Punishment and pleasure. Women, food and the imprisoned body.
Sociological Review, 50(2), 197–214.
Stephen, A. D., Beigg, C. L., Elliott, E. T., Macdonald, I. A., & Allison, S. P. (1997). Food
provision, wastage and intake in elderly hospital patients. Proceedings of the
Nutrition Society, 56, 220A.
Ugelvik, T. (2011). The hidden food. Mealtime resistance and identity work in a
Norwegian prison. Punishment and Society, 13(1), 47–63.
Valentine, G., & Longstaff, B. (1998). Doing porridge. Food and social relations in a
male prison. Journal of Material Culture, 3(2), 131–152.
Williams, P., & Walton, K. (2011). Review. Plate waste in hospitals and strategies for
change. E-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, 6(6),
e235–e241.