Identifying solutions to minimize meal tray waste: A mixed-method approach

BACKGROUND & AIMS

Over $150,000 are lost annually due to meal tray waste in a large hospital in the United States. This study aims to explore the root causes of meal tray waste within a decentralized foodservice model and strategies to mitigate waste.

METHODS

A mixed methods sequential explanatory design was used by first identifying hospital units high and low in meal tray waste using recorded food management data from January 2021 through September 2022, then conducting observations, mobile-interviews (n = 16), and in-depth interviews with hospital foodservice staff (n = 6) and nurses (n = 6) in each unit. Lastly, hospital and topic experts (n = 10) were engaged in strategizing solutions to reduce meal tray waste.

RESULTS

Findings indicate meal tray waste is increased when patients discharge and when standard trays (i.e., also known as house trays, which include items not requested by patients) are provided. Meal tray waste points to the unpredictability in a hospital that often arises due to patient circumstances, lack of coordination between nursing and foodservice staff, patients' food preferences, and the need for system and workflow improvements in a decentralized foodservice model.

CONCLUSIONS

Findings highlight considerations that may be applicable across diverse medical institutions seeking to reduce meal tray waste. Hospitals should choose the best foodservice model that suits their institution to manage operations efficiently, focusing on reducing waste, cost optimization, patient satisfaction, and sustainability.

Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods

AIM

To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions.

METHODS

This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer.

RESULTS

Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all.

CONCLUSIONS

This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints.

PRACTICE IMPLICATIONS

Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement.

IMPACT

What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital.

REPORTING METHOD

This manuscript is written in adherence with the Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).

Enhancing or impeding? The influence of digital systems on interprofessional practice and person-centred care in nutrition care systems across rehabilitation units

AIMS

Digital health transformation may enhance or impede person-centred care and interprofessional practice, and thus the provision of high-quality rehabilitation and nutrition services. We aimed to understand how different elements and factors within existing digital nutrition and health systems in subacute rehabilitation units influence person-centred and/or interprofessional nutrition and mealtime care practices through the lens of complexity science.

METHODS

Our ethnographic study was completed through an interpretivist paradigm. Data were collected from observation and interviews with patients, support persons and staff. Overall, 58 h of ethnographic field work led to observing 125 participants and interviewing 77 participants, totalling 165 unique participants. We used reflexive thematic analysis to analyse the data with consideration of complexity science.

RESULTS

We developed four themes: (1) the interplay of local context and technology use in nutrition care systems; (2) digitalisation affects staff participation in nutrition and mealtime care; (3) embracing technology to support nutrition and food service flexibility; and (4) the (in)visibility of digitally enabled nutrition care systems.

CONCLUSIONS

While digital systems enhance the visibility and flexibility of nutrition care systems in some instances, they may also reduce the ability to customise nutrition and mealtime care and lead to siloing of nutrition-related activities. Our findings highlight that the introduction of digital systems alone may be insufficient to enable interprofessional practice and person-centred care within nutrition and mealtime care and thus should be accompanied by local processes and workflows to maximise digital potential.

An ethnographic study exploring person-centred nutrition care in rehabilitation units

PURPOSE

Person-centred care (PCC) is an essential component of high-quality healthcare across professions and care settings. While research is emerging in subacute nutrition services more broadly, there is limited literature exploring the person-centredness of nutrition care in rehabilitation. This study aimed to explore person-centred nutrition care (PCNC) in rehabilitation units, as described and actioned by patients, support persons and staff. Key factors influencing PCNC were also explored.

MATERIALS AND METHODS

An ethnographic study was undertaken across three rehabilitation units. Fifty-eight hours of field work were completed with 165 unique participants to explore PCNC. Field work consisted of observations and interviews with patients, support persons and staff. Data were analysed through the approach of reflexive thematic analysis, informed by PCC theory.

RESULTS

Themes generated were: (1) tensions between patient and staff goals; (2) disconnected moments of PCNC; (3) the necessity of interprofessional communication for PCNC; and (4) the opportunity for PCNC to enable the achievement of rehabilitation goals.

CONCLUSIONS

PCNC was deemed important to different stakeholders but was at times hindered by a focus on profession-specific objectives. Opportunities exist to enhance interprofessional practice to support PCNC in rehabilitation. Future research should consider the system-level factors influencing PCNC in rehabilitation settings.

Developing and validating a novel staff questionnaire to identify barriers and enablers to nutrition and mealtime care on hospital wards

AIMS

Improving hospital nutrition and mealtime care is complex and often requires multifaceted interventions and implementation strategies to change how staff, wards and systems operate. This study aimed to develop and validate a staff questionnaire to identify multilevel barriers and enablers to optimal nutrition and mealtime care on hospital wards, to inform and evaluate local quality improvement.

METHODS

Literature review, multidisciplinary focus groups and end-user testing informed questionnaire development and establishment of content and face validity. To determine the construct validity, the questionnaire was administered to ward staff working in five wards across two facilities (acute hospital, rehabilitation unit). Exploratory factor analysis was used to estimate the number of factors and to guide decisions about whether to retain or reject individual items. Scale reliability was assessed using Cronbach's alpha.

RESULTS

The questionnaire was completed by 138 staff, with most respondents being nurses (57%) and working in the acute care facility (76%). Exploratory factor analysis supported construct validity of four of the original seven subscales. The final questionnaire consisted of 17 items and 4 sub sub-scales related to (1) Personal Staff Role; (2) Food Service; (3) Organisational Support, and (4) Family Involvement; each sub-scale demonstrated good reliability with Cronbach's alpha values all >0.70.

CONCLUSION

This novel and brief questionnaire shows good reliability and preliminary evidence of construct validity in this small sample. It provides a potentially useful instrument to identify barriers and enablers to nutrition and mealtime care from the staff perspective and inform where improvement efforts should be focused.

Foodservice systems and mealtime models in rehabilitation: Scoping review

AIMS

To describe current foodservice systems and mealtime care utilized in the rehabilitation setting. A secondary aim was to identify commonly used outcome measures in foodservice research in the rehabilitation setting.

DESIGN

A scoping review.

DATA SOURCES

PubMed, CINAHL, Scopus, Embase, PsycINFO and Cochrane were searched until January 2022.

REVIEW METHODS

The review was conducted according to Joanna Briggs Institute's methodology for scoping reviews. Included studies were conducted in the inpatient rehabilitation setting, adult population ≥18 years old and provided a description of at least one element of the foodservice system, food and menu, waste and/or eating environment.

RESULTS

Of 5882 articles screened, 37 articles were included, reporting 31 unique studies. Most rehabilitation units had cook-fresh production methods (50%), used decentralized bulk delivery methods (67%) had a communal dining room (67%) and had a 3-week menu cycle (71%). Mealtime care was predominantly provided by nursing staff, however few studies reported on specific activities. Nutritional intake was a key outcome measure across included studies (43%), with only six papers reporting on rehabilitation outcomes. Of the intervention studies (n = 9), all were aimed at improving nutritional intake through menu or mealtime care modifications; few (n = 3) studied changes in rehabilitation outcomes.

CONCLUSION

This scoping review identified a considerable lack of reporting of foodservice and mealtime care systems used in rehabilitation settings in the available literature. Further investigation is required to understand what models of mealtime care are provided to patients and to understand the impact of changes to foodservice and mealtime systems on patient outcomes.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was necessary for this review.

Food and Nutrition Champions in Residential Aged Care Homes Are Key for Sustainable Systems Change within Foodservices; Results from a Qualitative Study of Stakeholders

The role of foodservices in aged care is difficult to understand, and strategies to improve the nutritional care of residents are often unsustainable. In particular, food-first strategies such as food fortification are poorly executed in everyday practice and its execution relies upon the foodservice system in aged care homes. The aim of this study was to explore the perspective of staff on the role of foodservices in aged care and gauge the level of skills, education, access, time, and ability to deliver food fortification. Semi-structured interviews were conducted with foodservice managers, foodservice workers, dietitians, carers, and other managers who work in aged care homes across Australia. Participants were recruited purposively through email and through snowballing. Interviews (n = 21) were recorded, transcribed verbatim, and analyzed using inductive thematic analysis. Three themes and six sub-themes were identified. The three themes include the role of foodservices being more than just serving food, teamwork between all staff to champion nutrition, and workplace culture that values continuous improvement. These themes identify how staff perceive the role of foodservices in aged care and provide an important perspective on the long-term sustainability of food fortification strategies and how to improve current practice.

Delegation Opportunities for Malnutrition Care Activities to Dietitian Assistants-Findings of a Multi-Site Survey

Approximately one-third of adult inpatients are malnourished with substantial associated healthcare burden. Delegation frameworks facilitate improved nutrition care delivery and high-value healthcare. This study aimed to explore knowledge, attitudes, and practices of dietitians and dietitian assistants regarding delegation of malnutrition care activities. This multi-site study was nested within a nutrition care implementation program, conducted across Queensland (Australia) hospitals. A quantitative questionnaire was conducted across eight sites; 87 dietitians and 37 dietitian assistants responded and descriptive analyses completed. Dietitians felt guidelines to support delegation were inadequate (agreement: <50% for assessment/diagnosis, care coordination, education, and monitoring and evaluation); dietitian assistants perceived knowledge and guidelines to undertake delegated tasks were adequate (agreement: >50% food and nutrient delivery, education, and monitoring and evaluation). Dietitians and dietitian assistants reported confidence to delegate/receive delegation (dietitian agreement: >50% across all care components; dietitian assistant agreement: >50% for assessment/diagnosis, food and nutrient delivery, education, monitoring and evaluation). Practice of select nutrition care activities were routinely performed by dietitians, rather than assistants (p < 0.001 across all nutrition care components). The process for care delegation needs to be improved. Clarity around barriers and enablers to delegation of care prior to implementing reforms to the current models of care is key.

Multidisciplinary Provision of Food and Nutritional Care to Hospitalized Adult In-Patients: A Scoping Review

PURPOSE

Multidisciplinary approaches to nutritional care are increasingly emphasized and recommended. However, there is little evidence of how different disciplines work together collaboratively to deliver optimum quality care to adult in-patients. This scoping review aimed to describe the existing literature on multidisciplinary collaboration to identify the various disciplines involved and the features that influence collaborative working in implementing multidisciplinary food and nutritional care with adult in-patients.

METHODS

Multiple databases were searched, including MEDLINE Complete, Embase, CINAHL Complete, HMIC, and Scopus, from their inception to December 2019. Data were retrieved from eligible studies. A narrative description of findings is reported with respect to the disciplines involved, the aspects of nutritional care explored, and the collaborative processes categorized using the input, process, and outcome framework.

RESULTS

Thirty-one studies with heterogeneous study designs met the eligibility criteria. Studies were undertaken in six countries. Findings show a wide diversity of multidisciplinary collaborations in various aspects of nutritional care in all studies. Multidisciplinary nutritional care provision was facilitated by several processes, including training and development, communication and information sharing, and clinical leadership and management support. Outcomes were reported at the patient, team, and organizational levels.

CONCLUSION

This review reveals the significance of the interrelationship between different disciplines and their complementary contributions towards the delivery of optimal food and nutritional care. Key aspects include the involvement of different disciplines, the clarification of roles and multidisciplinary interrelationships, communication, information sharing, clinical leadership, and management support, all of which facilitated collaborative working. Our review uncovered that these features can significantly influence multidisciplinary working. This review is the first to present literature concerning the attributes that affect collaborative working. Further research is recommended specifically around multidisciplinary nutritional care processes and conditions that allow for better collaborative working.

Meals beyond the bedside: An ethnographic exploration of staffs' perspectives and experiences of communal dining in subacute care

Communal dining offers multiple benefits for hospital patients, yet dining rooms may be underutilized in practice. This study aimed to understand and explore staffs' perspectives and experiences of communal dining in subacute care, and the impacts on staff mealtime practice. Using qualitative, ethnographic methodology, 94 hours of fieldwork were conducted across two subacute care wards. Participants were staff involved in nutrition care or present on the ward at mealtimes. Ninety-one semistructured and ethnographic interviews were conducted with 59 staff, and 54 episodes of observation captured more than 190 staff. Interviews and field notes were thematically analyzed using an inductive approach. Three themes were identified: (i) benefits to patients; (ii) logistical and practical challenges; and (iii) supportive cultural factors. While staff recognized how communal dining benefited patients, logistical and practical challenges impacted their ability to facilitate it in practice. Healthcare organizations seeking to embed communal dining into the mealtime routine should recognize that clear delineation of staff roles and responsibilities, and cultural change involving normalization, setting expectations, and collective advocacy may be needed to optimize benefits for patients.

Health practitioner practices and their influence on nutritional intake of hospitalised patients

Objectives

In the hospital setting, poor dietary intake interacts with disease and represents a major and modifiable cause of malnutrition. Understanding barriers to adequate dietary intake is an important strategy to guide the development of interventions to improve nutrition intake. The aim of this study reported in this paper was to explore patient, family and health care professionals' perceptions of barriers to and enablers of adequate nutrition care and dietary intake of medical inpatients.

Methods

An exploratory qualitative study design incorporating group and individual interviews of patients (n = 14), their family members (n = 4), and health care professionals (n = 18) was undertaken. Participants were recruited pragmatically, using a mix of convenience and purposive sampling. A theoretically informed, semi-structured interview schedule was based on observations of practice and the Theoretical Domains Framework. Interviews were audio-recorded, transcribed verbatim and analysed inductively using a general inductive approach.

Results

Three key themes emerged from analysing participant interviews. Siloed approaches to nutrition care reflected the diverse range of health care professionals responsible for nutrition care but who often worked in isolation from their colleagues. Competing work priorities for nurses reflected the challenge in prioritise nutrition care which was often constrained because of other care needs or work-related pressures. Helping patients to eat highlighted that nurses were often the only health care professional who would provide assistance to patients at mealtimes and lack of available staff could negatively influence patients' nutrition intakes.

Conclusions

We have identified many complex and interrelated barriers which preclude adequate dietary intake in acute medical patients. These predominantly reflect issues inherent in the hospital culture and environment. Multi-faceted and sustainable interventions that support a facilitating nutrition culture and multidisciplinary collaboration, inclusive of patients and families, are needed to address these underlying barriers.