Has the new All Wales Nutrition and Catering Standards for Food … · 2018-12-06 · 2009). A study on sensory alterations between in house catering and cook/freeze systems found

Dissertation DAN 6004 ST20000560

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Has the new All Wales Nutrition and Catering Standards for Food and Fluid for Hospital Inpatients improved the service? Patient survey.

Abstract

Background: Adherence to standards in nutrition and catering in a hospital inpatient setting has not been extensively studied, which poses questions on the status of current services. Aspects including large scale catering, varying dietary needs and financial constraints emphasise the complexity of ensuring all patients receive their daily requirements of food and fluid. This study aimed to survey hospitalised patients to obtain their opinions on food and fluid provision, and thus determine whether the new All Wales Nutrition and Catering Standards for Food and Fluid for Hospital Inpatients has improved the service.

Method: This pre-post study design uses a questionnaire to assess patients’ opinions towards meal choice, quality and satisfaction of food and fluid provision. Questionnaires were distributed across all Health Boards and one National Health Service Trust in Wales in 2013, and repeated in 2015 to monitor the implementation of standards.

Results: A total of 68% and 54% of questionnaires were returned pre-post study with improved response rates when research was dietetic-led. At baseline, findings were variable across aspects of food and fluid provision with few consistent trends between Health Boards and Trusts. Food choice was of a high standard with statistically significant improvements at lunch (p= 0.000012) and evening meal (p = 0.000011) post-study. Food quality was satisfactory with no statistical differences found (p = 0.431). Fluid provision was of a surprisingly poor standard with insignificant findings (p = 0.580). Snack provision post evening meal was also of a poor standard at baseline but showed statistically significant improvements post-study (p = 0.001). Despite the above, overall satisfaction significantly improved post-study (p = 0.013). Observational findings demonstrate satisfaction is likely to be influenced by an a la carte menu type, and less in conventional food production.

Conclusions: Findings were consistent with previous research that food and fluid provision is complex. A statistically significant improvement in patient satisfaction post-study demonstrates the success of the new All Wales Standards, influenced mainly by food choice and improved snack provision. Based on the findings recommendations have been made to focus future research on improving snack provision, fluid provision and food quality, considering food service systems and how these relate to satisfaction. Keywords: National Health Service, standards, hospital food, hospital catering, satisfaction, choice


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Introduction

Adequate nutrition and hydration is recognised as an integral part of patient care at all

service levels, with particular focus on promoting recovery, reducing hospital stays, reducing

mortality and collectively contributing to a more cost-effective National Health Service

(NHS) (WAG, 2012). With many aspects to consider, such as large scale catering, patient

diversity, varying dietary needs and financial constraints, it is a complex task to ensure that

all patients receive their daily requirements of food and fluid (Hickson et al., 2007).

Moreover, achieving equal opportunities across varying hospitals, Health Boards and NHS

Trusts generates a further challenge. The NHS in Wales plans, secures and delivers

healthcare services through seven integrated Local Health Boards (LHBs) and three NHS

Trusts. All LHBs and one NHS Trust will be considered in this study.

Policies, standards, procedures and guidelines are seen to act as a “bridge between

evidence and practice”, however there is a need to study their acceptance and influence in

practice (Rutten et al., 2013; p2). Their existence plays a vital role in assisting decision

making for practitioners and patients to improve safety and health, nevertheless studies

show recommendations described in clinical guidelines are not always followed (Grol &

Grimshaw, 2003). Standards are quantifiable, low level mandatory controls used to increase

productivity, drive innovation and promote the success of a service (The British Standards

Institution, 2016). The National Institute for Health and Care Excellence (NICE) (2012)

supports the use of quality standards, proven success in work efficiency and improved

patient care.

In Wales, a series of policies, standards and guidelines have been created, enforced and

restructured by the Welsh Government, to ensure patients receive the highest possible


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quality of food and fluids in hospitals (See Appendix 1). The All Wales Nutrition and Catering

Standards for Food and Fluid Provision for Hospital Inpatients (AWNCS) were the most

recent standards published in 2011 requiring full adherence by April 2013. The aim of the

standards was to provide an All Wales framework to reduce the prevalence of malnutrition.

See Appendix 1 for sections of the AWNCS that will be considered in this study.

Recent findings have shown 28% of adults admitted to hospital to be at medium-high risk of

malnutrition (Russel & Elia, 2014), predominantly associated with older age groups (>65)

and an increased prevalence in women. This has improved since previous studies (Russel &

Elia, 2009), however the current status underlines that malnutrition remains a concern

across Wales. The extent of malnutrition has increased public expenditure with an

estimated £19.6 billion spent on disease-related malnutrition in adults and children in

England alone in 2011-12 (BAPEN, 2016). These costs correspond with medical

complications, re-admissions, increased hospital stays and mortality. In Wales, malnutrition

screening is part of protocol on admission to hospital with good adherence reported (WAG,

2012; Russell & Elia, 2014).

Many patients depend on hospital food as their primary source of nutrition but may

continue to lose weight secondary to illness, increased nutritional requirements and poor

appetite (Allison, 2012). Nutrient intake could potentially worsen if patients are presented

with unattractive and unappetising meals. Studies have established that patients are getting

between 30-75% of energy requirements and up to 70% of protein requirements (Allison,

2012), which may have adverse effects on clinical outcomes and financial resources. This

supports the need for flexibility in meal provision, strict monitoring of nutritional intake and

the availability of appropriate nourishing snacks (Walton, 2012). Studies in healthcare


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settings have identified in-between meal snacks to improve nutrient intake and reduce

wastage (Fabian, 2001; Baic, 2011). See Appendix 1 for AWNCS recommendations on snack

provision.

The provision of fluids to promote good hydration status is equally important for hospital

inpatients. Research and strategic policy commonly focuses on improving nutrition

standards and the importance of hydration may have been overlooked (RCN, 2007).

Research supports a positive association between good hydration and the prevention of

clinical conditions, and that adequate hydration can reduce the use or improve the

effectiveness of medications (NPSA, 2009; RCN, 2007). Nevertheless, inadequate hydration

is not uncommon in hospital settings with dehydration emphasised as an “ongoing cause of

concern for patient safety” that could lead to morbidity and mortality (McGloin, 2015; p18).

A Welsh audit has studied methods of maximising fluid intake, such as the use of fluid

balance charts, with findings in agreement with previous research that oral intake is poorly

recorded and that the fundamental problem lies within poor education and inconsistent

documentation (Tang & Lee, 2010; Jenkins & Richards, 2010). A major UK study by Wolff et

al. (2015) concludes that dehydration on admission to hospital particularly from a care

home was common, leading to significant risks of in-hospital mortality. See Appendix 1 for

AWNCS recommendations on fluid provision.

The NHS in Wales has varying institutional characteristics including size, menu types, food

production and delivery systems, and financial allocation on food, which collectively could

impact on the quality of food and fluid provided. Studies have investigated the effect of oral

nutritional supplements against nutritional and economic outcomes, however few have

investigated outcomes against the quality of hospital food alone, where the clinical evidence


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base appears weak (Elia et al., 2016). The use of alternative feeding methods may reduce if

oral diet is improved. The Department of Health (2012) questions quality differences across

the NHS as the cost of meals can vary from £1.60 to £2.40 per meal in different settings

(Allison, 2012).

Hospitals in Wales use either a la carte or cyclical menu types. There has been little

investigation into whether one menu type alone has a greater impact on nutritional status

or patient satisfaction than another, or any long term trends associated with a particular

menu type. Supportive a la carte menus have been studied however with insignificant

findings in nutritional intake and timings of food ordered in comparison to hospital meal

times (Munk et al., 2013).

Temperature, appearance and texture can be altered during the transportation process of

meals. Satisfaction in these aspects is found to improve with a “point of service” system

when investigating pre-plated vs bulk trolley services (Hartwell et al. 2007; Mahoney et al.

2009). A study on sensory alterations between in house catering and cook/freeze systems

found some sensory characteristics to be altered, however few and insignificant when

compared against foods that underwent the “stimulated food journey” (Mavrommatis et al.,

2011). Although bulk trolley systems may appear more desirable, they may not always be

appropriate, particularly for critically ill patients where oral intake is compromised or in

smaller institutions.

Although many studies contrast in their findings, food quality, food choice and service

quality are themes frequently mentioned in patients’ opinions on hospital meal provision;

concluding views on hospital food to be mostly positive (Stanga et al., 2003; Johns et al.,


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2010; Hartwell et al., 2016). It is evident that patient satisfaction is multi-factorial and there

is a need to study this locally.

This study examines all perceived aspects of food and fluid provision associated with patient

experience from their perspective pre and post implementation of the AWNCS. The study

aims to quantify the impact of each aspect to identify current strengths and areas for future

focus and development. The study shows how standards can provide a framework to

improve food and fluid provision for hospital inpatients.


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Materials and methods

Design and Materials

This pre-post study type used a standardised questionnaire designed by Procurement and

Public Health Dietitians in Wales. The questionnaire was developed from an original survey

in Wales that had been piloted, and discussed with patient experience managers across

Wales to be amended to suit the requirements of this study. Questionnaire designs have

been used in similar topic areas supporting its use (Stanga et al., 2003; Naithani et al., 2009).

Pre-post study designs have also been used to assess guideline adherence (Paquay et al.,

2010; Rutten et al., 2013). It is argued that a more detailed, interview based research design

may provide more valuable research than a standardised questionnaire (Sheppard, 2004).

Nevertheless due to the size of the study, time constraints and ethical constraints of an

undergraduate dissertation, this would not be possible.

The questionnaire was designed to explore patients’ attitudes towards three main topics;

meal choice, satisfaction and support to eat. Previous research has confirmed the need to

not only assess the quality of food served, but patients’ attitudes towards variety and

method of delivery and more, to gain a true insight into the patient experience and how to

improve meal provision as a service.

The questionnaire design had a mixed approach of quantitative and qualitative style

questions. Selected quantitative questions were studied and used for analysis (Appendix 2).

The majority of questions were closed so analysis could focus on categories and reduce bias.

Existing research has shown a quantitative approach to be most suited to this research to


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examine relationships and associations, with questionnaires recognised as suitable

methodology (Offredy & Vickers, 2010).

Ethical approval was received from Cardiff School of Health Sciences Ethics Panel within

Cardiff Metropolitan University (Appendix 3).

Research participants

Recruitment took place during Spring 2013 and was repeated during Spring 2015.

Participants were recruited from six disciplines (acute medicine, acute surgery,

rehabilitation medicine, learning disability, maternity and mental health) across seven

Health Boards and one NHS Trust in Wales. As the hospitals varied in size and type, the

number of questionnaires disseminated was based on 20% of beds available in each Health

Board/Trust. Questionnaires were then allocated to each discipline based on National

Statistics to ensure the sample was representative of the research population. As the

researcher did not coordinate this research, the percentage allocation to each discipline is

unknown. It was the responsibility of nurses, dietitians and catering staff to coordinate this

research, with training provided on how to gain and record information correctly without

any influence, to reduce the possibility of bias. The study design considered question

wording, chosen question types and structure to further reduce survey bias. Not requesting

patient identifiable information, having a researcher present for question clarification, and

sectioned questions to ensure the layout was clear are examples of this.

Patients were approached through an unscientific randomised process based on a

discussion with ward nursing staff considering willingness to take part and communication

abilities, excluding those who were unable to participate. An extent of sampling bias is


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apparent as the probability of selection was not equal and vulnerable patients could have

been missed; thus indicating the sample may not be fully representative of the hospital

population (Bowling, 2009). Adult patients willing and able to take part in the questionnaire

across the six disciplines were included in the study. Exclusion criteria included those

outside of the named disciplines, those unwilling or unable to communicate, and children.

Procedure

When approaching patients the purpose of research was explained and consent gained.

Patients were instructed to either self-administer or complete the questionnaire with

assistance based on their current hospital admission. Research shows self-administered

questionnaires to be less susceptible to information bias, but also demonstrates advantages

to having a researcher present to clarify questions (Edwards, 2010). Communication

inabilities and inappropriateness of patients asked to participate were problems

encountered when collecting data; however guidance from ward staff reduced this.

Statistical analysis

Data were analysed using the Statistical Package for Social Sciences, version 22, for both

descriptive and inferential statistics. A scoring system was used to code data with a discrete

value for unanswered questions (Appendix 2). All data was included in descriptive analysis

and matched pairs for inferential statistical analysis using “exclude cases listwise” criteria.

The population was divided by year, question and often into health board/ trust to test for

significant differences.

Due to response rate variation the statistical tests available were limited. Questions

analysed aimed to determine whether improvements had been made by using paired


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sample t-tests to compare data from 2013 to 2015, such as meal choice, fluid and snack

provision. Paired sample t-tests were conducted assuming that the patients were

approximately matched pairs of subjects, based on demographic characteristics. Pallant

(2013) supports paired-samples t-tests use in pre-test post-test experimental designs when

data is collected on two different occasions. Their purpose is to identify whether mean

scores from time 1 and 2 are statistically different. The limitation to this test for the present

study is that different participants were used at time 1 and 2.

Observational analysis combined with statistical data was used to provide tables to explore

whether satisfaction varied with menu type, food production and food delivery systems.


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Results

1. Demographic characteristics and response rates

Table 1: Demographic characteristics across all settings studied.

2013 2015

Age Group Under 16 years 16-25 years 26-45 years 46-65 years 66-85 years Over 85 years

n = 1512 0.1 3.3 10.5 22.7 46.7 13.9

n = 1747 4.8 3.2 12.5 22.5 43.1 13.8

Length of Stay Less than 1 week 1-3 weeks 4-6 weeks More than 6 weeks

n = 1492 29.2 36.3 15.3 19.3

n = 1729 30 35.5 14.6 20

Figures are a valid percentage of patients

In both years patients were predominantly between 66-85 years with a hospital stay of 1-3

weeks. Over two thirds of the hospital population were aged between 46-85 years, and

around a fifth of patients had a hospital stay greater than 6 weeks.


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Table 2: Questionnaire response rates and coordination of research.

Returned questionnaires varied from 17-110% and 18-74% pre-post test, highlighting

worsened response rates in the majority of post-test research (68% to 54%). It is evident

that response rates were highest when research was coordinated by dietitians. Response

rates were lowest in setting 7 with research being nurse led. Comments provided from

research coordinators found poor response to be related to patient difficulty completing

questionnaires, nursing and catering coordinated research, and the inappropriateness of

mental health and learning disability patients.

Health board/ NHS Trust

Responsible for coordinating research

Questionnaires

2013 2015 Distributed Returned % Returned Distributed Returned % Returned

1 Dietitians 400 395 99 1010 746 74 2 Dietitians 280 249 89 350 221 63 3 Catering 470 310 66 580 264 46

4 Catering 50 55 110 70 32 46 5 Nursing 300 190 63 420 235 56 6 Catering 400 279 70 490 234 48 7 Nursing 360 62 17 440 78 18 8 Catering 40 17 43 60 26 43

Total 2300 1557 68% 3420 1837 54%


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Food provision

Table 3. Descriptive and statistical analysis from patient reported information on various

aspects of food and fluid provision pre and post AWNCS.

B= Breakfast, L = Lunch, EM = Evening meal NAV – not displayed in SPSS output Interpretation of Mean: 1 = 1.Never, 2.Sometimes, 3.Usually, 4.Always, 5.Not applicable 2 =1. Too few, 2.About right, 3.Too many, 4.Not applicable 3 = 1.Very good, 2.Good, 3.Average, 4.Poor, 5.Very poor 4 = 1.Never, 2.Sometimes, 3.Usually, 4.Always 5= 1. Extremely dissatisfied-10.Extremely satisfied


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2. Choice

Table 4: Patients reporting being given a choice and number of choices of foods at

mealtimes.

Figures are a valid percentage of patients B= Breakfast, L = Lunch, EM = Evening meal

Descriptive statistics show an improvement in the mean and reduction in standard deviation

in all post-test research related to choice and number of choices at meal times (table 3).

The percentage of patients who stated “always” receiving a choice of food at mealtimes

ranged between 79.1 – 80.8% pre-study and 81.3-82.9% post-study. Statistically significant

findings were found in setting 1 at evening meal, and settings 3 and 7 at lunch and evening

meal (table 3).

Are you given a choice of foods at mealtimes?

Never Sometimes Usually Always Not applicable

B 2013 3.1 3.7 10.9 80.8 1.5

2015 2.2 3.7 11.6 81.3 1.3

L 2013 3.5 6.1 9.9 79.7 0.8

2015 2.4 2.3 11.2 82.9 1.2

EM 2013 3.5 5.5 11.1 79.1 0.8

2015 2.2 2.6 11.3 82.6 1.4

What do you think about the number of choices offered at mealtimes?

Too few About right Too many Not applicable

B 2013 15 81.7 1.4 1.8

2015 14.6 82 1.7 1.7

L 2013 17.9 78 2.6 1.6

2015 15.6 81 1.9 1.5

EM 2013 19.1 76.9 2.6 1.5

2015 17.2 79.4 1.8 1.6


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The percentage of patients who stated the amount of choices at mealtimes to be “about

right” was 76.9– 80.7% pre-study, with improvements of 79.4– 82% post-study, however

this was statistically insignificant (table 3). Nevertheless, around 15-20% of patients report

there being “too few” choices, particularly at evening meal, although this improved post-

test. Significant improvements in the number of choices offered was found in setting 2 at

breakfast, and setting 7 at lunch and evening meal (table 3). Collectively, setting 7 showed

the most statistically significant improvements in choice and numbers of choice offered at

lunch and evening meal.

3. Quality

Table 5: Patients reporting various factors associated with food quality.

Question Very Good Good Average Poor Very Poor

Presentation/

appearance

2013 24.6 40.9 26.8 5.7 2.1

2015 20.6 42.6 29.2 6.0 1.6

Flavour/

Taste

2013 20.3 35.7 30.8 9.7 3.5

2015 17.9 38.8 31.6 9.0 2.7

Overall Quality 2013 22.1 38.2 27.8 7.8 4.0

2015 18.4 43.6 29.1 6.4 2.4

Figures are of a valid percentage of patients

Descriptive statistics show around two thirds of all patients (65.5%-63.2% pre-post study)

answered “good” or “very good” in response to their opinion on the presentation and

appearance of food, with slightly worsened findings post-test. Fewer patients thought the

flavour and taste of food was either “good” or “very good”, with over 10% answering “poor”

or “very poor” (13.2% and 11.7% respectively). Setting 4 showed a statistically significant


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improvement in presentation and appearance post AWNCS (table 3). However, flavour/taste

of food and overall quality showed no significant differences post-test.

4. Snacks

Table 6: Patients reporting snack provision post evening meal.

Are you offered a snack after your evening meal, but before 10pm?

Never Sometimes Usually Always Mode

2013 36.1 22.2 15.4 26.3 1

2015 27.3 24.1 17.4 31.2 4

Figures are a valid percentage of patients Mode: 1 = Never, 2 = Sometimes, 3 = Usually, 4 = Always

In response to being offered a snack post evening meal, the mode changed from “never” to

“always” pre-post study. A paired samples t-test confirmed statistically significant

improvements in half of all settings (table 3). Despite improvements in overall snack

provision, less than a third of patients stated “always” receiving a snack and over a quarter

of all patients stated “never”.


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5. Fluid Provision

Table 7: Patients reporting fluid provision at mealtimes.

Are you offered a drink at mealtimes?

Never Sometimes Usually Always 2013 5.4 9.9 18.1 66.5 2015 11.9 7.2 15.6 65.3

Figures are a valid percentage of patients

In both years the majority of patients stated they “always” received a drink at a meal time

(66.5%-65.3% pre-post study) with statistically insignificant differences (table 3). Over a

third of patients report a response other than “always” to receiving a drink at mealtimes,

with the amount of patients reporting that they “never” received a drink worsening from

5.4% to 11.9% post-test. These findings demonstrate scope for improvement to improve

fluid provision.


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6. Food Service Characteristics

Table 8: Summary of setting characteristics related to post-test mean satisfaction of food

and fluid.

*1 = extremely dissatisfied, 10 = extremely satisfied

Most settings used a cyclical menu type, bulk trolley service system and cook freeze

production. There was variation within different hospital sites of some settings (5, 6, 7)

which were not studied further. From observation, the highest mean satisfaction is

associated with an a la carte menu (setting 8 and 2 pre-post study). The lowest mean

satisfaction was associated with a cyclical menu type but varied in the delivery service and

food production (setting 1 and 7 pre-post study).

Health

board/

NHS Trust

Menu

Type

Food service system Food production

technology

Mean Satisfaction 2013 (1-10)*

Mean Satisfaction 2015 (1-10)*

1 Cyclical Bulk Trolley Cook freeze 6.79 7.21

2 A la carte Bulk Trolley Cook freeze 7.61 8.30



5 Cyclical Bulk Trolley/Pre-plated Cook freeze/Conventional 7.79 7.61

6 Cyclical Bulk Trolley Cook freeze/Conventional 7.20 7.75

7 Cyclical Bulk Trolley/Pre-plated Conventional 6.95 7.08

8 A la carte Bulk Trolley Cook freeze 8.81 7.77

Overall Mode

8 8


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Satisfaction improved across 75% of settings (mean satisfaction improvement from 7.2 –

7.43/10 and statistically significant improvements in settings 1 and 6 (table 3). The mode

response across all settings was stable at 8/10 satisfaction.


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Discussion

This study aimed to examine, from the patients’ perspective, all perceived aspects of food

and fluid provision associated with patient satisfaction pre and post implementation of the

AWNCS. The study aimed to quantify the impact of each aspect to identify current

strengths, areas for future focus and development and demonstrate how standards can

provide a framework to improve food and fluid provision across the NHS in Wales.

The ethos of this research subject presented several limitations. It is acknowledged that this

study focuses on hospital inpatients in Wales alone and therefore findings may not be

transferable to other geographical locations. The extensive range of questions asked and

closed question types provided restricted information. This resulted in difficulty assessing

which aspects are the main contributors towards improving food and fluid provision,

although current literature emphasises satisfaction to be multi-factorial (Dall’Oglio et al.,

2015). An advantage, nonetheless, is that this study can be used to identify areas to focus

on in greater depth, possibly using focus groups or qualitative analysis. Stanga et al. (2003)

and Naithani et al. (2009) support quantitative analysis in similar studies.

The study promotes validity by including all data for descriptive analysis and matched pairs

for inferential statistics using paired samples t-tests. The disadvantage was that matched

pairs required answers from both years; resulting in data being excluded if one year had a

higher response rate than its paired data. This may have meant hospitals within a setting

were not given equal opportunity to be included in analysis. Paired samples t-tests

additionally assumed study participants were the same pre-post study (Pallant, 2013), but

this was untrue.


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As the researcher did not conduct the study, information was not provided on how the

AWNCS were implemented into each setting which could have impacted the compliance

and consequently study findings. The AWNCS is an extensive document consisting of

numerous aspects of food and fluid provision for the multi-disciplinary audience. The

complexity of guidelines may not be “understandable and usable for all target groups” with

varying education backgrounds (Francke et al., 2008). The AWNCS does use menu planning

as a practical method of encouraging compliance. NICE (2012) standards provide

accompanying guidelines and explain the purpose to each audience to promote

implementation, which has resulted in positive outcomes.

Questionnaire response rates were not a true reflection of patient responses but more how

successful each Health Board/Trust was in disseminating questionnaires. Responses were

variable (table 2), worsened post-study (68-54%) and did not reflect the anticipated sample

size. The quantity of questionnaires required to gain a representative sample across each

discipline was also unknown. The present study did not record refusal rates meaning the

extent of this is unknown. Collectively this may reduce the external validity of findings. It can

be assumed that an increased response rate would promote validity and representation of

the sample however power calculations are required to confirm this. Literature from studies

with a similar aim and method demonstrate inconsistencies in response rates, from 72%

(Naithani et al., 2009) to 97.5% (Stanga et al., 2003). It is likely dietitians had a greater drive

to improve response rates as the study purpose is within their profession and area of

interest, which could be a key consideration in future research. Dietitian led programmes

has shown to improve response rates and outcomes in relevant clinical areas (Hartmann-


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Boyce et al., 2015). The demands of nursing and catering roles may explain poorer

responses.

Findings from the study showed patients’ attitudes towards the aspects of food and fluid

provision studied to be mostly of a high standard, with implementation of the AWNCS

improving the service. The demographic characteristics including age group and length of

stay were found to be comparable pre and post-study promoting validity of study findings.

At baseline and follow-up, food choice was of a high standard with improvements shown at

each mealtime post-study, although no significant differences. This supports previous

research that food choice improves patient satisfaction (Johns et al., 2010). Around a fifth of

all patients reported choices of food to be “too few” at mealtimes, which may have

impacted satisfaction and could be a future investigation focus. Setting 7 showed

statistically significant improvements related to patients reporting receiving a choice and

the number of choices offered, however due to a poor response rate it is unknown whether

these findings are representative of the setting population.

Quality of food served including presentation, appearance, flavour and taste were rated

lower than expected which to some extent conflicts previous findings (Johns et al., 2010;

Hartwell et al., 2016). Assuming satisfaction was related to responses of “very good” or

“good”, less than two thirds were satisfied with overall food quality, with flavour/taste

scoring contributing to a lower satisfaction than presentation and appearance. There were

no overall significant differences related to all questions on food quality, with only one

setting showing a statistical difference post-study in presentation and appearance (setting

4). These findings emphasise that the quality of food directly impacts up on patient


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satisfaction and it would be valuable to investigate this against food service characteristics

to understand where improvements can be made.

The questionnaire gained limited information on fluid provision due to the sole focus at

mealtimes. The post-study questionnaire recognised this however data was not included as

comparisons could not be made. Findings showed around one third of all patients “always”

receive a drink at mealtimes, with no statistical differences post-study. As a mandatory

requirement of the AWNCS to receive a drink at mealtimes (WAG, 2012), this questions

whether fluid provision is any better at other times of the day, and therefore would

question whether patients receive the minimum fluid requirements of 1.5 litres a day (WAG,

2012). These poor findings reflect earlier conclusions that inadequate hydration is not

uncommon, increasing the risk of morbidity and mortality, and is subsequently an ongoing

concern for patient safety (McGloin, 2015). It would be beneficial for future research to

quantify total fluid intake of patients to compare to the ANWCS; focusing on identification

of barriers to meeting fluid requirements.

The AWNCS state all patients should receive a snack after their evening meal as the gap

between an evening meal and breakfast can be extensive (WAG, 2012). This question

produced the most statistically significant findings in the study, with half of all settings

showing a significant improvement and resulting in an overall statistical difference post-

study. Although improvements are acknowledged, baseline and current snack provision

were poor with less than a third of all patients stating they “always” received a snack after

their evening meal. Subsequently, there is still scope to improve adherence to fulfil the

AWNCS requirements for mandatory snacks post evening meal to assist in reducing the risk

of malnutrition (WAG, 2012).


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A recent study (Hartwell et al., 2016) agrees with a previous meta-analysis (Dall’Oglio et al.,

2015) that food quality and service quality were the highest predictors of patient

satisfaction. Aspects associated with food service, including menu types, food production

and delivery systems may reduce the acceptability or alter sensory perceptions of foods

(Johns et al., 2013). Food service characteristics were compared with overall satisfaction of

food and fluid, with observational findings suggesting an a la carte menu type was the

influential factor for the highest mean satisfaction (setting 2 and 8). It could be assumed

that this is due to more variation in choice rather than flexibility in timings, as research has

shown little difference in the timings between different menu types (Munk et al., 2013). The

lowest satisfaction post-test was associated with conventional production. It was difficult to

investigate further which aspect was most responsible for satisfaction due to variations

within Health Board/NHS Trust. Mavrommatis et al. (2011) recognised there was no method

to predict patient satisfaction related to quality of food and could not investigate different

service systems because of this. The authors additionally found bulk-trolley delivery to have

a better accepted texture and flavour in comparison to pre-plated, however changes were

minor and is unlikely to be the causal factor of satisfaction, supporting investigation into

wider areas of food provision. It would be useful for future research to compare food choice

with menu types.

Patient satisfaction is a method of measuring the quality of a service, with food and fluid

provision known to be multi-factorial. Mean satisfaction varied from 6.79-8.81/10 to 7.08-

8.30/10 pre-post study, with an overall statistically significant improvement. Combining all

aspects of food and fluid provision studied, this demonstrates the service to be of a high


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standard at baseline with improvements made post-study. These findings are consistent

with previous meta-analysis that dissatisfaction is uncommon (Dall’Oglio et al., 2015).

Whilst aspects of food and fluid provision are improving, it is recommended that

subsections of this study including food quality, snack provision and fluid provision require

greater investigation. It would be useful to understand why these are not of a higher

standard, focusing on barriers to change and practical methods of improving outcomes. This

should consider analysis at hospital level, and individual food service characteristics, in order

to generalise results. The AWNCS have stated the standards will be monitored at ward and

organisational level to understand how the service is changing and will highlight areas for

future focus (WAG, 2012). The findings from this research may influence dietetic practice as

to where and how dietitians focus future audits to assist in improving outcomes.

Furthermore, it could be beneficial to promote awareness to NHS workers and stakeholders

on the importance of the AWNCS to encourage compliance.

In conclusion, a significant improvement in patient satisfaction demonstrates the success of

having standards in place for food and fluid provision for hospital inpatients. This study adds

to existing evidence that food and fluid provision is complex and agrees with findings from

previous authors that the quality of food and food service characteristics (Johns, 2010;

Johns, 2013; Hartwell et al, 2016), as well and snack and fluid provision, can improve patient

satisfaction. Dietitians could play a key role in improving compliance through future audit.

Acknowledgements: The researchers would like to thank Jessica Bearman (Procurement

Dietitian) and Judith John (Public Health Wales Dietitian) for their contributions to the study.

Word Count: 5439 words


26

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