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More Food, Fewer Crises

a woman and a nurse talking and eating

It's lunchtime on Meyer 3, and patients head over to a small cafeteria in the unit’s lobby, where a steam table offers sloppy Joes, soup, green beans and fresh fruit. Nearby, a staff member stands behind a Formica countertop, organizing small bags of chips and pouring beverages. Once their plates are full, the patients take a seat at a nearby table and two nurses join them. Slowly, they begin to eat and talk. 

Few people outside the psychiatric realm would have any idea that new ground is being laid every time a meal such as this one rolls around. But the introduction of family-style dining last year has changed the atmosphere across  Meyer 3, a locked unit that accommodates up to 22 patients, many of them diagnosed with schizophrenia or affective illnesses, such as bipolar disorder. Initiated by the Hospital’s department of Food and Nutrition, the meals have been so successful that other psychiatric units in the departments of Psychiatry and Neurosciences are considering similar dining plans.

Until last year, the unit’s patient satisfaction scores regarding food service were abysmal, says Nurse Manager Patricia Sullivan. “There was this perception among the patients that the food wasn’t going to be good, that it was going to be cold, that people weren’t going to get what they ordered,” she says. “Something had to change.”

Before the switch, Meyer 3 patients selected from a menu provided a day in advance, just like most patients in the Hospital. Once they made their choices, there was no switching and no changing their minds. By the time the next day’s breakfast, lunch or dinner rolled around, however, many patients wanted something completely different. “Tastes change,” says Helen Mullan, the clinical nutrition manager for all of the Hospital’s adult units. “Patients may be in the mood for meatloaf today, but tomorrow they may not feel like eating a heavy meal.”

An unsavory or unsatisfying dinner may be no big deal for patients with a normal, healthy mindset. Indeed, most may forget their disappointment by the time their trays are cleared. But for patients with aggressive or violent tendencies, food service can be difficult, particularly when those patients become disgruntled. And the preordered trays added another layer of complexity.

Disorganized patients, dissatisfied with the contents of their own trays, would take food from other patients’ plates when they thought no one was looking. Some would grab the wrong tray entirely. Consequently, arguments broke out during what should otherwise be one of the pleasanter parts of the day. “We were actually seeing the most aggression by our patients during mealtimes,” says Amy Hardin, an NC-III on the unit.

woman eating with a fork

The meal plan’s rigidity was only one problem. Illiterate patients couldn’t read the menus; others forgot what they ordered. Then there were the patients with paranoia, who insisted on prepackaged meals. Meanwhile, some patients failed to order large enough portions and would still be hungry after they’d finished eating. And in a unit where many patients are admitted against their will—often brought in by family members or police—a bad meal makes an already difficult situation worse.

“When you’re in a hospital, you already feel like you have little control over your life,” says Karin Taylor, an advanced practice psychiatric nurse on Meyer 3. “Then, when a mealtime goes wrong, you think, great, now I don’t even have anything to eat. Family-style meals totally eliminate that, because patients can have what they want.”

Introducing that concept was Mullan’s brainchild. Last summer, concerned that food was creating too much strife, she and the rest of the dietary staff began contemplating how to make mealtimes less stressful. They found only two alternatives, however, that would work for their floor. One was individual room service, an option typically reserved for contagiously ill, bedridden or unstable patients. But room service was a bad idea on Meyer 3, where nurses say group settings help their patients develop some desperately needed social skills before they return to their communities.

While Mullan pondered family-style dining—their only other possibility—another group of nurses was formulating a new crisis-prevention program for the unit. They had heard about other hospitals’ success with family-style meals, so when Mullan presented the idea, they responded eagerly. The team hoped that by creating a more comfortable, trustworthy environment, they could prevent chaos before it struck. And, they thought, there was a good chance that offering flexible, choice-based mealtimes could eliminate much of the food-related dissension. 

“Food is the one thing patients feel like they know the most about,” Mullan says. “That’s why, in a hospital setting, patients are more likely to voice their opinions about food than anything else.”

So, in September 2006, the kitchen staff and nurses gradually began incorporating the change by rolling in the steam table for one or two meals a week, then for one meal a day, and finally for breakfast, lunch and dinner. Patient complaints decreased almost instantly. “By the time we introduced the third meal, 91 percent of patients on the unit were saying they were satisfied with the food service,” Mullan says. “They even said the food tasted better, even though it’s the same food. Just the presentation seems to make a difference to them.”

The meals provide patients with a more normal, real-world experience, similar to a regular cafeteria line. There is plenty of food to go around, and patients can select their meals at a moment’s notice, without any anxiety or fears of going hungry later.

“It’s more like what you would see on the outside,” she explains. “They don’t need to decide today what they’re going to be in the mood for tomorrow, or how hungry they will be.”

A dietary staff member is present at each meal to make sure patients don’t take more than they need or select items they shouldn’t have for medical reasons like diabetes. Meanwhile, to increase goodwill and communication between the care staff and patients, at least two nurses sit down in the cafeteria and eat with patients.

“To prevent crises, you have to create a trusting environment that makes patients feel like people are there to help them,” Taylor says. “Now, not only are they getting what they want, but the nurses are also eating with them. They realize we’re in this boat together.”

With today’s short hospital stays, eating together also allows nurses a rare opportunity to talk with patients about something other than illness, Hardin says. “We might not get to know that much about them personally,” she observes. “But at mealtimes they talk to each other and you get included in the conversation.”

Though there’s no research available to measure the benefits of family-style dining in psychiatric settings, there’s still good reason to believe it improves patient experiences. A recent study of nursing-home patients in the Netherlands concluded that family-style meals improved quality of life and promoted a healthier body weight. The study also concluded that eating together allowed patients more time to interact with staff members and one another.

The results are similar on Meyer 3. Satisfaction scores have risen, and patients praise the family-style meals in surveys distributed at the end of their hospital stays. Arguments and physical fights over food now happen rarely, if ever. Violence across the floor has decreased by 58 percent, something the nurses attribute at least partially to the family-style meals. Even paranoid patients, relieved to see staff members eating from the same serving dishes, rarely demand prepackaged meals.

“If people are satisfied with the food, they take that satisfaction and look at other things differently,” Taylor says. “It’s like in any situation: If you really like one part of something, it’s going to color how you look at the rest of the situation, whether you’re in a department store, a restaurant or a psychiatric hospital.”

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