RESEARCH

Review

A Systematic Review of Hospital Foodservice

Patient Satisfaction Studies
Immacolata Dall’Oglio, MSN, RN; Rosanna Nicolò, RD; Vincenzo Di Ciommo, MD, MSc; Natalia Bianchi, MSN, RN;
Gaetano Ciliento, MSN, RN; Orsola Gawronski, MSN, RN; Manuel Pomponi, MSN, RN; Marco Roberti, MSN, RN; Emanuela Tiozzo, MSN, RN;
Massimiliano Raponi, MD

ARTICLE INFORMATION ABSTRACT

Article history: The quality of hospital foodservice is one of the most relevant items of health care
Accepted 12 November 2014 quality perceived by patients and by their families. Patient satisfaction is considered a
Available online 27 January 2015 way of measuring the quality of services provided. The purpose of this study was to
retrieve and review the literature describing patient satisfaction with hospital food-
Keywords:
services. The systematic review was conducted on three electronic archives, PubMed,
Foodservice
Hospitalepatient satisfaction questionnaires Excerpta Medica Database, and the Cumulative Index to Nursing and Allied Health
Data collection/methods Literature (1988 through 2012), to search for any articles reporting patient satisfaction
Validation studies with hospital foodservices. A total of 319 studies were identified. After removing
duplicates, 149 abstracts were reviewed, particular attention being given to the pres-
2212-2672/Copyright ª 2015 by the Academy of ence of a description of the tool used. Thirty-one articles were selected and the full texts
Nutrition and Dietetics. were reviewed. Half the studies (n¼15) were performed in North America. Patient
http://dx.doi.org/10.1016/j.jand.2014.11.013 satisfaction scores were generally high, with some variation among hospitals and
different modes of food delivery that was investigated through intervention studies.
Qualitative studies were also reported (ethnographic-anthropologic methods with
interviews and focus groups). Quantitative tools were represented by questionnaires,
some of which relied on previous literature and only a few were validated with factorial
analysis and/or Cronbach’s a for internal consistency. Most analyses were conducted
assuming a parametric distribution of results, an issue not primarily tested. More
studies on the quality of hospital foodservice have been carried out in North America
than in Europe. Also, a variety of tools, most of which have not been validated, have
been used by the different investigating facilities.
J Acad Nutr Diet. 2015;115:567-584.

I
T IS WIDELY RECOGNIZED THAT FOOD AND OTHER
aspects of foodservice delivery are important elements in
patients’ overall perception of their hospital experience
and that health care teams have a daily commitment to
deliver appropriate food to patients.1-4 Provision of a foodser-
vice that not only meets but also exceeds the expectations of
the patient is considered essential for a quality service.5
The goals of a hospital foodservice are to provide inpatients
with nutritious meals that are beneficial for their recovery
and health, and also to give them an example of healthy
nutrition with menus tailored to patients’ specific health
conditions. When meals are carefully planned and custom-
ized to meet patients’ specific needs, and when patients
consume what they are served, these goals can be considered
as achieved.6,7 Accordingly, Hong and Kirk8 stated that meal
consumption by inpatients was a good indicator of dietary
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status and satisfaction with the foodservice. Furthermore,
foodservice quality is known to influence patient satisfaction
with hospital stay.9,10
Because the health care industry is increasingly competi-
tive and patients are becoming more discriminating about
quality, it has redefined patients, recognizing them as cus-
tomers,11 at least in the setting of a private health care in-
surance system like that of the United States.
The American Society for Quality defines quality in two
ways: “The characteristics of a product or service that bear
on its ability to satisfy stated or implied needs and a
product or service that is free of defects.”12 Defining
quality for hospital foodservice requires a balance between
these different features. Hospital menus should be based
primarily on clinical needs, as well as on patients’ prefer-
ences. Other important characteristics such as variety,
quality, and taste of food should be included. Moreover,
the hospital environment and a pleasant helpful attitude
of the nursing staff are important elements that should
be considered in a new qualitative approach to a complex
problem.13 Personal and sociocultural aspects have also
been identified as a main factor in acceptance of food
and in predicting food consumption.14 Thus, customer

ª 2015 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 567
RESEARCH
satisfaction with hospital foodservice is multifactorial and
difficult to assess. The problem is particularly evident in
pediatric hospitals because the customer is represented by
a child and his or her parent, each of whom has his or her
own expectations.
Surveys are limited in that they usually contain very few
general questions about foodservice, with the result that
there is not enough detailed feedback to precisely determine
patients’ wishes. Knowledge of patients’ expectations is an
essential baseline for monitoring and measuring the effect of
foodservice innovations or patients’ foodservice satisfaction
outcomes.15
The purpose of this study was to retrieve and review the
literature describing patients’ satisfaction with hospital
foodservices.
METHODS
A systematic literature search with electronic databases was
conducted for articles published from 1988 through 2012.
Inclusion Criteria
The main criterion of selection was the presence of an explicit
description of the instrument, tool, questionnaire, or in-
terviews applied to gather the data.
Search Strategy
Databases that yielded articles meeting the eligibility criteria
were MEDLINE (PubMed), Excerpta Medica Database
(EMBASE) and the Cumulative Index to Nursing and Allied
Health Literature (CINAHL). The search strategy used the
Medical Subject Headings and/or keywords: food preferences -
foodservice, hospital/standards - patient satisfaction - ques-
tionnaires and Boolean operator AND was used where
appropriate to combine the searches.
It was decided to extract data describing the population
being investigated (sample size and setting), the aim of the
study, and the pertinence of the study design; that is, if an
intervention was tested in a trial (ie, involving a particular
new food delivery system,3,13,16-22) or in an observational
investigation, including a comparison.3,11,23,24
Search terms included controlled terms from Medical
Subject Headings in PubMed and CINAHL headings in CINAHL
as well as free text terms. For EMBASE a search with free
words was applied. No limit was imposed except date of
publication: 1988 through 2012 (25 years).
Study Selection
Duplicate hits (ie, articles occurring in more than one data-
base) were identified. If the titles and abstracts appeared
relevant, then the full article was reviewed. Titles, abstracts,
and full text were evaluated independently by two readers to
identify those articles eligible for review. The evaluation
examined the pertinence of the studies to the issue of patient
satisfaction with hospital foodservices. Moreover, the inclu-
sion criteria had to be respected.
The articles that did not describe the data collection
methods used to evaluate patient satisfaction were excluded.
Data Extraction and Synthesis
Particular care was taken to assess the validity of the tools
described in the articles; that is, the extent to which the
568 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
questionnaires measured what they aimed to measure.
Briefly, it was ascertained whether the instruments (espe-
cially questionnaires) were assessed for presence of content
validity (comprehensiveness of different aspects), criterion
validity (association with a gold standard), and construct
validity (eg, evaluated by considering the extent to which the
tool is able to show the expected difference between two
groups of subjects).
Factor analysis, Cronbach’s a, and rotation were particularly
looked for. Briefly, the first is a well-established statistical
method for assessing construct validity, identifying groups
of answers demonstrating strong correlation among all the
answers within a group (named dimension or domain), and
weak correlations between answers within the group and
those outside the group. Eigenvalues (the total amount of
variance explained by each factor) are used to separate the
strongest attributes or factors from the weaker ones. Cron-
bach’s a measures internal consistency; that is, the extent to
which the items of a questionnaire are interrelated. Rotation
(a sort of transformation) minimizes the number of variables
of a structure and varimax rotation (the most commonly used
of many procedures) refers to the statistical procedure per-
formed to accomplish this task.
RESULTS
As shown by the flowchart (see the Figure), the total number
of titles and abstracts resulting from the searches and scru-
tinized for relevance was 205 from MEDLINE, 30 from
EMBASE, 74 from CINHAL, and 10 from manual search. The
literature search identified 319 articles, most of which were
from two archives: PubMed and CINHAL. The number of ar-
ticles was reduced to 149 after excluding items identified as
duplicates; a further 93 articles were excluded because the
title and abstract were not pertinent to the main study topic;
that is, patients’ foodservice satisfaction. Of the remaining 56
articles, 25 full texts were excluded because they did not
mention the data collection methods used. Texts were reex-
amined if there was any doubt about them meeting the in-
clusion criteria. Finally, 31 articles were included in the study,
as reported in the Table.
Figure. Flowchart showing selection of included studies in a
review of the literature describing patient satisfaction with
hospital foodservices.
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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice

Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Gregoire3 To compare patient General or 552 patients Questionnaires were Quantitative tools: patients’ Factor analysis Patients in hospitals where
satisfaction with medical/surgical 192 employees distributed by questionnaire with 16 with rotation dietary employees
foodservice hospital with employees to items, rated 1-5 (varimax) delivered meal trays rated
quality in 300-500 beds inpatients who Employees’ questionnaire identified the quality of food
hospitals where (n¼8 hospitals) consumed a regular with 20 items rated 1-5 2 factors: food significantly higher than
dietary (United States) diet for a minimum of quality and did patients in hospitals
employees 2 d. Questionnaires meal tray where nursing employees
deliver meals and were distributed to delivery; delivered trays.
in hospitals employees by Cronbach’s
where nursing department directors a estimated
personnel deliver but not
meals reported
Dubè and To identify the 1 acute care 132 inpatients The study was 2 items regarding Factor analysis Food quality was the most
colleagues35 psychological hospital conducted by means overall satisfaction followed critical dimension in
dimensions (Canada) of a questionnaire (a 7-point face scale) and by orthogonal explaining the overall
representing how distributed to the 26 specific items about rotation satisfaction of patients
patients perceive patients after 5-d stay foodservices satisfaction (varimax) with meals. Patient
the quality of (7-point face scale and satisfaction with meals is
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

foodservice and 5-point semantic significantly dependent on

which dimensions differential scale) satisfaction with food
best explain variation quality, customization,
in their satisfaction attitude of the staff who
deliver menus, meal service
timeliness, and meal service
reliability.
Gregoire23 To examine the Medical center 648 inpatients Questionnaires are Quantitative tool: 8-item Not investigated Ratings given by patients post-
relationship (United States) 1,648 distributed: questionnaire with discharge are less positive
between ratings post-discharge To inpatients in each 5-point scale ranging from than ratings given by
given on unit very poor to very good inpatients.
inpatient and To post-discharge
post-discharge patients by mail
questionnaires
with food and

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nutrition services

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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)
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Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

O’Hara and To identify food, Geriatric 65 inpatients Every patient was Quantitative tool: Not investigated Presentation of meals is the only
colleagues28 service, and continuing-care interviewed by 1 8 items; 7 questions were variable that predicts overall
patient variables units, geriatric of 12 trained scored on a 5-point scale satisfaction. More than half of
that predict rehabilitation volunteers from highly negative to subjects rated satisfaction as
overall patient unit, and highly positive response; 1 good/excellent.
satisfaction with physical question was scored on a
foodservice rehabilitation unit 3-point scale
(Canada)
Williams and To evaluate patient Pediatric oncology A total of 187 Patient satisfaction was Quantitative tool with Not investigated Both patients and parents were
colleagues16 satisfaction about setting inpatients evaluated before and 4 5 items much more satisfied with room
a new approach (United States) (number wk after the new service than with traditional
to foodservices of caregivers system implementation meal service; excellent ratings
that would unclear) increased by 35%.
improve patients’
oral intake
Lau and To examine Medical and 252 inpatients Inpatient questionnaires Quantitative tools: Investigated Courtesy of personnel: highest
Gregoire11 perceived quality surgical units 437 post- were distributed to all inpatients: 12 aspects but not ratings. Taste and quality
of food and (United States) discharge patients who received rated on a 5-point reported food: lowest ratings. Overall
nutrition services a meal tray scale. The questionnaire satisfaction higher in
using the ratings Another questionnaire was based on previous inpatients than post-
of inpatients and was mailed to research23 discharge.
post-discharge discharged patients. Quantitative tools: post-
patients Telephone interviews discharge: 5 questions
were conducted with from Press Ganey
patients whose overall questionnaire integrated
satisfaction declined with 9 questions
after discharge

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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)

Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Lambert and To determine Medicine and 395 inpatients Questionnaires Quantitative tools: Patient Validated by No significant differences found
colleagues17 whether there surgery 161 employees distributed to questionnaire with 16 previous amongst the 4 distribution
are differences department 19 foodservice inpatients consuming items, rated from 1-53 search3 systems.
in patients’, (19 acute care directors a regular diet for a Employee questionnaire3
employees’, hospitals) minimum of 2 d. Directors’ questionnaire
and foodservice (United States) Questionnaires were developed by authors
directors’ distributed to
satisfaction with employees and to
food and service directors
quality in hospital
using 4 types of
meal distribution
system
Oyarzun and To analyze the Surgical and 250 inpatients Patient satisfaction was The instruments were Not investigated: Patients satisfaction was high
colleagues18 efficiency and general evaluated before slightly modified from Reliability and did not change, whereas
effectiveness medicine unit and after the previous research11 quoted but nursing perception of patients
measurements (United States) implementation of 2 Quantitative tools: patient not reported satisfaction increased.
of a new patient new systems: spoken questionnaire included 11
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

foodservice menu (and later a new questions. Nursing

system that model that included questionnaire included 13
includes a spoken menu and statements regarding
spoken menu other additional nursing satisfaction and 9
features) questions regarding
nursing perceptions of
patient satisfaction
Hartwell To compare 2 Women’s health 180 inpatients Sample of dishes Consumer opinion cards Not investigated Scores not reported. Satisfaction
and hospital and orthopedic collected from 3 and qualitative interviews enhanced when there was
Edwards36 foodservice wards at a National consecutive meals, and about quality indicators of choice at the point of
systems: plated Health Service patients satisfaction, foods (temperature, flavor, consumption (cafeteria trolley
system and hospital were evaluated before portion size, texture, system). This system was also
cafeteria trolley (United Kingdom) and 6 mo after the opinion) associated with enhanced
system using new system overall consumers’
parameters of implementation. satisfaction.

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food safety Only patients on a
and consumer normal diet included
opinion

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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)
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Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Ferguson To develop and Acute care 125 patients Surveys to be completed 7 potential dimensions Factor analysis About 83.3% of patient
and evaluate a hospital receiving care were left with the of satisfaction were followed by satisfaction services is
colleagues27 simple, reliable, (Australia) from clinical subjects and collected identified. Subjects were orthogonal determined by 4 dimensions:
and valid tool nutrition no later than the also asked to indicate their rotation staff presentation skills, staff
for measuring service following day level of overall satisfaction (varimax) interpersonal skills, nutrition
patient with clinical nutrition and Cronbach’s supplements, and perceived
satisfaction with services, using a 5-point a coefficient health benefits. Cronbach’s
inpatient clinical Likert scale a>.90.
nutrition services
Folio and To evaluate patient Acute care 861 inpatients Patients were Quantitative tool: Not investigated Before implementation, “good” is
colleagues19 satisfaction with trauma hospitals interviewed 1 mo 9 items; all items provide the most frequent response.
the spoken menu (2 hospitals) before and after new answers on After implementation, there
system in (United States) system implementation 3-point scale (very good, was a significant improvement
comparison to good, fair) except for the in the number of “very good”
the traditional item on the amount (very, in all categories.
food-delivery quite, very fairly satisfied,
system not enough), variables
were collected by using a
modified version of a
survey tool during patient
interviews28
Watters To investigate Internal medicine, 39 discharged The discharged patients Qualitative methods: the The participants Patients thought that the food
and patients’ surgery, patients attended focus groups last part of the interview in the focus served in the hospital should
colleagues14 perceptions cardiology and 11 nurses The nurses attended involved questions groups completed be a model for a healthy diet.
of hospital Women’s Health 116 inpatients focus groups developed from the focus a validation Ongoing education and
foodservice and at a tertiary before Meal rounds involved group themes questionnaire communication with patients
which factors teaching discharge talking to inpatients to determine and nurses is important in
influence it hospital during their hospital how well the improving satisfaction.
(Canada) stay themes represented
their perceptions
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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)

Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Stanga and To obtain patient’s University hospital 309 inpatients The questionnaire Quantitative tool: Not investigated 86% of respondents were
colleagues24 opinions about and District was given to the questionnaire with 16 satisfied or very satisfied with
hospital food in Hospital patients and collected items, modified after hospital food.
order to improve (Switzerland) personally by the pretest on 20 patients There was a significant
menu planning investigators correlation between
and the food Patients who had trouble satisfaction with the food, the
delivery understanding the size of the portions, and the
process language of the survey range of choice on the menu;
were helped by there was a highly significant
dietitians correlation between food
satisfaction and its perceived
aroma and taste.
Wright and To evaluate 2 Medical, surgical, 540 discharged The 2 questionnaires Quantitative tools: Internal consistency WHFPSQ provides a more
colleagues15 questionnaires orthopedic, patients were administered PIQa: items ordered on tested with positive, more reliable
for measuring rehabilitation, simultaneously to the 5-point Likert scale from Cronbach a measure of food quality, meal
patient satisfaction and maternity same patients during a 1¼very poor to coefficient. service quality, and overall
with hospital units 2-wk period 5¼excellent; (WHFPSQ foodservice satisfaction than
foodservice (Australia) WHFPSQb:18 items ordered a¼.89, PIQ the PIQ. Because the WHFPSQ
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

on 5-point Likert scale a¼.75) differentiates the foodservice

from 1¼always to into several detailed
5¼never components, it is considered
more effective at identifying
specific areas where quality
interventions may be
required.
Williams and Clinical trial to Pediatric 200 inpatients Sequentially admitted Quantitative tool: 10 items, Not investigated Significant difference between
colleagues32 determine oncology with leukemia patients were each could be scored on a the 2 groups (scores not
whether patients setting or solid tumors randomly assigned to a 4-point scale from no/ reported)
eat more (United States) (number group that dined with never to always Patients who ate at the same
proteins and of caregivers a caregiver or to a time as their caregiver
calories when unclear) group that dined reported experiencing
eating with alone. A caregiver had significantly higher
relatives or when to be available to eat satisfaction with their

RESEARCH
they are alone all meals with the foodservice than those who
patient during the 3-d dined alone.
treatment period

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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)
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Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Capra To design a valid 2 public hospitals 1,807 hospital A sample of 1,807 Quantitative tool: WHFPSQ Factor analysis 6 statements loaded on 4 factors
and and reliable and 1 private inpatients and inpatients completed was refined, reducing the and Cronbach’s a accounting for 57% of total
colleagues26 questionnaire to hospital 540 discharged the questionnaire number of questions from variance (food quality, meal
measure patient (Australia) patients (pediatric and 21 to 18, and renamed service quality, staff service,
satisfaction with psychiatric units ACHFPSQc1 environment, with
acute care excluded) while eating Cronbach’s a¼0.61-0.89).
hospital at least 1 meal. The
foodservices remaining 540 patients
were recruited by
random selection of
discharged patients
Wright To explore the 2 public hospitals 1,807 inpatients Questionnaires were Quantitative tool: The Validated by There was a significantly larger
and factors that most and 1 private and 540 placed on meal trays. ACHFPSQ,26 which previous number of overall results in
colleagues4 affect consumer hospital discharged Other questionnaires contains 18 foodservice search26 the “very good” category. The
satisfaction and (Australia) patients were mailed to statements rated on a taste of meals was the most
to demonstrate participants recruited 5-point Likert scale from important determinant of
the empirical and by random selection “always” to “never” and an overall foodservice
practical value of from hospital mailing overall rating from “very satisfaction.
a detailed lists good” to “very poor”
foodservice
satisfaction
instrument
Edwards To measure A large teaching 57 inpatients Patient satisfaction was Quantitative tool: a Pretested with Greater acceptance of food was
and patients’ hospital 11 stakeholders evaluated: questionnaire with 15 qualitative obtained with the Steamplicity
Hartwell20 acceptance Postoperative (medical staff, during a 2-wk period items, and qualitative validity, not system
of the food surgical ward catering using the existing methods (semistructured otherwise Patients preferred the
provided and (United States) managers, cook-chill foodservice interviews) developed on investigated Steamplicity system in all
stakeholders’ visitors and operation the basis of literature and areas: food choice, ordering,
satisfaction with ward during a 2-week period previous research delivery, and food quality.
Cook-chill hostesses) using the new
April 2015 Volume 115 Number 4

foodservice Steamplicity process

operation and
Steamplicity (a
new cooking
process)

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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)

Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Wadden To compare patient Pediatric 40 in- and 2 randomly selected Quantitative tool: interview Not investigated Significant increase of
and satisfaction with oncology and outpatients patient groups were items were scored as satisfaction in overall
colleagues21 a room service hemodialysis surveyed before and 2 greatly exceed satisfaction quality,
menu style vs a (Canada) wk after expectations, exceed temperature, and variety of
traditional menu implementation of expectations, met food were noted after
room service menu. A expectations, did not meet implementation of room
parent was expectations, and service menu.
interviewed for therefore dichotomized
children younger than
age 12 y
Kuperberg To determine the Pediatric: oncology, 54 inpatients Patient satisfaction data Quantitative tool: Tested for face Room service resulted in
and effect of a new surgical, and were collected for the questionnaire with 6 items and content improved satisfaction with:
colleagues22 delivery system burns/trauma units 3 d before and the 3 and 4 possible answers: validity with food temperature, perception
room service (Canada) d during excellent, good, fair, and 35 patients; of food, meal-serving times,
model on patient implementation of the poor (adapted from ref 16) otherwise not and the perception that the
satisfaction room service model investigated food met patient needs.
Fallon To demonstrate A private, 551 inpatients 3 1-day surveys of Quantitative tool: The Validated by Patient satisfaction with the
and how the 440-bed foodservice ACHFPSQ26 previous foodservice at this private
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

colleagues34 ACHFPSQ can be hospital satisfaction were search26 facility was consistently high.
used to monitor (Australia) conducted in 2003-
trends in 2005
foodservice
satisfaction
Donini To verify, over A private geriatric 591 interviews Subjective assessment: Quantitative tool: 11 Not investigated The overall ratings of meals
and a 5-y hospital (subjective Interviews with questions for normal diets under observation improved:
colleagues29 period, the accredited by the assessment) questionnaires about and 6 for therapeutic diets, Positive opinions ranged from
course of the National Health from 2001 to normal or therapeutic with answers on 4 levels 18% in 2002 to 48.3% in 2006.
quality of the Service 2004 diets
institutional (Italy) and 572 meals
catering (objective
assessment)

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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)
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Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Naithani To evaluate a Cancer, renal, 764 inpatients The survey was Questionnaire: 27 items in 5 Factorial analysis Food access varied across
and new patient general medical, conducted during 3 or domains derived from (principal hospitals and wards,
colleagues13 experience- orthopedic, elderly 4 visits to the wards qualitative survey component compromised inpatients with
based measure geriatric, medical included (n¼29). The analysis and poor health, older age.
of food access admissions, and questionnaires were eingenvalues Development of a reliable and
for use in general surgical completed either by calculated), valid questionnaire measure
hospitals units (n¼4 self-administration or internal of hospital food access.
hospitals) by interview consistency
(United Kingdom) depending on (Cronbach a)
participants’ capacities reported
Tranter To identify themes Medical and surgical 1,077 patient Study data were Quantitative tool: Press Not investigated Temperature of hot food items is
and in patient-written units survey obtained from the Ganey quality the most frequently
colleagues33 comments about (United States) medical center’s questionnaire (“Meal” mentioned issue. Other
food-quality responses to Press section) with use of 3 prominent comments related
satisfaction to Ganey patient meals: questions assessed to receiving what was ordered
explore satisfaction on a 5-point scale. A space and choice/variety.
differences questionnaire is provided for comments.
among patients collected from Patient comments were
discharged hospital condensed into 5
patients comment themes (food
issue, receiving what was
wanted, satisfaction with
staff, general, and other)
Porter Explore patient 1 acute and 1 66 patients in 2 cross-sectional surveys ACHFPSQ26 Validated Satisfaction rate as “good/very
and satisfaction with subacute care 2006 and 51 of hospital inpatients by previous good” by the majority of
Cant37 hospital wards patients in were conducted search26 patients in both surveys.
foodservices (Australia) 2007 2 mo after the
from onsite and introduction of offsite
offsite cook-chill food production, the
production survey was repeated
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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)

Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Johns To study hospital National Health 41 inpatients, Respondents were asked Qualitative method: Coding Not investigated 144 positive and 81 negative
and foodservice Service hospital in randomly to list the aspects of and frequencies first, comments food/food quality,
colleagues39 the south of selected the hospital ‘‘meal followed by qualitative choice, and service staff were
England in medical and experience’’ that they analysis most frequently mentioned.
(United Kingdom) surgical wards liked and disliked
most, and to give
reasons for their
choices.
Respondents’ positive
and negative
comments were
entered into a
spreadsheet
Wright To develop a 9 residential aged 103 geriatric/ The questionnaire was 61-item questionnaire, Factor analysis Resident Foodservice
and foodservice care and 2 rehabilitation posed to a 5-point scale from “always” identifies a Satisfaction Questionnaire is a
colleagues31 satisfaction geriatric/ patients and convenience sample of to “never”: 9 items from short version 4-factor tool explaining 40% of
instrument rehabilitation units 210 aged residents. A structured the ACHFPSQ (Capra (4 factors þ 24 variance: meal quality and
that represents (Australia) care residents interview was used 2005), plus 8 items from items) and an enjoyment, autonomy, staff
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

residents’ with respondents who focus groups of dietitians extended form consideration, hunger, and
opinions and were physically or and 44 items from (12 factors, 37 food quantity.
incorporates visually impaired literature items). Internal
items that are consistency:
useful for Cronbach’s
foodservice a¼.64-.91
managers

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Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)
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Sample Data collection

Authors Aims Setting size methods Instruments Validity Results

Wright To quantify the 9 residential aged 103 geriatric/ The questionnaire was The Resident Foodservice Validated by Patient and resident
and relationship care facilities and 2 rehabilitation posed to a Satisfaction previous characteristics, and structural
colleagues30 between hospital-based patients 210 convenience sample of Questionnaire,31 with 37 search31 and systems-related
foodservice geriatric/ aged care residents and patients statements on a 5-points foodservice variables were
satisfaction, rehabilitation units facility of the units Likert scale more important for
foodservice (Australia) residents influencing foodservice
characteristics, (n¼313) satisfaction than
demographic characteristics of food quality.
and contextual
variables in
geriatrics/
rehabilitation
and residential
aged care
Jessri To investigate General medical and 98 inpatients Patients of a hospital Focus group and interviews Theoretical 3 categories of patients’
and inpatients’ surgical hospitals were chosen to saturation, dissatisfaction were problems
colleagues38 satisfaction (n¼5) participate in focus confirmability, concerning food quality and
with meals (Iran) groups; the themes and credibility quantity-related problems at
that emerged were reported the hospital-personal factors.
used to prepare an
interview for use with
patients of 4 other
hospitals in which
meal observation also
took place
Messina To measure 55 wards of a public 603 inpatients The questionnaires were Slightly modified version of Factor analysis Staff/service highly rated, more
and patient University Hospital distributed to the the acute care hospital (principal than food quality. Patient’s
colleagues40 satisfaction (Italy) patients by nurses or foodservice patient component satisfaction mostly influenced
with foodservice hospital staff using a satisfaction questionnaire analysis), by food quality.
in an Italian convenience sample (AHFPSQ): 21 items15 internal
April 2015 Volume 115 Number 4

hospital consistency
(Cronbach’s a)

(continued on next page)

 RESEARCH

Aims of the Studies Reviewed

3 main factors identified: food

quality, presentation, and
The main objective of most of the studies selected for this
review was to evaluate patient satisfaction with hospital food
and foodservice. Some studies also explored patient satis-
faction concerning health personnel.3,14,17,20,25 Only one study
explored food access in hospital, but it also gave information
delivery. about patient food satisfaction.13 Four studies focused on the
Results

validation of data collection instruments (question-

naire),4,13,26,27 and two of these also gave information about
patient food satisfaction.4,13

Setting
analysis with

The studies were conducted in different countries: Canada

component

(n¼5), the United States (n¼10), Italy (n¼2), Switzerland

rotation
Table. Characteristics of 31 studies included in the systematic review of patient satisfaction with hospital foodservice (continued)

Validity

(n¼1), United Kingdom (n¼4), Australia (n¼8), and Iran

Principal

(n¼1).
Most of the studies were conducted in adults, four of them
in a geriatric setting.28-31 Only four studies were conducted in
an inpatient pediatric setting.16,21,22,32 Two studies explicitly
to “strongly disagree”
from “strongly agree”

excluded psychiatric and pediatric units from their data

5-point Likert’s scale
12-item questionnaire,

collection.4,11 In addition to these two units, Tranter and

colleagues33 also excluded obstetrics, gynecology, and critical
Instruments

care units. Fallon and colleagues34 also excluded certain

units: intensive care, cardiac postoperative unit, labor ward,
nursery, and day surgery, whereas Dubè and colleagues35
only excluded long-termecare units.
period, and to evaluate

Comparison
the quality, ordering,

acceptability of food
delivery, and overall
questionnaires were
used to record food
intake over a 24-h

Seven studies compared new foodservice systems to tradi-

Data collection

tional food-delivery systems with the aim of improving

patient satisfaction.16,18-20,22,36,37 The new systems were
Standardized

provided

similar to a hotel room service. Patients ordered meals from

methods

an extended choice menu approximately 2 hours before

meal service. Six studies examined the relationship be-
tween ratings given on inpatient and post-discharge
questionnaires.4,11,14,21,23,26
167 stakeholders
National Spinal Injury 115 inpatients

Sample Size and Population

Sample

Twelve studies had a sample size <200 patients;14,16,20-

size

22,27,28,35-39
10 studies had a sample size between 200 and
600 patients,15,17,18,24,25,29-32,34 and nine studies a sample size
ACHFPSQ¼Acute Care Hospital Foodservice Patient Satisfaction Questionnaire.

>600 patients.3,11,13,19,23,26,29,33,40 Subjects were mostly in-

(United Kingdom)

WHFPSQ¼Wesley Hospital Foodservice Patient Satisfaction Questionnaire.

patients, but in some studies discharged patients11,14,15,21 or

outpatients21 were involved as well. None of the trials reports
any information about the power of the study.
Centre
Setting

Data Collection
Two different research methods were identified to assess
satisfaction: quantitative and qualitative methods. The
quantitative assessment of satisfaction was performed using
satisfaction with
food intake and

patients and by

questionnaires. The qualitative assessment was accomplished

Assess patients’

current food
provision, as

stakeholders

PIQ¼Parkside Inpatient Questionniare.

with interviews or focus groups.

judged by

There was great variation in the number of items among

the different questionnaires described in the studies. Seven
Aims

studies used questionnaires consisting of fewer than 10

items,16,19,22,23,28,32,33 11 studies used questionnaires with 10
colleagues25

to 20 items,3,11,15,17,18,20,24,25,26,34,37 and four studies used

questionnaires consisting of more than 20 items.4,13,35,40 Only
Authors

one study did not report the number of items on the ques-
and
Wong

tionnaire.21 All items of the questionnaires were rated on a

b
a

Likert scale and focused on factors like food quality (taste,

April 2015 Volume 115 Number 4 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 579
RESEARCH
amount, variety, and temperature of food), time of the meal
tray delivery, and staff/service issues (attention and cour-
tesy). Dubè and colleagues35 used a 7-point face scale, Wright
also added physical environment factors (hospital smell that
stops patients from enjoying meals, noise of finished meal
trays being removed, and chipped and/or stained crockery
and cutlery).4
Only two studies used focus groups to evaluate patient
satisfaction14,38: Watters and colleagues14 organized focus
groups with post-discharge patients, and the themes that
emerged were further explored through meal rounds in-
terviews with pre-discharge patients to determine areas for
improvement.14 Jessri and colleagues38 used focus groups to
prepare an open-ended interview guide. An open-ended
written form was used by Johns and colleagues,39 and the
most frequent themes were food, choice, and service staff.
Two articles based their questionnaires on the Press Ganey
patient satisfaction questionnaire created by Press Ganey
Associates more than 20 years ago.11,33 This company has
carried out patient-satisfaction assessment in more than
7,000 hospitals throughout the United States. The Press
Ganey questionnaire contains 39 standard questions, three of
which are included in a section entitled “Meals” (quality of
food, temperature of food, and courtesy of person delivering
meal tray). Each statement is rated on a 5-point scale ranging
from 1¼very poor to 5¼very good.
Many studies have not specified the time when patients
were interviewed.13,16,17,19,21,24,25,30,38 Some of the reviewed
studies were conducted during hospitalization, in particular
just before or just after arrival and consumption of the
meal.13,3,4,20,22,26,29,34,36,40 Four studies were conducted both
during hospitalization and after discharge of patients,11,14,23,26
and one only after discharge.4
Validity
Only six studies assessed validity and internal consistency
with appropriate statistical analysis (ie, factor analysis and
Cronbach’s a).3,13,26,27,31,40 Capra and colleagues26 reported
the results of the factor analysis with eigenvalues in one ta-
ble, and Cronbach’s values for each domain in another table.
Two studies explored validity with factor analysis25,35 and
one study only investigated internal consistency.15
Gregoire3 performed factor analysis on patient and
employee ratings to determine whether they could be
grouped into a smaller number of factors that would capture
the underlying dimensions. Items loading at 0.40 or greater
on only one factor were retained.
Naithani and colleagues13 tested construct validity with
factorial analysis. The principal component analysis gave a
low eigenvalue for the domain of food choice (0.83), and
internal consistency was poor for the same domain (Cron-
bach’s a¼.41). Naithani and colleagues13 constructed a
questionnaire in which the items were derived from the
qualitative data obtained from interviews with 48 men and
women on eight wards at two London teaching hospitals.
These qualitative data identified five key domains of people’s
experience of food access in hospital: feeling hungry, orga-
nizational, physical barriers, food choice, and food quality. A
draft questionnaire was developed with five domains and
response options were coded into a Likert-like scale with four
categories. To evaluate the internal consistency and validity
580 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
of the questionnaire, it was implemented in a survey at four
London hospitals.13 Ferguson and colleagues27 and Wright
and colleagues31 reported tables of correlations between
each item and factors, without reporting the crude results.
The study by Ferguson and colleagues27 specifically investi-
gated malnutrition in an adult acute hospital, reporting high
reliability (Cronbach’s a>.90 for all factors). The study by
Wright and colleagues31 reported the explained variances by
four factors of foodservice satisfaction, including meal quality
and quantity, with acceptable reliability (Cronbach’s a<.70).
Wright and colleagues15 only examined Cronbach’s a co-
efficient, but did not report the observed values. The authors
evaluated two questionnaires for measuring patient satis-
faction: the Parkside Inpatient Questionnaire (PIQ) and the
Wesley Hospital Foodservice Patient Satisfaction Question-
naire (WHFPSQ). PIQ contained items on a 5-point Likert
scale from “very poor” to “very good,” focusing on courtesy of
foodservice staff, flavor, and temperature of the food; menu
choice; and timeliness of meal delivery. WHFPSQ had 18
items rated on a 5-point Likert scale from “always” to “never,”
focusing on food quality, meal service quality, staff/service
issues, and physical environment. WHFPSQ obtained more
positive and more reliable measures of food quality, meal
service quality, and overall food service satisfaction than the
PIQ. This questionnaire was slightly modified to become the
Acute Care Hospital Foodservice Patient Satisfaction Ques-
tionnaire (ACHFPSQ).26
However, neither the article by Capra and colleagues26 on
the development and validation of the questionnaire, nor the
article by Wright and colleagues4 reporting the associations
of satisfaction with staff and characteristics of the meal re-
ported the outcomes.
Two studies applied principal component analysis to vali-
date the constructs of the questionnaires, but did not inves-
tigate their internal consistency.25,26
In the study by Wong and colleagues,25 validity was
analyzed in the context of an audit comprising a first ques-
tionnaire on food intake, followed by evaluation of the
foodservice and an open question concerning possible im-
provements,25 whereas no data are reported in the article by
Capra and colleagues.26
Dubè and colleagues35 analyzed data by factor analysis
followed by orthogonal rotation (varimax), after pretesting
four versions of the questionnaires to obtain easy to complete
formats. Kuperberg and colleagues22 tested the questionnaire
for face and content validity without reporting how this was
done. No crude results about satisfaction were provided. All
the other articles quoted journal articles containing the
original versions of the questionnaires, without reporting the
validity of the instruments.
During article analysis, one inconsistency was noted: in
Wright’s study, the ACHFPSQ questionnaire is said to contain
21 items.4 According to Capra, the ACHFPSQ questionnaire
has been reported to contain 18 items, whereas the previous
WHFPSQ questionnaire contained 21 items.26 However, in the
original article validating the WHFPSQ, it was described as
having 18 items.15
Outcomes
The majority of the ratings for food and nutrition service
were good or very good/excellent for all attributes assessed,
April 2015 Volume 115 Number 4

even if results are not always comparable. More than 80%
of inpatients of a Swiss hospital were satisfied (or very
satisfied) with food.24 Overall satisfaction was good in about
half of patients, the main factors being food quality, presen-
tation, and delivery.25 Similarly, Dubè and colleagues35 found
that food quality, customization, and attitude of the staff
were the factors significantly associated to satisfaction
with meals and with foodservice. Presentation of meals
was the only variable that predicted overall satisfaction
(P<0.001).28
Three articles used a questionnaire containing items clus-
tered in two factors: meal tray delivery and food quality.3,17,18
The first factor was relevant for the aim of the first study and
showed a preference for meal delivery by dietary personnel
rather than nursing personnel.3 Studies by Lambert and col-
leagues17 and Oyarzun and colleagues18 assessed different
distribution systems and the spoken menu respectively. No
major differences between the two factors were observed, in
any case with high scores (w4, on a scale of 1 to 5).
A similar degree of satisfaction was reported by Wright in
an article comparing ACHFPSQ with another questionnaire (a
median of 4.0, maximum score being 5); in the same article,
satisfaction increased with increasing age.15 The same ques-
tionnaire was used to monitor the foodservice, without major
change across three times (scores always >4 in all four di-
mensions, namely food and meal service quality, staff, and
environment),34 whereas scores were lower (most of them
3) in two surveys in the same institution carried out to
evaluate a model where food is cooked and then rethermal-
ized.37 In this last article, categorical data were also provided,
with around 80% of “good/very good” ratings and only 2% to
3% of “poor/very poor” satisfaction.37 An Italian study40 was
the only one to report the odds ratio of satisfaction, which
was mainly influenced by food quality (odds ratio 17.2;
P<0.001), followed by meal service quality (odds ratio 4.7;
P<0.001).
Another two articles used a modified version of the same
tool to investigate the change in satisfaction after discharge.
Gregoire23 found a decline, whereas Lau and Gregoire11 found
that all variables received mean ratings of good to very good
from both inpatients and post-discharge patients. The spoken
menu was shown to increase patient satisfaction,19 but the
results cannot be compared with those of the study quoted as
being the origin of the questionnaire28 because the very poor/
poor categories were removed.
A different perspective was investigated by Naithani and
colleagues,13 who investigated food access and found that
food quality in women, elderly patients, and in those with
self-rated fair/poor health carried a significant risk of food
access limitation.
Eight studies investigated the effects of some innovations
in foodservice mainly with a beforeeafter design.16,18-22,32,37
Of these, two used the same questions about satisfac-
tion16,22; both evaluated the influence of room service in
pediatric settings, allowing patients to select foods from a
menu in their room. Both showed an improvement in satis-
faction, as was also observed by a randomized trial in chil-
dren, but which used another tool.21 Another study, also a
randomized trial, was conducted in the hospital where the
first of the above-mentioned studies was carried out,16 but
the investigator (the same as for the first study) used a
different ad hoc questionnaire, finding higher satisfaction in
April 2015 Volume 115 Number 4
RESEARCH
the patients who ate with their caregiver. Unfortunately the
crude data were not reported.32
Two other investigations used the same instrument.3 The
first evaluated the introduction of a spoken menu (a food and
nutrition practitioner presented menus to the patients), with
or without additional features (eg, a menu for a fee), but
patients’ satisfaction was unchanged.18 In the second, no
difference was found between traditional foodservice (meals
delivered to patients by an employee or a nurse) and
nontraditional distribution (meals delivered by an employee
or nurse trained to provide a range of services).17 Another
instrument was used to evaluate the spoken menu and pro-
duced contrary findings, which suggest an improvement in
satisfaction, but that cannot confirm or refute the first evi-
dence.19 “Steamplicity” is another delivery system, wherein a
patient can order from an extended menu. An individual
chilled meal is then brought to the ward and cooked there in
a microwave oven. This delivery system was found to increase
satisfaction tested with ad hoc tools,20 whereas no increase
was observed comparing offsite to onsite production of the
meals.37
Food quality in women, elderly patients, and in those with
self-rated fair/poor health carried a significant risk of food
access limitation.13
Accessibility to food is one of the themes emerging from a
Canadian qualitative study,14 together with food quality, va-
riety, selection, and choice as well as service. All of these
factors figure among those most frequently mentioned in the
qualitative study by Johns and colleagues39 (food, choice, and
service). Food quality was also the first concern in the third
qualitative study, conducted in Iran (“It is as cold as ice.”),
where about half the patients were dissatisfied.38 Timing was
foremost among the hospital-related issues (“Breakfast
serving time is torture”) without specifying whether the time
of serving was too early or too late.38
DISCUSSION
In this literature review, 31 articles were found from seven
different countries (Canada, United States, Italy, Switzerland,
United Kingdom, Australia, and Iran) that explore patient
satisfaction with hospital foodservice. Seven of the articles
investigate patient satisfaction, relating interventions to
improve food delivery.17,18,19-22,36 The surveys were con-
ducted mainly in the specific context of private insurance-
based health care, and showed a rather good level of
satisfaction.
Our literature review shows several tools that have been
used to measure and monitor perceived quality regarding
hospital foodservice. These instruments may be qualitative or
quantitative. Focus groups belong to the qualitative study
design and their use was found to be functional for the
construction of the questionnaires used, because they allow a
better understanding of the service under investigation and
detect potential elements. Qualitative methods were used as
an approach to address further aspects of the issue that merit
a different, less rigid approach.14
The quantitative tools are represented by the question-
naires that are administered at the same time as, or after, the
provision of foodservice. Questionnaires have been the
standard method for evaluating satisfaction with foodservice
systems. However, questionnaires often lack information
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 581
RESEARCH
specific enough to be acted upon and it is more informative
to talk to patients about the meals they are receiving. O’Hara
and colleagues28 state that the questionnaire contributes to a
continuing quality assurance process that allows food and
nutrition practitioners to track the effect of changes made to
food and foodservices as well as to monitor areas that require
modification.
Few studies investigated the validity of the instruments
(questionnaires) they used. The analysis of instruments
revealed that many questionnaires (n¼13)16,17,19-
24,28,29,32,33,36
were not evaluated for validity or internal
consistency. Unlike quantitative methodology, qualitative
methodology, generally speaking, provides insight into the
patient experience and is more likely to shed light on factors
inducing dissatisfaction, as has been shown in several
studies.13,14
The open-ended questions often found at the end of the
questionnaires may evoke uninhibited and spontaneous
comments on the part of patients concerning the nuances
and specificities of the hospital foodservice, and may even
provide useful information for improvement. For example,
Tranter and colleagues33 suggest that respondents who
willingly provided additional written comments may have
had a more extreme opinion of food quality during their
hospital stay. In particular, the results of the research by
Tranter and colleagues33 suggest that respondents who pro-
vided written comments tend to give lower ratings for food
quality. Most importantly, patients’ written comments pro-
vide foodservice managers with detailed and specific infor-
mation useful for identifying concerns that cannot be
determined from simple satisfaction rating questions. The
comments revealed new areas that reflect patients’ needs and
influence their perception of food quality.
Among the quantitative approaches, some question-
naires,21,28 as used by Folio and colleagues19 but with the
addition of a question about the courtesy of the servers,
report the results—unlike other instruments—as proportions
of the single answers, without considering the values of the
Likert scale (1 to 5) as a continuous variable. Construct val-
idity was therefore not amenable to statistical evaluation
with the above-mentioned procedures, and results are easily
reported as proportions of the answers; for example, the
overall satisfaction scored as “very good” increased in the
Brandywine Hospital from 31.5% to 66.4% after the imple-
mentation of a new delivery system.19
Regarding analyses, it must be mentioned that nonpara-
metric distributions of frequencies (ie, quantitative variables
that do not show a Gaussian or “normal” distribution) were
never taken into consideration, whereas they should be
suspected in the event of greater frequencies of higher
values of satisfaction (ie, “excellent” or “good”). Except in
one article, nonparametric statistics, based on ranks (carry-
ing some loss of information), has not been applied, with P
values potentially inflated by the assumption of parametric
distributions.18
Hospitals are increasingly under pressure to document
patient satisfaction outcomes.41,42 At the same time, patient
satisfaction data are becoming an important tool for health
care insurance corporations to fund hospitals.43 Food satis-
faction in hospital is the result of an evaluation process that
does not always depend solely on the quality of the service,
but also on the prejudices and expectations of the patient. In
582 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
fact Gregoire3 stated that patient assessment of meal service
is multidimensional. Dubè and colleagues35 reported that
patient perceptions of foodservice could be represented by
seven dimensions: food quality, meal service timeliness,
service reliability, temperature of cold food, attitude of the
staff who deliver menus, attitude of the staff who serve
meals, and customization.
Other methods that could provide detailed information for
the exploration of patient food satisfaction are: focus groups,
interviews, and meal rounds that involve visits by members
of foodservice staff to patients during meal times to enquire
about food intake and satisfaction, as well as observing tray
setup, appearance of food, and need for feeding assistance.
When overall satisfaction ratings given by the same in-
dividuals, both as inpatients and after discharge, were
compared these ratings often changed; in many cases the
ratings decreased after discharge.11,23 This could be because
the patient feels freer to make more negative comments
when he no longer needs hospital care. In addition, the re-
sults of this research suggest that ratings given by inpatients
are not reliable predictors of their ratings after discharge.11
Gregoire3 stated that additional research is needed to
explore with patients why changes in ratings occur.
Another difficulty encountered in exploring patient satis-
faction with foodservice is the questionnaire length. Our re-
view shows that the validated tools are generally longer than
those that are not validated. In fact the nine validated ques-
tionnaires contain between 10 and 20 items,3,15,25,26,27 be-
tween 20 and 40 items,13,35,40 or more than 40 items.31
Longer questionnaires analyze more aspects of the issue
under investigation at the potential cost of less complete
answers. However, many hospitals used short questionnaires,
with fewer than 10 items.16,19,22,23,28,33
Two articles11,33 proposed administering the Press Ganey
satisfaction questionnaire44 to discharged patients to eval-
uate general satisfaction with the care provided. The Press
Ganey satisfaction questionnaire was created by Irwin Press
and Rodney Ganey for patient-satisfaction assessment in
hospitals and allows participating hospitals to measure their
satisfaction ratings against comparable institutions. On this
questionnaire, patients are asked to evaluate three aspects of
meals (eg, quality of food, temperature of food, and courtesy
of person serving tray); space is provided for written
comments.
Although questionnaires have been validated to explore
satisfaction in specific settings, such as residences/wards for
elderly persons,28,29,30,31 few instruments exist to measure
customer satisfaction related to foodservice, especially for
pediatric patients. Our review revealed that there are very
little data on pediatric hospital food satisfaction. The pedi-
atric setting is a particular area that requires special attention
and treatment. Children are considered to have special needs,
linked to reliance on parents and to the dynamics of their
family. This is obviously all related to the age of the child: the
younger or sicker the child is, the more important it is to
meet these special needs. In children with long-standing
illness, Williams and colleagues16 found that patient satis-
faction increased when the patient had more control over his
or her meals. When children and their parents lose this
control because of repeated hospitalizations, tests, and pro-
cedures, they strive to maintain some control wherever
possible.16 When children are granted more autonomy
April 2015 Volume 115 Number 4

concerning the timing of meals, they feel better and conse-
quently eat better. Children with cancer have little control
over the course of events in their lives and granting them
some control in this area makes a significant difference to
their happiness while hospitalized.16
The exclusion of some articles—for example, those with limited
validation procedures or different analyses—may be a limitation
of our review, but expanding inclusion seemed to add potential
distortions. It cannot be excluded that other results, even from
articles published more than 25 years ago or lacking data
collection methodology, could have contributed to our study.
However, our review did include studies with quantitative or
qualitative approaches, with or without interventions,
in different scenarios with the limitation of the explicit reporting
of the methods (eg, tools, data collection, and analyses).
Another limitation is the systematic distortion that may
affect all the reviewed surveys and which is caused by the
social desirability bias; that is, the attitude of respondents to
answer questions positively to satisfy the investigator. This
may be a possible explanation for the lower scores observed
after discharge in some studies.11,23 Studies involving inde-
pendent observers could help to avoid this distortion.
CONCLUSIONS
Hospital foodservices have the difficult task of delivering the
food that many and very different patients require, at the
right times, and in a complex institution. Nevertheless, ac-
cording to the literature, dissatisfaction seems to be quite
uncommon, at least in Western countries where most of the
studies are performed.
In these countries, patients’ satisfaction with hospital
foodservice has been extensively investigated in many
different contexts with the aim of ameliorating the quality of
the health services. To accomplish this aim, the measurement
of patient satisfaction requires the availability of simple,
sensitive, specific, validated, and reliable instruments.
Our review shows that different approaches have been used
to assess patients’ satisfaction with the foodservice, whether
qualitative or quantitative. In this context, many question-
naires have been developed and, with these tools, each insti-
tution is able to perform its own specific assessment, especially
to evaluate innovations in the delivery of food. Exploration of
patient satisfaction with ad hoc tools is tailored to the context
of each hospital but limits the comparability of their results so
that few firm conclusions can be reached. However, it can be
affirmed that patients’ satisfaction with hospital foodservice
does not only depend on food quality, but also on the way it is
presented and delivered; for example, provision of a spoken
menu and room service. It should be recognized that, whatever
the methods and the environment, every patient makes
an implicit comparison with his or her own home when
answering questions about satisfaction with hospital food-
service, and most of the results published should be considered
significant achievements.
Some facets have been ignored; for instance, the possibility
of nutrition education. Others have to be further explored; for
instance, in contexts where nutrition is a key element of care,
or where foodservice satisfaction is particularly difficult to
detect, as in pediatric settings. In fact, in the pediatric setting,
feeding must ensure the normal growth of children, despite
the difficulties caused by disease and/or its treatment.
April 2015 Volume 115 Number 4
RESEARCH
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AUTHOR INFORMATION
I. Dall’Oglio is a nurse manager, R. Nicolò is a research fellow, O. Gawronski is a nurse, and E. Tiozzo is nurse director, Professional Development,
Continuing Education, and Nursing Research Service; V. Di Ciommo is senior registrar physician, Epidemiology Unit; N. Bianchi is nurse director,
G. Ciliento is a nurse manager, M. Pomponi is a nurse manager, and M. Roberti is a nurse, Organization and Quality Nursing Service; and M.
Raponi is medical director, Medical Directorate, all at Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy.
Address correspondence to: Immacolata Dall’Oglio, MSN, RN, Professional Development, Continuing Education, and Nursing Research Service,
Bambino Gesù Children’s Hospital, IRCCS, Piazza S. Onofrio 4, Rome, Italy 0039. E-mail: immacolata.dalloglio@opbg.net
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
A grant from the Italian Ministry of Health supported this research.
ACKNOWLEDGEMENTS
The authors thank Alessandra Loreti, MSL, librarian at the Bambino Gesù Children’s Hospital, IRCCS, for literature retrieval, and Luisa Russo, a
Master’s in Nursing Sciences student at University of Tor Vergata-Rome, for her collaboration in the synthesis of some articles included in the
Table.

584 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS April 2015 Volume 115 Number 4