Who defined nursing as assisting service to person who are wholly or partly dependent when they are no longer able to give or supervise their care?

Feeding completely dependent persons is a common activity in many health care settings; however, it has received relatively little attention by researchers. Recently, there has been a call for nurses to revisit some of the so-called “basic” tasks that have been eliminated from nurses’ responsibilities and relegated to non-professional staff. This article details an analysis of the findings of ten published qualitative research reports about feeding completely dependent persons who are elderly. Drawing on procedures of meta-ethnography described by Noblit and Hare (1988), Meta-Ethnography: Synthesizing qualitative studies Newbury Park: Sage Publications) and later by Paterson, Thorne, Canam, and Jillings (2001), Meta-study of qualitative health research. A practical guide to meta-analysis and meta-synthesis Thousand Oaks: CA Sage Publications), the authors identify two central themes within the primary research; feeding as task and feeding as relationship. Based on the meta-ethnographic findings, two areas for future research are suggested; exploring structural and institutional influences on the feeding practices of health care providers and exploring how nurses mediate the tension between the relationship and task perspective of feeding completely dependent persons.

Many persons in hospitals, nursing homes and their place of residence require complete assistance from another to receive food by mouth. Such people are considered completely dependent in regard to feeding (Nettina, ). Humans suffering from dementia are often dependent in terms of feeding (Bäckström, Norberg & Norberg, ) but also conditions such as stroke, multiple sclerosis and Parkinson's disease in some cases may lead to feeding dependencies (Bäckström et al., ). When a person is totally dependent and must be fed by a caregiver, they need to coordinate their behaviour in both technical and artful ways. In order to achieve this, the two persons involved must be able to perceive and interpret one another's verbal and non-verbal behaviour (Athlin, Norberg & Asplund, ) and to respond accordingly. The main responsibility for this cooperation lies with the feeders. Their experiences, educational background and personal beliefs may influence the course of the mealtime for both themselves and the person involved (Kowanko, ; Kowanko, Simon & Wood, ).

The feeding of completely dependent persons in health care settings is considered a basic and elementary nursing skill that is taught to beginning nursing students as one of their primary roles (Jilka, ); however, little empirical evidence exists about the nurse's role in regard to feeding such persons. The nursing literature pays little attention to the art of feeding completely dependent persons beyond the technical aspects of preventing aspiration and, to a lesser extent, assisting people with dementia to focus on eating.

Some researchers have lamented that feeding completely dependent persons is now considered by many nurses to be a non-nursing task (Kayser-Jones & Shell, ; Kowanko, ; Kowanko et al., ; Pearson, ; Xia & McCutheon, ). These authors consider feeding to be a significant nursing intervention, particularly because they have determined that when completely dependent persons are not fed appropriately, their quality of life and nutritional status may be negatively affected (Kayser-Jones & Schell, ; Kowanko, ). They suggest that empirical research regarding feeding completely dependent persons could provide insights about the nurse's role in this regard.

In the following article, we will present a meta-ethnography of ten qualitative studies that investigate the experience of feeding completely dependent elderly individuals in health care settings. Although several of these research reports do not centre specifically on nurses feeding completely dependent persons (i.e. the feeders may be aides or non-professional health care workers), we will demonstrate that a meta-ethnography of qualitative research regarding feeding completely dependent persons will reveal both the art and the science of this nursing role. To conduct the meta-ethnography, we used the procedures initially outlined by Noblit and Hare () and further elaborated by Paterson, Thorne, Canam, and Jillings ().

In the article, we will identify the central metaphors that are represented in the ten published research reports. We will draw on these metaphors as the foundation for our discussion about the implications of the research findings for our current understanding of nurses’ roles in feeding completely dependent people. We will conclude the article with a discussion about what is currently missing or ambiguous in this body of literature that has implications for future research in this area.

Paterson and colleagues (2001) caution that a theoretical framework is necessary in a meta-ethnographic study to delimit the analysis to the boundaries of the researchers’ particular interests. The theoretical framework that we have selected for this meta-ethnography is the theory of the art of nursing by Chinn (). According to Chinn, the art of nursing is revealed in nursing practice that includes determining the meaning of the experience, establishing a meaningful connection, performing nursing activities in skilful and sensitive ways, making decisions based on the evidence that is known, and performing nursing activities in an ethical and moral manner. She describes the art of nursing as deeply embedded in an understanding of nursing, including theory, technical skills, personal knowing, and ethics (Chinn, ). She proposes that nursing is not a series of activities and skills but an integrated pattern of knowing that forms the whole of the nursing experience and practice as a “healing art” (Chinn, , p. 288) and that this art requires knowledge of human experience and knowledge of the art itself.

We used Chinn's () theory of nursing art to direct the sampling procedures for the meta-ethnography; e.g. we included only research reports that articulated the nature of the feeding experience, including how the practitioners integrated their knowledge in their feeding practice. We also drew on the framework in our analysis of the findings. For example, we compared the data that were reflective of feeding as a task with those that portrayed feeding as relationship to search for ways in which the various forms of knowing articulated by Chinn () were evident. We categorized the findings in terms of the caregiver's knowledge of human experience and knowledge of the art of feeding completely dependent people that were illustrated in the descriptions of feeding in the primary research included in this synthesis.

Meta-analysis of qualitative research has been assigned various terms, such as meta-ethnography (Noblit & Hare, ) and meta-data-analysis (Paterson et al., ) but these share common methodological procedures and assumptions. Noblit and Hare () are the developers of meta-ethnography, which entails an analysis of the research findings that are reported by primary researchers. It is essentially an analysis of the analysis of research data provided by primary researchers in their reports of the research (Paterson et al., ). In meta-ethnography, the researcher compares the findings of individual research studies with those found in all primary research reports and in a sample of primary research that has been selected for analysis.

The following computerized bibliographic databases were used to search for primary research reports: Web of Science, Academic Search Elite, Health Source: Nursing/Academic Edition, MEDLINE, CINAHL, Digital Dissertations, and Embase (1980–2006). The searches were conducted in 2006. Initial attempts to search for these reports using the search term “feeding” was largely unsuccessful as the term elicited articles about breast feeding, enteral therapy, or feeding partially dependent persons. The terms “feeding behaviour” and “feeding methods” in combination with the terms “nursing” and/or “caring” were more productive for the purposes of the meta-ethnography. Papers about “breast feeding” and “enteral nutrition” were excluded and the search was limited to “all adults over the age of 18”.

The search resulted in 138 publications. Several of those reports referred to use of Katz’ and Akpom's () Activities of Daily Living (ADL) Index to specify the persons as completely dependent. Their interpretation of this index was not faithful to the original definition of complete dependency in feeding as developed by Katz and Akpom () who defined complete dependency in feeding as “assistance in the act of feeding”. Several researchers interpreted this to include persons who needed assistance in terms of pre-cutting their food, pouring liquids and buttering bread. Consequently, we excluded research in which the primary researchers’ conceptualization of complete dependency included partial dependency attributes. The research reports that were deemed relevant to our purposes were written in English, German or French; we were able to read those in English and French but we asked translators to translate those written in German.

During the initial search of the databases, we scrutinized the citations for titles that suggested relevance to the meta-ethnography. Then the abstracts of those titles with relation to the subject were reviewed and if the abstract had any relevance, the article was identified and read in its entirety. A publication was selected if it described a study that included at least one participant who was totally dependent on help from others during meals whether the dependency was temporary or permanent. Another important criterion was that it should be possible to discern findings related to complete dependency from other results. The selected publications had their reference lists scrutinized for additional literature not retrieved in the databases. The search resulted in ten scientific papers suitable for inclusion in the meta-ethnography and all but one of these focused on the perspective of the practitioner.

The selection criteria that we used for inclusion in the meta-analysis were:

1. the researcher(s) investigated feeding by mouth of completely dependent persons in health care settings, such as the hospital or long term care facility, from the perspective of either the person who was being fed or the feeder

2. participants were adults (18 years and older);

3. the research approach was qualitative;

4. the researcher(s) focused on the feeding of completely dependent persons either as a sole focus or as a discrete phenomenon within the study; and

5. the findings were reported as detailed, descriptive textual or narrative accounts of the phenomenon under study.

We did not include studies in which feeding included gastric tube feed or enteral feeds, even if these were in combination with oral feeding.

There is considerable debate among researchers who conduct qualitative meta-synthesis research (e.g. Eastabrooks, Field & Morse, ; Jensen & Allen, ; Paterson et al., ; Zimmer, ) about whether primary research reports should include studies with various methodologies or the same research approach. Sandelowski and Barosso () have clearly articulated the challenges with attempting to discern if a research report is truly representative of a grounded theory study, an ethnography, or another qualitative research method. Taking their lead, we chose to exclude only those reports that we did not consider as qualitative research. Typically data in such reports were open-ended answers to a structured interview; i.e. a list of words or phrases or responses categorized by percentages or numbers of the participants who answered in this way.

An overview of the selected studies is found in . Most of this research emanated from North America and Sweden. The focus of all but one study was the experience or perceptions of practitioners in feeding; the perspective of completely dependent persons in this body of research is largely neglected. The research methods used were largely generic descriptive in the 1980s. In the 1990s and 2000s, specific research approaches were named, such as grounded theory and ethno-methodology. Five of the primary research studies were conducted in nursing homes. The remainder occurred in a variety of elderly or mental health care facilities or in hospitals. Observation of feeding, at times combined with interview, was the most common data collection strategy.

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We followed the steps for identifying, comparing and contrasting the findings of primary research reports as detailed by Noblit and Hare () and expanded by Paterson and colleagues (2001). We began by identifying key metaphors (see ) that are evident in the primary research findings. Key metaphors are words, phrases, ideas, concepts, themes, or categories that encapsulate the essence of the research findings. We hypothesized about how these metaphors are reflected in relationships that exist between various primary research findings. We returned to the primary research reports to test the hypotheses that we generated. For example, we hypothesized that the nature of the setting influenced whether practitioners viewed the feeding experience as a chore or a connection with the person. In the review of the primary research, we determined that several setting factors influenced practitioners’ perception of the feeding experience, including the institution's system of meal tray delivery and returns, the amount of distraction in the setting, and the staffing quotient in the setting. We also looked for primary research findings that appeared to contradict one another or were contrary to our own experience. Then we searched for further data to support why the contradiction might exist.

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We addressed rigor within the meta-ethnography by applying the criteria of truth-value, applicability, consistency, and neutrality (Lincoln & Guba, ). We did this by reading each primary research report at least five times. We conducted individual appraisals of the primary research reports using a tool developed by Paterson et al. () and then shared our appraisals with each other, arriving at a consensual decision about the various elements of the appraisal (e.g. the major findings). We documented our methodological procedures and decisions, such as how we determined which reports met our selection criteria and those we excluded in the research, including what we considered qualitative research and what we believed was not a qualitative study.

Two themes are apparent in the meta-analysis of the ten primary research reports: feeding as task and feeding as relationship.

The majority of the primary research reports described feeding completely dependent persons as task, one in which the feeder is focused on getting the job done in a series of prescribed steps. This theme encompassed the metaphors of feeding as technical, feeding as efficient and feeding as a chore.

Several studies revealed that feeding was most often considered by health care practitioners as a technical procedure. For example, Athlin and colleagues (1990) quote a practitioner who says, “You distribute a portion that seems to be suitable, and then you go on until the plate is empty. If they are satisfied before, or they would want some more, are things you never think about” (p. 151). One of the common technical strategies used by practitioners in this body of research is food mixing, an activity in which the caregiver makes circular stirring movements in the food with the spoon (van Ort & Phillips, ). Sometimes food mixing involved mixing more than one type of food, such as meat and a dessert. Solid food was at times mixed with liquids in an unappetizing way and persons were forced to “drink” their meal (Kayser-Jones & Schell, ; van Ort & Phillips, ).

Researchers (Michaelsson, Norberg & Norberg, ; Kayser-Jones & Shell, ) have identified a number of technical aspects of feeding that have a questionable, if not negative, impact on the quality of life of the completely dependent person. They have observed that some practitioners who focus on the task of feeding use bibs and cutlery that are culturally or developmentally inappropriate (Kayser-Jones & Schell, ; Pierson, ) because they are concentrating on the speed of the task, rather than on the person. Michaelsson et al. () found that practitioners forced some persons with dementia to open their mouth for food by covering their nostrils in an effort to speed up the feeding process.

The main concern of practitioners who assume a task view of feeding completely dependent persons is the time that the tasks takes; feeding is considered by many practitioners to be extremely time-consuming, particularly in institutions that are poorly staffed or have systems in place that demand that feeding be completed within a narrow window of time (Kayser-Jones & Schell, ).

Practitioners have been observed by primary researchers to practice a number of questionable strategies to maximize the efficiency of the feeding process. These include feeding different persons simultaneously (van Ort & Phillips, ; Kayser-Jones & Shell, ; Pierson, ; Pearson, Fitzgerald & Nay, ). To make this possible, persons are seated together to allow one caregiver to feed more than one person at a time (Pierson, ). This arrangement makes it possible for a caregiver to step in and replace any other carer during the meal (Pierson ). Pierson, () observed that this strategy at times resulted in the person being fed with cutlery that belongs to another.

Another strategy used by some task-focused practitioners is to rush from room to room, giving one person a bite of food, rushing to another room to give someone else a bite, and then move to a third or a fourth person (Kayser-Jones & Schell, ). Feeding completely dependent persons in bed and not getting them up in a chair is another strategy used by practitioners to save time; this can result in several problems for the person, including the difficulty seeing the food and the possibility of aspiration (Kayser-Jones & Schell, ). Kayser-Jones and Schell () indicate that some practitioners recognized that “It's better for the residents to get up and not eat in bed” but they “have so many persons and can't help the residents get out of bed” (p. 67).

Many structural and institutional factors influence practitioners’ focus on feeding as efficient. For example, Kayser-Jones and Schell () found that when the meal trays must be returned to the institutional kitchen by a specific time, practitioners experience pressure to feed the persons in a hurried way and consequently, attempt to feed completely dependent persons as efficiently as possible. The researchers give as an example that practitioners who experience such time constraints tell the person, “Don't talk, eat!” (p. 68).

Staffing levels within the institution or department influence the feeding experience because if the staffing is inadequate, the practitioner may attempt to increase the speed of the feeding to compensate for the demands of an untenable workload. Pierson () found that nurses often worked within a self-appointed time limit to feed completely dependent persons; they allocated a particular time to feed such persons and did not continue past that time, despite the needs of the person.

Several researchers describe practitioners’ response to feeding completely dependent persons as boring (Pearson et al., ), unpleasant (Athlin et al., ; Kayser-Jones & Schell, ; Pelletier, ), time-consuming (Pierson ; Pearson et al., ), and stressful (Kayser-Jones & Schell, ; Pellitier, ). They reported that many practitioners viewed feeding completely dependent persons as an unpleasant task, or a chore. One way that this view was revealed was when practitioners would place the person's tray in the room beside the person where no one can see that the person is not being fed; the practitioners often attempted to rationalize this practice by providing alternative explanations, such as the person was not hungry (Kayser-Jones & Schell, ).

Another way in which this metaphor was expressed is that practitioners talked about “switching” so that they did not have to feed a completely dependent person every day (Pearson, Fitzgerald & Nay, ). Some researchers indicated that practitioners saw the practice of repeatedly assigning one staff member to assist the same resident who is difficult to feed as “unfair” (Pearson et al., ).

Feeding is perceived as a chore because not only it is regarded by some practitioners as a meaningless task but also because it often occurs in settings in which the practitioner has difficulty focusing on the person. For example, meals given in the dining areas of long-term care facilities are often noisy and staff who are feeding persons are frequently interrupted by other persons, staff or visitors (Athlin, Norberg & Jansson, ; van Ort & Phillips, ). Repeated distractions make it difficult for practitioners to behave in a way that sustain feeding; e.g. watch or talk to the person (van Ort & Phillips, ).

Some researchers indicated that practitioners at times view feeding as an opportunity to establish or to sustain relationships with the completely dependent person. They expressed this perspective in the metaphors feeding as connection, feeding as spending time with the person, and feeding as acknowledging the person.

Athlin and colleagues (1990) observed that the level of practitioners’ commitment to connecting in a meaningful way with persons during feeding is a significant determiner of whether they view the person as an object to be manipulated or as an individual with unique feelings, wishes and needs. They report that practitioners who are committed to connection during feeding were more inclined to pay attention to the persons’ cues about what they wanted and liked in feeding than practitioners who held a task perspective. This is congruent with Pelletier's () finding that nurses’ aides who viewed feeding as a time to connect by socializing with the person were attentive to the person's wishes and needs during feeding. “During feeding, you get time to get to know this person and see how it is to be them” (p. 8).

Researchers who observed the relationship perspective in action indicate that it results in many positive person outcomes for both person and practitioner. For example, Kayser-Jones and Schell () found that careful nuanced assistance, provided in a non-threatening atmosphere supportive for dignity and independence was most effective in gaining residents’ willingness to cooperate during feeding.

Practitioners who held a relationship perspective of feeding completely dependent persons believed that this required more time than was typically allocated to the activity. Pearson and colleagues (2003) indicated that the organizational culture about feeding was an additional influence in the time that such practitioners had available to them for feeding completely dependent persons. Nurses in their study who expressed a desire to spend more time feeding persons stated that their colleagues might consider them lazy if they did so.

Spending time feeding completely dependent persons was considered a significant nursing role by practitioners who held a relationship perspective. In a study conducted in two Dutch nursing homes, Pasman, Mei The, Onwuteaka-Philipsen, van der Wal and Ribbe () found that the nurses considered spending sufficient time to assure that completely dependent persons achieved adequate nutritional status to be one of nurses’ main responsibilities in the care of such persons. They assumed personal responsibility if the persons did not eat well. At times, they blamed themselves if the person did not eat (Pasman et al, ). “I didn't manage to feed her properly” (p. 317).

Practitioners who hold a relationship perspective of feeding completely dependent persons often manifest this in their acknowledgement that the person is an individual, a unique person (Athlin et al., ). In an attempt to connect with the “person inside the person”, practitioners attempt to discover the person's desires and needs in being fed (Athlin et al., ; Pearson et al., ). They often apply their personal experience and likes to the feeding experience. “… and many times in the morning I think, it feels a bit stupid to give them that gruel… . You just go to yourself; if you should be woken up in the morning and given gruel as soon as you open your eyes. I don't think I would like that” (Athlin et al., p. 150).

Acknowledging the person requires the practitioner to recognize that the series of technical steps that were learned in training or basic education about feeding are insufficient to capture the contextualized and personal experience of feeding a completely dependent person. “Nothing I did in CNA class on feeding is the same here” (Pelletier, , p. 8).

The meta-ethnography of ten qualitative research reports about feeding completely dependent persons has revealed a dialectical tension that is experienced among health care practitioners. This tension occurs between viewing feeding as an unpleasant but efficient and prescribed task and perceiving feeding as relationship. It is in the relationship of the practitioner with the person who is being fed that the art of nursing, as espoused by Chinn (), is most evident. Here, health care professionals use their assessment and communication skills to build relationships with the completely dependent person as they feed the person. Within such relationships, nurses capitalize on the feeding experience to assess the person and to interact with him or her in a meaningful way, while providing for the person's nutrition in a manner that is tailored to the individual's needs, wishes and context. Performed this way, feeding is a body–mind experience where practitioners use their intuition and imagination to bring together their technical, theoretical, personal and ethical skills in a creative whole making the process an art form (Chinn, ).

On the contrary, the task perspective of feeding completely dependent persons generates feeding that is hurried and often disregards the person's humanity and individuality. It is apparent in the body of primary research analyzed in this meta-ethnography that health care practitioners often recognize that the task focus leads to less than ideal outcomes for the persons and for themselves. They are not able to integrate skills from different areas as Chinn () suggests, and mealtime is viewed as merely mechanics. Chinn () emphasizes that clinical experience is the ground from which nursing art arises. Since the health care practitioners in the reviewed studies have a great deal of experience and work in settings where meals usually are served three times a day, they ought to have the conditions to develop artistic feeding. However, time pressure and other challenging structural conditions may not leave them space enough to reflect on their practice and this is crucial for achieving integrated knowledge.

The question of whether feeding completely dependent persons is a nursing role or simply a basic task to be relegated to a non-professional practitioner is partially answered in the analysis of relationship versus task perspective of feeding. When feeding is perceived as an opportunity for establishing or sustaining relationship between the feeder and the person, the role of the feeder is congruent with the art of nursing and it should be assumed by a nurse. If, however, the task perspective dominates the feeding experience, a non-nurse may carry out the technicalities of this activity. When feeding is considered an art, it is implied that the act of feeding is a body–mind experience rather than only a mind experience (Chinn, ). To ensure that the act of feeding completely dependent people is an art, the feeder needs to organize the work of feeding in a way that acknowledges the significance of mealtime and gives priority to the humanity of the person more than the technical approach permits.

An important issue is the person's perspective regarding if or when the task perspective may surpass the need for a relationship perspective and vice versa. For example, do completely dependent persons identify situations or contexts in which one perspective is more beneficial or useful to them than others? Only one team of primary researchers (Kayser-Jones & Schell, ) included the persons’ perspective. Pearson and colleagues (2003) indicate that they have written a research report that includes the persons’ perspective but we were unable to locate that report.

Researchers, such as Kowanko and colleagues (1999), have illustrated that nurses often experience frustration when they are required to resolve the tension between feeding as task and feeding as relationship; these researchers have indicated that nurses feel pressured to assume a task perspective. Nurses often feel as if they have abandoned their nursing role when they are unable to feed persons in a connected and personal way (Pearson et al., ). However, realities such as time constraints caused by increasing workloads and inadequate staffing levels may result in nurses not having sufficient time to fulfil their nursing role as they would like (Pearson et al., ).

There is a need for further research that examines how nurses are able to make sense of the tension that exists between the relationship and task perspective of feeding completely dependent persons in health care settings and how they respond to this tension. There is also a need for research that identifies the structural and institutional factors that foster a task or relationship perspective of feeding, as well as investigations of the person and practitioner outcomes associated with both perspectives. For example, the data in the primary research reports point to staffing levels as influencing the adoption of the task or relationship perspective about feeding among health care practitioners. Since the majority of this research relied on self-reports by practitioners, the exact nature of the association between the staffing levels in the institution or department and the perspective of feeding is not entirely clear. Future research should investigate this association in greater depth.

It should be acknowledged that half of the research represented in this meta-ethnography was conducted in nursing homes. The unique attributes of this institutional setting, such as viewing completely dependent persons as residents and not patients, has not been explored within this article; however, this could be a topic suitable for further investigation.

We have identified the findings of a meta-ethnography of ten published qualitative research reports about the feeding of completely dependent elderly persons in health care settings. The paucity of research in this area is revealing of how little attention the study of this phenomenon has received. This in turn suggests that the feeding of completely dependent persons has not been an interest to many nursing researchers because feeding has been considered a basic task that can be relegated to anyone who has the time to do so. This meta-ethnography has suggested, however, that there is a distinct nursing role in feeding completely dependent persons and that the practice of feeding by nurses deserves recognition as an art form within the profession.

Table I.  Overview of primary research reports in the present study.

Table II.  Key metaphors found in the analysis of data in the present study.

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