Professional boundaries of food and care: efficiency, satisfaction, and collegiality in a case study of hospital foodservice reform

Professional boundaries of food and care: efficiency, satisfaction, and collegiality in a case study of hospital foodservice reform | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Professional boundaries of food and care: efficiency, satisfaction, and collegiality in a case study of hospital foodservice reform Sofia Rapo, Ethel Kautto This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9167818/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Hospital meals are important for patients’ well-being and recovery, but research on hospital foodservice has mainly focused on foodservice systems and patient outcomes rather than on how meal-related work is governed, organised, and valued in practice. This study analysed a hospital foodservice reform in a publicly funded Swedish hospital. A cook-serve foodservice system based on immediate preparation and service of meals was replaced with cook-chill production involving advance preparation, chilling, plating, and reheating before service of meals. Additionally, menus were expanded and ward-based service staff called meal hosts were introduced. The aim of this study was to analyse how the foodservice reform shaped professional relations between the kitchen, the ward, and ward-based service. Methods The study design was a qualitative case study. The foodservice reform was followed 2017–2022 through study visits, organisational update meetings, and semi-structured interviews. Key informants were purposively selected based on their closeness to the foodservice reform and represented different parts of the hospital organisation. In total, 18 interviews were conducted with 12 participants before, during, and after implementation. Data was analysed using Bacchi’s poststructural interview analysis. Results Two overarching discourses were salient: market-oriented discourse based on efficiency and customer satisfaction, and a discourse of enduring hospital hierarchies. Internal contracts, budgets, and the foodservice reform concept guidelines shaped how meal-related work was organised and valued. The kitchen was legitimised through quality and patient satisfaction, the ward retained substantial power over how ward-based service was organised, which remained only conditionally legitimate. Although ward-based service was visible in everyday meal work, it was not consistently recognised and was often valued mainly when it reduced the workload of healthcare staff. Conclusions Hospital foodservice reform should be understood not only as a matter of food production and logistics, but also as a matter of governance. In this case, meal-related work was framed as something that could be bought, measured, and negotiated rather than treated as a shared care responsibility. If ward-based service roles are expected to contribute to patient care, they need to be recognised, included in collaboration, and supported in organisational arrangements. Food Service Hospitals Health Care Reform Qualitative Research Healthcare Governance Background Hospital meals are important for patients’ well-being and recovery. Previous research has highlighted that interprofessional collaboration and ward culture matter for how meals are delivered and prioritised in inpatient care. Patients have reported that they value dietitians and other healthcare professionals working together to provide holistic care, but have also described how poor collaboration has negatively affected their nutrition care and foodservice experience [ 1 ]. Hospital staff have described how professional collaboration around meals is frequently undermined by a lack of shared vision about the importance of meals, limited understanding of each other’s roles and competing priorities [ 2 – 4 ]. Studies have indicated that high workloads for staff and short lengths of stay for patients contribute to nutrition being deprioritised, and that framing meal work as only requiring common sense has reinforced the idea that mealtime work is low-skilled and peripheral [ 2 , 5 – 9 ]. In turn, good communication between service staff and nursing staff has been described as contributing to positive mealtime experiences for patients, and including mealtimes as a recurring topic in staff meetings has been suggested as a way to make meals a part of overall care work [ 10 ]. Overall, this indicates that collaboration around meals is both crucial and fragile, depending on how responsibilities, authority, and resources are organised and recognised within the hospital. A recent scoping review including 103 studies published between 2000 and 2023 highlighted that research in relation to improving hospital foodservice and nutrition care has mainly focused on foodservice systems and patient outcomes while professional training, competence, teamwork, and leadership has received less attention [ 11 ]. In a subsequent study, the authors also described a divide between service divisions and clinical divisions in relation to foodservice work, which was normalized as low status work [ 12 ]. Relation-building through taking a genuine interest in each other’s work, key contacts across divisions and management levels, and explicit structures for teamwork were described as important for change, as well as the need to involve all professional groups. Further, a recent Swedish study examined managers’ experiences of implementing care-related services in hospital care units and likewise identified challenges related to role clarity, communication, and integration across staff groups [ 13 ]. However, questions of responsibility, communication, and integration across staff groups do not arise within neutral organisational settings [ 14 , 15 ]. More specifically, work in healthcare has been described as having enduring hierarchies, where status differences shape communication, authority, and whose contributions are recognised [ 16 ]. Some forms of clinically authoritative work are accorded higher status than care- and service-oriented work [ 17 – 19 ]. Hospital foodservice can be seen as part of this undervalued service labour, with implications for whose work is recognised as central and whose contributions are treated as optional in everyday work around meals. These hierarchies also intersect with the gendered organisation of labour in healthcare [ 20 , 21 ]. Nursing, foodservice, and ward-based service are professional fields historically associated with feminised care and service work, still, these professions are not valued and recognized equally [ 14 , 18 ]. This suggests that power operates through an unequal recognition of clinically authoritative work relative to supportive and hospitality-oriented forms of labour [ 14 , 22 , 23 ]. Support services in public healthcare are sometimes organised through internal purchaser-provider arrangements between units, which was also the case in our study setting. Such arrangements can be formalised through internal contracts, including service-level agreements, which specify what service is to be provided and on what terms it is to be monitored, reviewed, and priced [ 24 ]. The internal price of goods and services exchanged between units within the same organisation is commonly referred to as transfer pricing [ 25 ]. These concepts originated in management and accounting research and previous studies have suggested that their application in public healthcare is complex, since support services and clinical services are interdependent and internal charging may raise practical tensions around costs, collaboration, and service provision [ 24 , 26 ]. Previous research has also suggested that transfer pricing is influenced by hierarchical authority, and that public healthcare operations are difficult to reduce to an ‘optimal’ price because managerial and clinical actors operate with different values and logics [ 26 , 27 ]. In practice, internal contracts, service-level agreements, and transfer-pricing can be understood as closely related mechanisms through which transactions within an organisation are made specifiable and measurable [ 24 ]. In the present study, internal contracting is used as an umbrella term and treated as a tool for governing [ 28 ]. In earlier work focusing on the present case of foodservice reform, we argued that three governing discourses permeated the political decision-making process leading to the adoption of the reform proposal: choice, flexibility, and cost-effectiveness [ 29 ]. These discourses also fit within a broader neoliberal discourse [ 28 , 30 , 31 ]. The present study shifts attention from policy to practice. The aim was to analyse how a foodservice reform, through discourses, discursive practices and governance, shaped professional relations between the kitchen, the ward, and ward-based service. Methods Design and study setting This study was a case study, which is an appropriate study design when interested in exploring a phenomenon in depth and in its natural context [ 32 ]. Setting of the case study – The foodservice reform In 2011, idea generation for a hospital foodservice reform began in a Swedish publicly financed tertiary care hospital. In this case, hospital meals were deemed too expensive and the cook-serve production kitchen was old and needed remodelling. A multi-professional project group was appointed with the task to design, plan, implement, and evaluate a new and efficient foodservice concept. The previous cook-serve production unit was replaced with cook chill production, where food is cooked in large batches, chilled, and individually portioned. The cook chill design enabled an in-patient menu with multiple options for main courses, side dishes, and soups, thus introducing more food choice to patients. Ward kitchens were expanded to fit chilled storage of meals and display cases for snacks, desserts, and appetizers freely available at any time. Additionally, set meal times were replaced with flexible service meaning patients could choose when to order food. A new meal-focused service concept was introduced in the form of the meal host. This role was intended to emphasise hospitality and accommodate the new service flow including the additional steps of taking up menu orders as well as reheating and plating meals at the ward. Another purpose of the meal host role was to relieve healthcare staff of meal-related non-clinical work. Prior to the foodservice reform, the hospital had implemented care related services (CRS), a ward-based non-clinical service model involving task shifting from nurse assistants and care assistants to service staff employed by the service unit. Typical CRS tasks include cleaning of surfaces, inventory management, transportation, and meal service [ 13 ]. In the present case, wards had already adopted CRS to achieve task shifting when the foodservice reform was implemented and the meal host role was introduced. Meal-related work at the wards was therefore shaped by a broader service structure already in place, in which wards purchased services from the service unit through internal contracts. Therefore, staffing varied between wards depending on what was stipulated in the internal contracts between wards and the service unit. In some wards, service staff rotated between different duties, including the meal host role, whereas in other wards the meal host role was staffed more consistently by the same person. The foodservice reform was politically approved in 2014 and implemented in 2020. The cost of CRS and meal hosts had to be fitted into existing budgets at the wards. Participants and materials An invitation to conduct research on the foodservice reform was initiated by the original project lead. However, although the authors received support in gaining access to the hospital, hospital representatives did not have any additional role in the study design, analysis, decision to publish, or preparation of the manuscript. The foodservice reform was followed from 2017 to 2022 through study visits, online status update meetings, and both face-to-face and online interviews. The present study builds on purposive sampling of key informant interviews. Key informants were identified and recruited during study visits to the hospital, often introduced to the researchers by the project lead or encountered in meetings. From a power-perspective, who is considered a key informant warrants careful consideration [ 33 ]. In this case, key informants were chosen based on their closeness to the foodservice reform, decision-making opportunities, and to ensure representation from different parts of the hospital organisation. To reduce the risk of identifiability, detailed job titles, unit affiliations, or other characteristics that could make individuals easily identifiable are not reported. Quotes are labelled broadly and potentially identifying details are removed. An advisory statement expressing the ethical appropriateness of the study was granted from the Swedish Ethical Review Authority (Reg. no. 2019–05132). Data collection Interviews were conducted by the first author (SR) at three occasions: face-to-face at the hospital three months prior to the implementation of the foodservice reform (2019, n = 6), online and on the phone six months after the implementation (2020, n = 9), and face-to-face at the hospital two years after the implementation (2021, n = 3). In total, 18 interviews were conducted with 12 participants. Two participants were interviewed three times, two participants twice, and eight participants once. The Covid-19 pandemic affected data collection. Of the 18 interviews conducted, 15 lasted 60 to 90 minutes. Three interviews conducted during the pandemic were shorter, lasting approximately 15 minutes, and were conducted by phone to minimise disruption to clinical responsibilities. Most participants were women, reflecting the gendered composition of the occupational fields involved. Interviews were audio recorded, and then transcribed verbatim. Interviews were semi-structured and followed an interview guide with an opening question, three main topics, and a closing question. Follow-up questions centred around whatever topic the interviewee brought up. Each interview started with a general question about what a normal day at work looks like for the interviewee. The following three main topics were how they perceived their professional role, the foodservice reform, and hospital meals in general. Questions included for example what they liked or would like to change about their professional role, what they wished others knew about their work, what benefits and disadvantages they thought the foodservice reform would have/had, what they would change if they were almighty, and how hospital meals should be. Interviews were ended with questions about their professional background, and finally “if there was something they wished I had asked but didn’t”. The interview guide can be found as supplementary material [Additional file 1]. Study visits were conducted by the first author in 2018, 2019, and 2021, and additional organisational update meetings were attended online approximately every six months. Notes were taken during these activities and used as contextual knowledge to support interpretation of interviews (for example terminology, routines, and reform milestones). Analytical approach The analytical approach in the present study builds on Bacchi’s analysis of discourses. Bacchi distinguishes analysis of discourse from discourse analysis as two different analytical traditions [ 34 ]. In this distinction, analysis of discourse focuses on systems of thought instead of language use. Discourses according to Bacchi are historically produced ways of thinking that establish frames of reference that are difficult for people to think and act outside of. Bacchi takes a Foucault-informed poststructuralist approach to interviews, which has implications for how interview data is understood and analysed. The focus is on discursive practices: what can be said and done and the rules and norms that make it possible to say. A discursive practice can be exemplified as repeated ways of doing and talking that make certain things “obvious” at the ward while other things are harder to imagine, for example in relation to professional hierarchies and task allocation. It should also be noted that the focus is not on personal experience but rather on what is possible to be, do, or say [ 35 ]. This directs attention to the conditions under which sayings and doings are produced rather than to interviewees’ experiences. The goal of the analysis was not to evaluate the foodservice reform, but rather to focus on how particular practices and organisational arrangements were articulated as natural, inevitable, or “reasonable”. The key terminology used in the analysis was problematizations, governing technologies, discourses, discursive practices, subject positions, and effects. Problematizations refer to the specific ways an issue is constituted as a problem in need of attention, change, or intervention [ 36 ]. Governing technologies refer to the concrete tools through which such problematizations are operationalised in practice, such as procedures, classifications, routines, instruments, role definitions, and organisational arrangements. Discourses are historically produced clusters of meanings and practices governed by rules that define what can be thought, said, and done, and what counts as true, reasonable, or possible in a specific field [ 37 ]. Discursive practices are the recurring ways of doing and talking through which such discourses are enacted. Subject positions refer to the roles made available within these practices, while effects refer to what these arrangements make possible, legitimate, or difficult in practice. In this way, discourses have practical effects on ward-based work. How actors are positioned affects what makes sense to do in practice, for example who is invited to meetings, how performance is measured, and which aspects of work are made visible or remain invisible. Based on these theoretical understandings, Bacchi has articulated a methodology for analysing interviews: poststructural interview analysis [ 35 ], which has influenced the analysis in the present study. Although poststructural interview analysis is described in terms of steps, in reality the analysis moves between different questions posed to the material. Noting what can be said or done is the first step, following an analysis of how it became sayable, which discursive practices are involved, what they produce, which problem representations and governing technologies are made visible, and which subject positions are made available. Researcher reflexivity is an important part of this methodology and the researchers’ own bias and alternative ways of thinking should be continuously considered. In the present study, reflexivity was practiced through continuous discussion of data and analysis between the two female authors. This first author (SR) represented an organisational background and was a PhD student. The second authors represented a clinical background and was an experienced qualitative researcher (PhD, RD). Process of analysis Interviews were transcribed verbatim and read multiple times for familiarization. The transcripts were then coded with qualitative analysis software MAXQDA24 by the first author (SR). Speaker role and time of interview were coded to support contextual understanding of the material. This enabled attention to whether particular ways of problematising the foodservice reform were linked to specific stages in the implementation process. However, interview timing did not emerge as a notable basis for the final analysis. Following the poststructural interview analysis approach, the material was coded in relation to problem representations, underlying assumptions, governing technologies, subject positions, and effects. Building on these codes, analysis focused on discourses by asking “what is the overall way of thinking and talking made visible by these codes”? Discursive practices were analysed by asking “what are people actually doing, repeatedly, that enacts this discourse”? Subject positions and effects were then connected to the identified discourses and discursive practices. These steps were iterative, shifting repeatedly between codes, coded segments, speaker roles and discourses. Quotes were selected to illustrate subject positions and are presented with potentially identifying details removed. The results are reported as three site-specific bundles of discursive practices that show how discourses are enacted in meal-related work, and what subject positions and effects follow for the kitchen, the ward, and ward-based service. Reporting followed Consolidated Criteria for Reporting Qualitative studies (COREQ) [ 38 ] when applicable and a COREQ protocol can be found as supplementary material [Additional file 2]. Results In the material, two overarching governing discourses were salient. First, market-oriented discourse based on efficiency and customer satisfaction. Second, participants continuously referred to an enduring hospital hierarchy in which clinical authority and professional boundaries shape what counts as legitimate work and whose perspectives are included. There were two main governing technologies; internal contracts and budgets. However, the foodservice reform design as a coherent concept also functioned as a governing technology by establishing an authoritative model for how meal-related work should be organised. National regulations were likewise invoked as justificatory resources, though less consistently. Interviewee accounts described wards as “customers” who “buy” meals and services through internal contracts, while the production kitchen and service unit were positioned as providers. Internal contracts as part of a purchaser-provider model were therefore understood as a governing technology. One informant explicitly contested the budgetary logic of this set-up by framing internal contracting as a matter of allocation rather than collaboration, as shown in the quote below: But in the end, as I said, it’s really just a matter of playing with the numbers and deciding where to allocate the money Several accounts described the concept of service staff at wards as politically mandated, while financing remained a ward responsibility within existing budgets. Service provision was articulated as a practical dilemma where ward-based service was desired but difficult to fund at the ward level without budgetary supplementation. While concerns were raised that financing ward-based service could require a trade off in relation to clinical staffing, one account emphasised that ward-based service had been incorporated without budget supplementation and without subsequent reductions in nursing assistant posts: “Yes, that [fear of having to let healthcare staff go to be able to finance service staff] has been discussed. It was discussed when ward-based service was introduced as a project with funding two years ago, but then after six months it was incorporated into line operations, without any additional funding. So you could say we’ve been running at a deficit, but since then there hasn’t been any talk of cutting back or reducing nursing assistants and so on. So we’ve still been able to keep the same staffing level we had when the project started.” Participants also described how inclusion in dialogue and decision-making about meals was shaped by a taken-for-granted hierarchical order and limited opportunities to meet. One informant phrased this by linking interprofessional collaboration to both hierarchy and organisational conditions: ”But then there is a general hierarchical basic order at our hospitals, although it isn’t as it used to be when doctors were Gods and so on… and I don’t think it is consciously, this is unconsciously. It’s like an old culture and a system failure, I mean, there isn’t enough space to get together, for dialogue.” Further, interviewee accounts described the foodservice reform concept as inherently good and as something that should work if implemented properly. In this framing, problems were articulated as failures of implementation rather than of the foodservice reform concept itself: …the concept itself is very good, if everything is in place and if everything works within the concept, you know? Below, discursive practices and the subject positions and effects they produced in relation to the discourses described above are presented analytically categorised into three organisational sites: the kitchen, the ward, and ward-based service. While interview accounts were fairly aligned concerning the kitchen and the ward, they were less aligned concerning service and the roles of service staff. The kitchen: the quality controller Across interviews, “quality” of meals was repeatedly problematized and articulated as a central aspect of meal-related work and a key justification for the foodservice reform. Quality was made actionable through recurring descriptions of practices such as controlling taste and presentation, refining recipes, and managing menu design. These practices were framed as non-negotiable and articulated using customer-oriented language, where the meal was described as an experience that should correspond to what is paid for: … and quality and food, no matter if it is [the new foodservice concept] or a restaurant or whatever, we should always have good quality food no matter what… they pay for an experience and it should be, they should get what they pay for. Interview accounts described careful work with recipes, tasting and presentation. One participant described a dish as “ one of the best fish dishes I’ve ever eaten ” and therefore necessary to include in the menu. Such accounts enacted restaurant quality as a standard through which the foodservice reform could be evaluated, and positioned culinary expertise as an appropriate basis for menu decisions. Quality was also located within a narrative of change where production technologies and public expectations of food were described as having developed over time and foodservice was described as needing to keep up: I mean, like in the 90’s, it was all ovens everywhere, almost no griddles and that means OK you just heat up foods. So, the attitude is different now, and also, citizens make more demands and have higher expectations, like what do I put in my body, we have higher expectations on food and are more mindful of what we eat and so both restaurants and foodservice have to keep up with that development. In relation to discourses and practices, the production kitchen was positioned as a quality controller responsible for both producing and monitoring quality. At the same time, customer-oriented language produced a subject position of the eating patient as an evaluator of experience, making satisfaction a reasonable basis for assessing quality and a central marker of foodservice reform success. Further, patient satisfaction was repeatedly connected to food intake and recovery, often articulated by stating “ food is medicine” , which legitimized satisfaction as clinically relevant to recovery, rather than merely connected to service. Across the material, the food was repeatedly celebrated and it was also a focal point of the foodservice reform in interview accounts. This had the effect of establishing the kitchen as a legitimate site of expertise and of making meal quality a central basis for valuing meal-related work. The ward: the hegemonic customer and the gatekeeping manager Participants articulated recurring practices of contracting, customer meetings, and negotiations that shaped how ward needs were defined and addressed. Although the service concept was described as politically mandated, meals and ward-based service work were translated into a ward-level need that had to be specified, negotiated, and financed as a purchasable service rather than articulated as shared work. Wards were described as customers, with varying frequency of customer meetings and accommodation of their needs depending on how many meals and how much service they bought. At the same time, accounts described uncertainty about what the contracts covered in terms of service agreements, or in other words, the extent of services that had been bought. In relation to these customer negotiation practices, prioritising wards that buy more was made intelligible as reasonable, positioning them as hegemonic customers. This contributed to normalizing mealtime work as something wards purchase rather than a shared responsibility. Further, interview accounts described practices in ward management as something that shaped whether ward-based service staff were included or marginalised. Management practices were framed as filters for information and attitudes about the foodservice reform: A lot of the information that goes out about [the foodservice concept] doesn’t reach the staff. Information, information, and information, and then the staff say, nobody told me I had no idea. In relation to these practices, ward management was positioned as gatekeepers of service staff inclusion. Interview accounts included articulations of engagement as well as uninterest. Managers could be positioned or position themselves as engaged and positive, actively involving service staff in meetings and ward routines as well as articulating appreciation for the support they offered, or as seeing service staff mainly as “ someone who is there and does what they are told .” The subject position of the gatekeeping manager mediated access to information and everyday routines, shaping whether service staff were positioned as colleagues or as invisible extras. This made it intelligible why interprofessional collaboration between service staff and clinical staff could be organised differently between wards despite a shared formal foodservice reform design. The effect was that ward-level management and contracting practices retained substantial power over whether service staff were included, informed, and recognised in everyday work. Service: the peripheral service staff, the subjugated service staff, and the collegial service professional In relation to ward-based service work, interview accounts were less aligned than accounts related to the kitchen and the ward. This heterogeneity was treated analytically as its own finding where service work emerged as a key site where competing problem representations were negotiated. Two dominant problematisations recurred across the material. First, service was problematised as a purchasable and contract-defined auxiliary function. Second, it was problematised as a question of legitimacy and belonging. These dominant problematisations were supplemented by secondary ones concerning professional boundaries and information flows. This section traces how these problematisations sometimes aligned and sometimes competed, producing multiple service staff positions and uneven conditions for interprofessional collaboration between service staff and clinical staff. Based on this heterogeneity, this section has been divided into subsections for clarity. Practices concerning information access, enactment of regulated professional boundaries, and everyday recognition shaped available subject positions for service staff. In relation to these practices and recurring transactional descriptions, three positions recurred: the peripheral service staff, the subjugated service staff and the collegial service professional. Collaboration-oriented practices, for example inclusion in meetings and shared routines, were described as uneven across wards. When these practices were present they positioned service staff as colleagues. The value of ward-based service staff was often articulated in relation to them unburdening healthcare staff from service related work. The peripheral service staff Interview accounts described service staff as non-clinical staff who refrained from certain bedside tasks like adjusting beds or providing eating assistance, with patient safety legislation [ 39 ] invoked as justification. The analysis focused on how these regulated boundaries were enacted in everyday meal-related work and whether collaboration practices between service and care staff were described as present or absent. In the account below, the support that service staff provided to unburden nurses was appreciated while information flows were described as contingent on collaboration practices: Yeah, I mean, I think it’s really good, the assistant nurses can have a bit more time for nursing care and for conversations, and they can completely let go of ordering and that kind of thing. So it’s really good, truly. What could be the downside is that you don’t see the whole chain of care. Before, the assistant nurse handled both the ordering and the conversation about food with the patient, and you don’t really get that conversation in the same way with this concept. But there is good communication between service staff and the care staff, and we’ve designed that, but still—well, that can be the downside, I suppose. And then sometimes… before, you could see if the patient couldn’t eat on their own for example, because sometimes it can be a bit difficult. A meal gets put down, and then you realise after a while that they haven’t even taken the first bite, and then half an hour has passed. So it’s kind of that, you have to have close collaboration, so that it becomes as good as possible for the patient. This account constructs close collaboration as necessary to prevent breaks in information flows, while expressing the perceived value of service staff as a function that unburdens assistant nurses. In accounts where service staff were included in routines such as daily morning meetings, information sharing was described as working more smoothly. On the contrary, when information sharing was problematised, such routines were described as absent and service staff were described as having to spend time searching for patient information, sometimes discovering information gaps they did not previously know of. In this position, analytically labelled the peripheral service staff position, service staff were described in ways that positioned them as physically present but organisationally peripheral: responsible for meal-related work, yet not recognised as part of the team. ”It’s the responsibility of the healthcare staff to ordain diets while service staff are responsible for serving meals, there is a significant difference in area of responsibility… I’d say [flow of information] is not a huge problem because we work really hard with it but if we didn’t work so hard all the time then it would be a problem” In this account, the professional boundary between service staff and clinical staff is enacted as legitimate, while simultaneously problematising the coordination work required to make the flow of information function, positioning service staff as dependent on ward-provided information and therefore as peripheral to patient-related decision-making. The subjugated service staff Practices of everyday recognition as well as inclusion and exclusion in ward social life positioned service staff as sometimes devalued and marginal, hence analytically labelled the subjugated service staff position. Some accounts described a poor social working environment, for example how service staff had been excluded from social events such as celebratory meals during holidays or shared coffee breaks, and how they sometimes received demeaning comments. This position was also linked to the practice of internal contracting: They quite often hear, what do we need you for? It should be, I don’t think we pay for this service, it’s a shame, but most people are really sweet, but one such comment can ruin the whole day, that’s what is remembered. Interview accounts described how service staff were sometimes referred to simply as “ the service person” , a practice that reduced them to a function rather than a colleague with a name. Service work was described as becoming visible mainly in situations where tasks remained unfinished, rather than through recognition of competing priorities and lack of time. In this way, talking in terms of value-for-money combined with everyday interaction practices positioned service staff as lower-status workers whose presence it was possible to question. One account explicitly linked these practices to both the hospital hierarchy and a transactional framing: ”I think it’s deeply rooted, etched into the walls… hospital environments have always had hierarchies… but I think it’s also about money, we have bought this service and we want value for money, so, that’s one thing, not being a natural part of the care team.” This account shows how service work was made intelligible as subordinate to clinical work, legitimized by referring to an enduring hospital hierarchy. The collegial service professional In contrast, a collegial position was made available through recognition practices that defined hospitality and interpersonal work as specialised competences necessary for the foodservice reform’s ambitions articulated in relation to the reform design as a coherent concept. Where such recognition was absent, the same competence claims did not translate into inclusion. Some accounts also framed these competences as complex and difficult to sustain within staffing and budgeting constraints, while emphasising that especially the encounter between a meal host and patient could be decisive for patient experience: From a financial perspective, it would be better if all service employees are able to perform all service related tasks on the ward so that it is possible to be flexible with staffing. That is, having service employees with multiple competencies. But it’s difficult to maintain such a broad competence; it’s a huge challenge. Because, however you look at it, the meal host role requires more competence, it’s harder and involves a more complex skill set… Because above all, the meal host role is the encounter with the patient, which is often perhaps at least as decisive as the food on the plate. The professional role of the meal host was also described as placing “ very high demands on social or interpersonal competence”. In some accounts, tensions were noted when staff were recruited for their hospitality skills and passion for the meal host role, but other service tasks like cleaning subsequently were perceived as unpopular, making the service staff role complex to fulfil. Put together, these accounts show that a collegial positioning was dependent on whether coordination routines and recognition practices were described as in place, and on whether service was valued primarily as unburdening care work or problematised as a ward-level cost. The effect was that service staff’s legitimacy remained uneven and contingent rather than fully secured. Discussion This study suggests that hospital foodservice reform should not be understood only as a change in food production and meal delivery, but also as a change in how meal-related work was governed, understood, and valued. In this case, internal contracting and customer-oriented language framed meals as something that could be bought, evaluated, and improved, rather than simply as part of care. This shifts attention from internal contracts as administrative tools to contracts as devices that organise what counts as legitimate meal-related work. This did not mean that wards autonomously defined the need for ward-based service from the outset. Rather, the foodservice reform concept was politically authorised at a strategic level, while wards became the operational site where that mandate had to be interpreted, financed, and translated into everyday practice. These arrangements were not merely administrative background conditions. They functioned as discursive practices and governing technologies through which a particular organisational order was produced and normalized [ 37 ]. What became intelligible was not meal work as a shared care responsibility, but meal work as a set of purchasable and measurable contributions. In line with earlier organisational research, the hospital cannot be assumed to function as one coherent organisation experienced in the same way by all actors [ 40 ]. Instead, it may be better understood as multiple organisations within one. From this perspective, staff may be oriented primarily to their local work setting rather than to the hospital as a unified organisation. The present findings suggested that the kitchen, ward, and service were not simply coordinated parts of one foodservice system, but differently positioned organisational sites with unequal power to define what counted as legitimate meal-related work. The kitchen emerged as a strongly valued site of quality and improvement. Although food production work itself was relatively invisible at ward level, food as a product was highly visible and was repeatedly associated with patient satisfaction in interview accounts. The ward was the site where the politically approved service concept was operationalised into local arrangements. It therefore functioned as a gatekeeping site where service needs were prioritised and organised in practice, and where the relevance of other contributions was filtered through existing hierarchies. Ward-based service occupied a more uncertain position. Although visible in everyday meal-related work, its contribution was not consistently recognised and often had to be justified in terms of relieving healthcare work or reducing burden. Service could therefore be valued when it facilitated the meal process and reduced the workload of healthcare staff, but it could also be questioned as a cost or treated as an auxiliary function that had to justify its presence. This interpretation is also consistent with recent research on CRS in Swedish hospital wards, where unclear task allocation, limited integration into existing ward routines, and organisational separation between CRS staff and ward staff complicated collaboration and made the new service role more difficult to become accepted and established in everyday ward work [ 13 ]. In the present study, a central lived effect of the foodservice reform was the uneven distribution of value and legitimacy across these three sites. The kitchen was legitimised through quality and patient satisfaction, the ward retained authority to define ward-based service in practice, and service itself remained only conditionally legitimate. The findings also indicated that meals should not be treated as a purely technical and logistical matter. Previous research has shown that physical tasks often become the visible measure of “work” while emotional labour remains harder to account for and is often carried by lower-status workers close to patients [ 18 ]. Hands-on care tasks such as feeding patients and noticing problems may be undertaken by lower-status staff who nevertheless remain positioned low in the hospital hierarchy [ 23 ]. Related research has also shown that embodied and emotional care, often expected of female frontline workers, remains necessary but insufficiently recognised, while technical and disembodied skills are increasingly valued [ 20 ]. Rather than suggesting that logistics are unimportant, the present findings indicated that foodservice reform alone does not secure patient experience or nutrition care when the relational dimensions of meal-related work remain weakly recognised. This argument can also be related to previous analyses of neoliberal restructuring in hospital care, where growing workloads, intensified demands, organisational control, and budgetary discipline may marginalise care practices [ 41 , 42 ]. The findings of this study also need to be understood in relation to the wider organisation of work in Swedish women-dominated welfare sectors, where labour remains strongly gender segregated and where New Public Management reforms have reshaped the public sector in recent decades [ 21 ]. Power structures in everyday work may remain difficult to articulate, partly because they are uncomfortable to discuss and difficult to influence [ 43 ]. In the present study, such structures became visible in how meal-related work was differentiated, valued, and justified across kitchen, ward, and service. The present study has several strengths and limitations. The case study design enabled an in-depth analysis of a hospital foodservice reform in its natural organisational context and was well suited to the study aim of examining how discourses, discursive practices, and governing technologies shaped meal-related work. The study therefore offers a conceptual contribution by showing how hospital foodservice reform can be analysed as a governance issue, rather than only as a matter of food systems or patient outcomes. Further, the foodservice reform was followed over several years through study visits, organisational update meetings, and interviews conducted before, during, and after implementation, and participants were purposively recruited from different parts of the hospital organisation. However, the study was also limited by its single-case design and by its reliance on purposively selected key informants, which meant that the findings were context-specific and that some perspectives on everyday meal-related work were less visible. Data collection was also affected by the Covid-19 pandemic. In sum, the analysis suggested that reorganising hospital foodservice involves more than improved food quality or efficient task redistribution. It also involves struggles over how work is defined, whose contributions are recognized, and how care is coordinated across organisational and professional boundaries. In this case, communication, inclusion, and recognition were not secondary implementation issues but part of the organisational conditions through which meal-related work could be enacted as care rather than as a peripheral support function. This suggests that research on hospital foodservice therefore needs to address governance, hierarchy, and inclusion alongside nutrition, efficiency, and satisfaction outcomes. Conclusions This study shows that hospital foodservice reform is not only about food production, logistics, or patient satisfaction, but also about how meal-related work is governed, understood, and valued. The analysis made visible a set of assumptions that might otherwise remain taken for granted. The analysis showed that internal contracting and customer-oriented language framed meal-related work as something that could be bought, measured, and negotiated rather than treated as a shared care responsibility. While the kitchen was strongly legitimised through quality and patient satisfaction, the ward-based service remained conditionally legitimate. The findings also suggest that if ward-based service roles are expected to contribute to patient care, they cannot be treated as peripheral support functions. They need to be included in collaboration, recognised in everyday ward work, and supported by organisational arrangements that make their role clear and their working situation sustainable in practice. More broadly, the study highlights that hospital meals carry value beyond nutrition alone. Hospital foodservice should therefore be understood as an organisational and relational part of care, not as a secondary service surrounding it. Abbreviations COREQ Consolidated Criteria for reporting qualitative studies CRS Care Related Services Declarations Ethics approval and consent to participate An advisory statement expressing the ethical appropriateness of the study was granted from the Swedish Ethical Review Authority (Reg. no. 2019-05132). All participants provided informed consent to participate. Participants received both written and verbal information about the study, including that participation was voluntary and that they could withdraw at any time without giving a reason. Participants were also informed that data from the interviews could be published in research articles in anonymised form, with all identifying characteristics removed. All methods were carried out in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The qualitative interview data generated and supporting the findings of this study are not publicly available due to ethical restrictions and the risk of participant identification. Requests for further information about the data should be directed to the corresponding author (SR). Competing interests The authors declare that they have no competing interests. Funding This research didn’t receive any funding. Authors' contributions S.R designed the study and was responsible for data collection, data analysis, and drafting the manuscript. E.K. supervised the study and contributed to interpretation of data, as well as drafting and editing of the manuscript. Both authors reviewed the manuscript. Acknowledgements Our sincere thanks to prof. Maria Carbin and prof. Agneta Hörnell for their insightful advice and constructive feedback. We would also like to thank the study participants for their time and invaluable insights. 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Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1SemistruturedinterviewguideRapoSProfessionalboundariesoffoodandcare.pdf Supplementaryfile2COREQChecklistRapoSProfessionalboundariesoffoodandcare.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 11 May, 2026 Reviewers agreed at journal 09 May, 2026 Reviewers invited by journal 24 Apr, 2026 Editor assigned by journal 23 Apr, 2026 Editor invited by journal 30 Mar, 2026 Submission checks completed at journal 30 Mar, 2026 First submitted to journal 30 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9167818","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":630886460,"identity":"dbf6da9b-93e5-430d-929a-3b95d75c5f51","order_by":0,"name":"Sofia Rapo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYFACxgcHIAzmA8RqYTaAKmVLIF4LlMFjgFcdHMi3NzMe+MFwT96cveeb1M02Bnt+QloMzhxmONjDUGy4s+fsNuncNobEmQ2EtEjkHzjAw5DAuOFGLlhLAsxruB02I5nh4B+GBPsNN3KegbTY2xPSwnAjmeEw0JZEoBY2kBbGDcT45bCMQULyzp5jxtY55yQSZxB0WHsz88c3FQm229mbH97OKbOx528gZA3ELjACAQmi1MN1jYJRMApGwSjADgBhTT4kfAxfsAAAAABJRU5ErkJggg==","orcid":"","institution":"Umeå University","correspondingAuthor":true,"prefix":"","firstName":"Sofia","middleName":"","lastName":"Rapo","suffix":""},{"id":630886465,"identity":"c3d4810f-5a32-4183-b09b-b8c390cb65db","order_by":1,"name":"Ethel Kautto","email":"","orcid":"","institution":"Umeå University","correspondingAuthor":false,"prefix":"","firstName":"Ethel","middleName":"","lastName":"Kautto","suffix":""}],"badges":[],"createdAt":"2026-03-19 09:40:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9167818/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9167818/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108495516,"identity":"9923ff41-ebb4-40c2-a995-31d0970aab12","added_by":"auto","created_at":"2026-05-05 10:10:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":244628,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9167818/v1/5823d3e4-c320-4699-9317-efdf69ada9fa.pdf"},{"id":108453147,"identity":"1a7eec99-0ea1-4cf5-b29a-04f2e166216e","added_by":"auto","created_at":"2026-05-04 20:16:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":71811,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1SemistruturedinterviewguideRapoSProfessionalboundariesoffoodandcare.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9167818/v1/e7a2bec30939359c0a8e9943.pdf"},{"id":108494097,"identity":"f8cca866-11a6-4658-bb50-a06a3ae1fbe2","added_by":"auto","created_at":"2026-05-05 10:02:35","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":433210,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2COREQChecklistRapoSProfessionalboundariesoffoodandcare.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9167818/v1/a8df724a50b97e19d6ec4442.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eProfessional boundaries of food and care: efficiency, satisfaction, and collegiality in a case study of hospital foodservice reform\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHospital meals are important for patients\u0026rsquo; well-being and recovery. Previous research has highlighted that interprofessional collaboration and ward culture matter for how meals are delivered and prioritised in inpatient care. Patients have reported that they value dietitians and other healthcare professionals working together to provide holistic care, but have also described how poor collaboration has negatively affected their nutrition care and foodservice experience [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Hospital staff have described how professional collaboration around meals is frequently undermined by a lack of shared vision about the importance of meals, limited understanding of each other\u0026rsquo;s roles and competing priorities [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Studies have indicated that high workloads for staff and short lengths of stay for patients contribute to nutrition being deprioritised, and that framing meal work as only requiring common sense has reinforced the idea that mealtime work is low-skilled and peripheral [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In turn, good communication between service staff and nursing staff has been described as contributing to positive mealtime experiences for patients, and including mealtimes as a recurring topic in staff meetings has been suggested as a way to make meals a part of overall care work [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Overall, this indicates that collaboration around meals is both crucial and fragile, depending on how responsibilities, authority, and resources are organised and recognised within the hospital.\u003c/p\u003e \u003cp\u003eA recent scoping review including 103 studies published between 2000 and 2023 highlighted that research in relation to improving hospital foodservice and nutrition care has mainly focused on foodservice systems and patient outcomes while professional training, competence, teamwork, and leadership has received less attention [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In a subsequent study, the authors also described a divide between service divisions and clinical divisions in relation to foodservice work, which was normalized as low status work [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Relation-building through taking a genuine interest in each other\u0026rsquo;s work, key contacts across divisions and management levels, and explicit structures for teamwork were described as important for change, as well as the need to involve all professional groups. Further, a recent Swedish study examined managers\u0026rsquo; experiences of implementing care-related services in hospital care units and likewise identified challenges related to role clarity, communication, and integration across staff groups [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, questions of responsibility, communication, and integration across staff groups do not arise within neutral organisational settings [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. More specifically, work in healthcare has been described as having enduring hierarchies, where status differences shape communication, authority, and whose contributions are recognised [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Some forms of clinically authoritative work are accorded higher status than care- and service-oriented work [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Hospital foodservice can be seen as part of this undervalued service labour, with implications for whose work is recognised as central and whose contributions are treated as optional in everyday work around meals. These hierarchies also intersect with the gendered organisation of labour in healthcare [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Nursing, foodservice, and ward-based service are professional fields historically associated with feminised care and service work, still, these professions are not valued and recognized equally [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This suggests that power operates through an unequal recognition of clinically authoritative work relative to supportive and hospitality-oriented forms of labour [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSupport services in public healthcare are sometimes organised through internal purchaser-provider arrangements between units, which was also the case in our study setting. Such arrangements can be formalised through internal contracts, including service-level agreements, which specify what service is to be provided and on what terms it is to be monitored, reviewed, and priced [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The internal price of goods and services exchanged between units within the same organisation is commonly referred to as transfer pricing [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These concepts originated in management and accounting research and previous studies have suggested that their application in public healthcare is complex, since support services and clinical services are interdependent and internal charging may raise practical tensions around costs, collaboration, and service provision [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Previous research has also suggested that transfer pricing is influenced by hierarchical authority, and that public healthcare operations are difficult to reduce to an \u0026lsquo;optimal\u0026rsquo; price because managerial and clinical actors operate with different values and logics [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In practice, internal contracts, service-level agreements, and transfer-pricing can be understood as closely related mechanisms through which transactions within an organisation are made specifiable and measurable [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the present study, internal contracting is used as an umbrella term and treated as a tool for governing [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn earlier work focusing on the present case of foodservice reform, we argued that three governing discourses permeated the political decision-making process leading to the adoption of the reform proposal: choice, flexibility, and cost-effectiveness [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These discourses also fit within a broader neoliberal discourse [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The present study shifts attention from policy to practice. The aim was to analyse how a foodservice reform, through discourses, discursive practices and governance, shaped professional relations between the kitchen, the ward, and ward-based service.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eDesign and study setting\u003c/p\u003e \u003cp\u003eThis study was a case study, which is an appropriate study design when interested in exploring a phenomenon in depth and in its natural context [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSetting of the case study \u0026ndash; The foodservice reform\u003c/p\u003e \u003cp\u003eIn 2011, idea generation for a hospital foodservice reform began in a Swedish publicly financed tertiary care hospital. In this case, hospital meals were deemed too expensive and the cook-serve production kitchen was old and needed remodelling. A multi-professional project group was appointed with the task to design, plan, implement, and evaluate a new and efficient foodservice concept. The previous cook-serve production unit was replaced with cook chill production, where food is cooked in large batches, chilled, and individually portioned. The cook chill design enabled an in-patient menu with multiple options for main courses, side dishes, and soups, thus introducing more food choice to patients. Ward kitchens were expanded to fit chilled storage of meals and display cases for snacks, desserts, and appetizers freely available at any time. Additionally, set meal times were replaced with flexible service meaning patients could choose when to order food. A new meal-focused service concept was introduced in the form of the meal host. This role was intended to emphasise hospitality and accommodate the new service flow including the additional steps of taking up menu orders as well as reheating and plating meals at the ward. Another purpose of the meal host role was to relieve healthcare staff of meal-related non-clinical work.\u003c/p\u003e \u003cp\u003ePrior to the foodservice reform, the hospital had implemented care related services (CRS), a ward-based non-clinical service model involving task shifting from nurse assistants and care assistants to service staff employed by the service unit. Typical CRS tasks include cleaning of surfaces, inventory management, transportation, and meal service [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present case, wards had already adopted CRS to achieve task shifting when the foodservice reform was implemented and the meal host role was introduced. Meal-related work at the wards was therefore shaped by a broader service structure already in place, in which wards purchased services from the service unit through internal contracts. Therefore, staffing varied between wards depending on what was stipulated in the internal contracts between wards and the service unit. In some wards, service staff rotated between different duties, including the meal host role, whereas in other wards the meal host role was staffed more consistently by the same person.\u003c/p\u003e \u003cp\u003eThe foodservice reform was politically approved in 2014 and implemented in 2020. The cost of CRS and meal hosts had to be fitted into existing budgets at the wards.\u003c/p\u003e \u003cp\u003eParticipants and materials\u003c/p\u003e \u003cp\u003eAn invitation to conduct research on the foodservice reform was initiated by the original project lead. However, although the authors received support in gaining access to the hospital, hospital representatives did not have any additional role in the study design, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e \u003cp\u003eThe foodservice reform was followed from 2017 to 2022 through study visits, online status update meetings, and both face-to-face and online interviews. The present study builds on purposive sampling of key informant interviews. Key informants were identified and recruited during study visits to the hospital, often introduced to the researchers by the project lead or encountered in meetings. From a power-perspective, who is considered a key informant warrants careful consideration [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this case, key informants were chosen based on their closeness to the foodservice reform, decision-making opportunities, and to ensure representation from different parts of the hospital organisation. To reduce the risk of identifiability, detailed job titles, unit affiliations, or other characteristics that could make individuals easily identifiable are not reported. Quotes are labelled broadly and potentially identifying details are removed. An advisory statement expressing the ethical appropriateness of the study was granted from the Swedish Ethical Review Authority (Reg. no. 2019\u0026ndash;05132).\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eInterviews were conducted by the first author (SR) at three occasions: face-to-face at the hospital three months prior to the implementation of the foodservice reform (2019, n\u0026thinsp;=\u0026thinsp;6), online and on the phone six months after the implementation (2020, n\u0026thinsp;=\u0026thinsp;9), and face-to-face at the hospital two years after the implementation (2021, n\u0026thinsp;=\u0026thinsp;3). In total, 18 interviews were conducted with 12 participants. Two participants were interviewed three times, two participants twice, and eight participants once. The Covid-19 pandemic affected data collection. Of the 18 interviews conducted, 15 lasted 60 to 90 minutes. Three interviews conducted during the pandemic were shorter, lasting approximately 15 minutes, and were conducted by phone to minimise disruption to clinical responsibilities. Most participants were women, reflecting the gendered composition of the occupational fields involved. Interviews were audio recorded, and then transcribed verbatim.\u003c/p\u003e \u003cp\u003eInterviews were semi-structured and followed an interview guide with an opening question, three main topics, and a closing question. Follow-up questions centred around whatever topic the interviewee brought up. Each interview started with a general question about what a normal day at work looks like for the interviewee. The following three main topics were how they perceived their professional role, the foodservice reform, and hospital meals in general. Questions included for example what they liked or would like to change about their professional role, what they wished others knew about their work, what benefits and disadvantages they thought the foodservice reform would have/had, what they would change if they were almighty, and how hospital meals should be. Interviews were ended with questions about their professional background, and finally \u0026ldquo;if there was something they wished I had asked but didn\u0026rsquo;t\u0026rdquo;. The interview guide can be found as supplementary material [Additional file 1].\u003c/p\u003e \u003cp\u003eStudy visits were conducted by the first author in 2018, 2019, and 2021, and additional organisational update meetings were attended online approximately every six months. Notes were taken during these activities and used as contextual knowledge to support interpretation of interviews (for example terminology, routines, and reform milestones).\u003c/p\u003e \u003cp\u003eAnalytical approach\u003c/p\u003e \u003cp\u003eThe analytical approach in the present study builds on Bacchi\u0026rsquo;s analysis of discourses. Bacchi distinguishes analysis of discourse from discourse analysis as two different analytical traditions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In this distinction, analysis of discourse focuses on systems of thought instead of language use. Discourses according to Bacchi are historically produced ways of thinking that establish frames of reference that are difficult for people to think and act outside of.\u003c/p\u003e \u003cp\u003eBacchi takes a Foucault-informed poststructuralist approach to interviews, which has implications for how interview data is understood and analysed. The focus is on discursive practices: what can be said and done and the rules and norms that make it possible to say. A discursive practice can be exemplified as repeated ways of doing and talking that make certain things \u0026ldquo;obvious\u0026rdquo; at the ward while other things are harder to imagine, for example in relation to professional hierarchies and task allocation. It should also be noted that the focus is not on personal experience but rather on what is possible to be, do, or say [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This directs attention to the conditions under which sayings and doings are produced rather than to interviewees\u0026rsquo; experiences. The goal of the analysis was not to evaluate the foodservice reform, but rather to focus on how particular practices and organisational arrangements were articulated as natural, inevitable, or \u0026ldquo;reasonable\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe key terminology used in the analysis was problematizations, governing technologies, discourses, discursive practices, subject positions, and effects. Problematizations refer to the specific ways an issue is constituted as a problem in need of attention, change, or intervention [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Governing technologies refer to the concrete tools through which such problematizations are operationalised in practice, such as procedures, classifications, routines, instruments, role definitions, and organisational arrangements. Discourses are historically produced clusters of meanings and practices governed by rules that define what can be thought, said, and done, and what counts as true, reasonable, or possible in a specific field [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Discursive practices are the recurring ways of doing and talking through which such discourses are enacted. Subject positions refer to the roles made available within these practices, while effects refer to what these arrangements make possible, legitimate, or difficult in practice. In this way, discourses have practical effects on ward-based work. How actors are positioned affects what makes sense to do in practice, for example who is invited to meetings, how performance is measured, and which aspects of work are made visible or remain invisible.\u003c/p\u003e \u003cp\u003eBased on these theoretical understandings, Bacchi has articulated a methodology for analysing interviews: poststructural interview analysis [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], which has influenced the analysis in the present study. Although poststructural interview analysis is described in terms of steps, in reality the analysis moves between different questions posed to the material. Noting what can be said or done is the first step, following an analysis of how it became sayable, which discursive practices are involved, what they produce, which problem representations and governing technologies are made visible, and which subject positions are made available. Researcher reflexivity is an important part of this methodology and the researchers\u0026rsquo; own bias and alternative ways of thinking should be continuously considered. In the present study, reflexivity was practiced through continuous discussion of data and analysis between the two female authors. This first author (SR) represented an organisational background and was a PhD student. The second authors represented a clinical background and was an experienced qualitative researcher (PhD, RD).\u003c/p\u003e \u003cp\u003eProcess of analysis\u003c/p\u003e \u003cp\u003eInterviews were transcribed verbatim and read multiple times for familiarization. The transcripts were then coded with qualitative analysis software MAXQDA24 by the first author (SR). Speaker role and time of interview were coded to support contextual understanding of the material. This enabled attention to whether particular ways of problematising the foodservice reform were linked to specific stages in the implementation process. However, interview timing did not emerge as a notable basis for the final analysis.\u003c/p\u003e \u003cp\u003eFollowing the poststructural interview analysis approach, the material was coded in relation to problem representations, underlying assumptions, governing technologies, subject positions, and effects. Building on these codes, analysis focused on discourses by asking \u0026ldquo;what is the overall way of thinking and talking made visible by these codes\u0026rdquo;? Discursive practices were analysed by asking \u0026ldquo;what are people actually doing, repeatedly, that enacts this discourse\u0026rdquo;? Subject positions and effects were then connected to the identified discourses and discursive practices. These steps were iterative, shifting repeatedly between codes, coded segments, speaker roles and discourses. Quotes were selected to illustrate subject positions and are presented with potentially identifying details removed.\u003c/p\u003e \u003cp\u003eThe results are reported as three site-specific bundles of discursive practices that show how discourses are enacted in meal-related work, and what subject positions and effects follow for the kitchen, the ward, and ward-based service.\u003c/p\u003e \u003cp\u003eReporting followed Consolidated Criteria for Reporting Qualitative studies (COREQ) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] when applicable and a COREQ protocol can be found as supplementary material [Additional file 2].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the material, two overarching governing discourses were salient. First, market-oriented discourse based on efficiency and customer satisfaction. Second, participants continuously referred to an enduring hospital hierarchy in which clinical authority and professional boundaries shape what counts as legitimate work and whose perspectives are included. There were two main governing technologies; internal contracts and budgets. However, the foodservice reform design as a coherent concept also functioned as a governing technology by establishing an authoritative model for how meal-related work should be organised. National regulations were likewise invoked as justificatory resources, though less consistently.\u003c/p\u003e \u003cp\u003eInterviewee accounts described wards as \u0026ldquo;customers\u0026rdquo; who \u0026ldquo;buy\u0026rdquo; meals and services through internal contracts, while the production kitchen and service unit were positioned as providers. Internal contracts as part of a purchaser-provider model were therefore understood as a governing technology. One informant explicitly contested the budgetary logic of this set-up by framing internal contracting as a matter of allocation rather than collaboration, as shown in the quote below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBut in the end, as I said, it\u0026rsquo;s really just a matter of playing with the numbers and deciding where to allocate the money\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral accounts described the concept of service staff at wards as politically mandated, while financing remained a ward responsibility within existing budgets. Service provision was articulated as a practical dilemma where ward-based service was desired but difficult to fund at the ward level without budgetary supplementation. While concerns were raised that financing ward-based service could require a trade off in relation to clinical staffing, one account emphasised that ward-based service had been incorporated without budget supplementation and without subsequent reductions in nursing assistant posts:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, that [fear of having to let healthcare staff go to be able to finance service staff] has been discussed. It was discussed when ward-based service was introduced as a project with funding two years ago, but then after six months it was incorporated into line operations, without any additional funding. So you could say we\u0026rsquo;ve been running at a deficit, but since then there hasn\u0026rsquo;t been any talk of cutting back or reducing nursing assistants and so on. So we\u0026rsquo;ve still been able to keep the same staffing level we had when the project started.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Participants also described how inclusion in dialogue and decision-making about meals was shaped by a taken-for-granted hierarchical order and limited opportunities to meet. One informant phrased this by linking interprofessional collaboration to both hierarchy and organisational conditions:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026rdquo;But then there is a general hierarchical basic order at our hospitals, although it isn\u0026rsquo;t as it used to be when doctors were Gods and so on\u0026hellip; and I don\u0026rsquo;t think it is consciously, this is unconsciously. It\u0026rsquo;s like an old culture and a system failure, I mean, there isn\u0026rsquo;t enough space to get together, for dialogue.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFurther, interviewee accounts described the foodservice reform concept as inherently good and as something that should work if implemented properly. In this framing, problems were articulated as failures of implementation rather than of the foodservice reform concept itself:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;the concept itself is very good, if everything is in place and if everything works within the concept, you know?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBelow, discursive practices and the subject positions and effects they produced in relation to the discourses described above are presented analytically categorised into three organisational sites: the kitchen, the ward, and ward-based service. While interview accounts were fairly aligned concerning the kitchen and the ward, they were less aligned concerning service and the roles of service staff.\u003c/p\u003e \u003cp\u003eThe kitchen: the quality controller\u003c/p\u003e \u003cp\u003eAcross interviews, \u0026ldquo;quality\u0026rdquo; of meals was repeatedly problematized and articulated as a central aspect of meal-related work and a key justification for the foodservice reform. Quality was made actionable through recurring descriptions of practices such as controlling taste and presentation, refining recipes, and managing menu design. These practices were framed as non-negotiable and articulated using customer-oriented language, where the meal was described as an experience that should correspond to what is paid for:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip; and quality and food, no matter if it is [the new foodservice concept] or a restaurant or whatever, we should always have good quality food no matter what\u0026hellip; they pay for an experience and it should be, they should get what they pay for.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterview accounts described careful work with recipes, tasting and presentation. One participant described a dish as \u0026ldquo;\u003cem\u003eone of the best fish dishes I\u0026rsquo;ve ever eaten\u003c/em\u003e\u0026rdquo; and therefore necessary to include in the menu. Such accounts enacted restaurant quality as a standard through which the foodservice reform could be evaluated, and positioned culinary expertise as an appropriate basis for menu decisions.\u003c/p\u003e \u003cp\u003eQuality was also located within a narrative of change where production technologies and public expectations of food were described as having developed over time and foodservice was described as needing to keep up:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI mean, like in the 90\u0026rsquo;s, it was all ovens everywhere, almost no griddles and that means OK you just heat up foods. So, the attitude is different now, and also, citizens make more demands and have higher expectations, like what do I put in my body, we have higher expectations on food and are more mindful of what we eat and so both restaurants and foodservice have to keep up with that development.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn relation to discourses and practices, the production kitchen was positioned as a quality controller responsible for both producing and monitoring quality. At the same time, customer-oriented language produced a subject position of the eating patient as an evaluator of experience, making satisfaction a reasonable basis for assessing quality and a central marker of foodservice reform success. Further, patient satisfaction was repeatedly connected to food intake and recovery, often articulated by stating \u0026ldquo;\u003cem\u003efood is medicine\u0026rdquo;\u003c/em\u003e, which legitimized satisfaction as clinically relevant to recovery, rather than merely connected to service. Across the material, the food was repeatedly celebrated and it was also a focal point of the foodservice reform in interview accounts. This had the effect of establishing the kitchen as a legitimate site of expertise and of making meal quality a central basis for valuing meal-related work.\u003c/p\u003e \u003cp\u003eThe ward: the hegemonic customer and the gatekeeping manager\u003c/p\u003e \u003cp\u003e Participants articulated recurring practices of contracting, customer meetings, and negotiations that shaped how ward needs were defined and addressed. Although the service concept was described as politically mandated, meals and ward-based service work were translated into a ward-level need that had to be specified, negotiated, and financed as a purchasable service rather than articulated as shared work. Wards were described as customers, with varying frequency of customer meetings and accommodation of their needs depending on how many meals and how much service they bought. At the same time, accounts described uncertainty about what the contracts covered in terms of service agreements, or in other words, the extent of services that had been bought. In relation to these customer negotiation practices, prioritising wards that buy more was made intelligible as reasonable, positioning them as hegemonic customers. This contributed to normalizing mealtime work as something wards purchase rather than a shared responsibility.\u003c/p\u003e \u003cp\u003eFurther, interview accounts described practices in ward management as something that shaped whether ward-based service staff were included or marginalised. Management practices were framed as filters for information and attitudes about the foodservice reform:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA lot of the information that goes out about [the foodservice concept] doesn\u0026rsquo;t reach the staff. Information, information, and information, and then the staff say, nobody told me I had no idea.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn relation to these practices, ward management was positioned as gatekeepers of service staff inclusion. Interview accounts included articulations of engagement as well as uninterest. Managers could be positioned or position themselves as engaged and positive, actively involving service staff in meetings and ward routines as well as articulating appreciation for the support they offered, or as seeing service staff mainly as \u0026ldquo;\u003cem\u003esomeone who is there and does what they are told\u003c/em\u003e.\u0026rdquo; The subject position of the gatekeeping manager mediated access to information and everyday routines, shaping whether service staff were positioned as colleagues or as invisible extras. This made it intelligible why interprofessional collaboration between service staff and clinical staff could be organised differently between wards despite a shared formal foodservice reform design. The effect was that ward-level management and contracting practices retained substantial power over whether service staff were included, informed, and recognised in everyday work.\u003c/p\u003e \u003cp\u003eService: the peripheral service staff, the subjugated service staff, and the collegial service professional\u003c/p\u003e \u003cp\u003eIn relation to ward-based service work, interview accounts were less aligned than accounts related to the kitchen and the ward. This heterogeneity was treated analytically as its own finding where service work emerged as a key site where competing problem representations were negotiated. Two dominant problematisations recurred across the material. First, service was problematised as a purchasable and contract-defined auxiliary function. Second, it was problematised as a question of legitimacy and belonging. These dominant problematisations were supplemented by secondary ones concerning professional boundaries and information flows. This section traces how these problematisations sometimes aligned and sometimes competed, producing multiple service staff positions and uneven conditions for interprofessional collaboration between service staff and clinical staff. Based on this heterogeneity, this section has been divided into subsections for clarity.\u003c/p\u003e \u003cp\u003ePractices concerning information access, enactment of regulated professional boundaries, and everyday recognition shaped available subject positions for service staff. In relation to these practices and recurring transactional descriptions, three positions recurred: the peripheral service staff, the subjugated service staff and the collegial service professional. Collaboration-oriented practices, for example inclusion in meetings and shared routines, were described as uneven across wards. When these practices were present they positioned service staff as colleagues. The value of ward-based service staff was often articulated in relation to them unburdening healthcare staff from service related work.\u003c/p\u003e \u003cp\u003eThe peripheral service staff\u003c/p\u003e \u003cp\u003eInterview accounts described service staff as non-clinical staff who refrained from certain bedside tasks like adjusting beds or providing eating assistance, with patient safety legislation [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] invoked as justification. The analysis focused on how these regulated boundaries were enacted in everyday meal-related work and whether collaboration practices between service and care staff were described as present or absent. In the account below, the support that service staff provided to unburden nurses was appreciated while information flows were described as contingent on collaboration practices:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYeah, I mean, I think it\u0026rsquo;s really good, the assistant nurses can have a bit more time for nursing care and for conversations, and they can completely let go of ordering and that kind of thing. So it\u0026rsquo;s really good, truly. What could be the downside is that you don\u0026rsquo;t see the whole chain of care. Before, the assistant nurse handled both the ordering and the conversation about food with the patient, and you don\u0026rsquo;t really get that conversation in the same way with this concept. But there is good communication between service staff and the care staff, and we\u0026rsquo;ve designed that, but still\u0026mdash;well, that can be the downside, I suppose. And then sometimes\u0026hellip; before, you could see if the patient couldn\u0026rsquo;t eat on their own for example, because sometimes it can be a bit difficult. A meal gets put down, and then you realise after a while that they haven\u0026rsquo;t even taken the first bite, and then half an hour has passed. So it\u0026rsquo;s kind of that, you have to have close collaboration, so that it becomes as good as possible for the patient.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis account constructs close collaboration as necessary to prevent breaks in information flows, while expressing the perceived value of service staff as a function that unburdens assistant nurses. In accounts where service staff were included in routines such as daily morning meetings, information sharing was described as working more smoothly. On the contrary, when information sharing was problematised, such routines were described as absent and service staff were described as having to spend time searching for patient information, sometimes discovering information gaps they did not previously know of. In this position, analytically labelled the peripheral service staff position, service staff were described in ways that positioned them as physically present but organisationally peripheral: responsible for meal-related work, yet not recognised as part of the team.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026rdquo;It\u0026rsquo;s the responsibility of the healthcare staff to ordain diets while service staff are responsible for serving meals, there is a significant difference in area of responsibility\u0026hellip; I\u0026rsquo;d say [flow of information] is not a huge problem because we work really hard with it but if we didn\u0026rsquo;t work so hard all the time then it would be a problem\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn this account, the professional boundary between service staff and clinical staff is enacted as legitimate, while simultaneously problematising the coordination work required to make the flow of information function, positioning service staff as dependent on ward-provided information and therefore as peripheral to patient-related decision-making.\u003c/p\u003e \u003cp\u003eThe subjugated service staff\u003c/p\u003e \u003cp\u003ePractices of everyday recognition as well as inclusion and exclusion in ward social life positioned service staff as sometimes devalued and marginal, hence analytically labelled the subjugated service staff position. Some accounts described a poor social working environment, for example how service staff had been excluded from social events such as celebratory meals during holidays or shared coffee breaks, and how they sometimes received demeaning comments. This position was also linked to the practice of internal contracting:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey quite often hear, what do we need you for? It should be, I don\u0026rsquo;t think we pay for this service, it\u0026rsquo;s a shame, but most people are really sweet, but one such comment can ruin the whole day, that\u0026rsquo;s what is remembered.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterview accounts described how service staff were sometimes referred to simply as \u0026ldquo;\u003cem\u003ethe service person\u0026rdquo;\u003c/em\u003e, a practice that reduced them to a function rather than a colleague with a name. Service work was described as becoming visible mainly in situations where tasks remained unfinished, rather than through recognition of competing priorities and lack of time. In this way, talking in terms of value-for-money combined with everyday interaction practices positioned service staff as lower-status workers whose presence it was possible to question. One account explicitly linked these practices to both the hospital hierarchy and a transactional framing:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026rdquo;I think it\u0026rsquo;s deeply rooted, etched into the walls\u0026hellip; hospital environments have always had hierarchies\u0026hellip; but I think it\u0026rsquo;s also about money, we have bought this service and we want value for money, so, that\u0026rsquo;s one thing, not being a natural part of the care team.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis account shows how service work was made intelligible as subordinate to clinical work, legitimized by referring to an enduring hospital hierarchy.\u003c/p\u003e \u003cp\u003eThe collegial service professional\u003c/p\u003e \u003cp\u003eIn contrast, a collegial position was made available through recognition practices that defined hospitality and interpersonal work as specialised competences necessary for the foodservice reform\u0026rsquo;s ambitions articulated in relation to the reform design as a coherent concept. Where such recognition was absent, the same competence claims did not translate into inclusion. Some accounts also framed these competences as complex and difficult to sustain within staffing and budgeting constraints, while emphasising that especially the encounter between a meal host and patient could be decisive for patient experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFrom a financial perspective, it would be better if all service employees are able to perform all service related tasks on the ward so that it is possible to be flexible with staffing. That is, having service employees with multiple competencies. But it\u0026rsquo;s difficult to maintain such a broad competence; it\u0026rsquo;s a huge challenge. Because, however you look at it, the meal host role requires more competence, it\u0026rsquo;s harder and involves a more complex skill set\u0026hellip; Because above all, the meal host role is the encounter with the patient, which is often perhaps at least as decisive as the food on the plate.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe professional role of the meal host was also described as placing \u0026ldquo;\u003cem\u003every high demands on social or interpersonal competence\u0026rdquo;.\u003c/em\u003e In some accounts, tensions were noted when staff were recruited for their hospitality skills and passion for the meal host role, but other service tasks like cleaning subsequently were perceived as unpopular, making the service staff role complex to fulfil.\u003c/p\u003e \u003cp\u003ePut together, these accounts show that a collegial positioning was dependent on whether coordination routines and recognition practices were described as in place, and on whether service was valued primarily as unburdening care work or problematised as a ward-level cost. The effect was that service staff\u0026rsquo;s legitimacy remained uneven and contingent rather than fully secured.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study suggests that hospital foodservice reform should not be understood only as a change in food production and meal delivery, but also as a change in how meal-related work was governed, understood, and valued. In this case, internal contracting and customer-oriented language framed meals as something that could be bought, evaluated, and improved, rather than simply as part of care. This shifts attention from internal contracts as administrative tools to contracts as devices that organise what counts as legitimate meal-related work. This did not mean that wards autonomously defined the need for ward-based service from the outset. Rather, the foodservice reform concept was politically authorised at a strategic level, while wards became the operational site where that mandate had to be interpreted, financed, and translated into everyday practice. These arrangements were not merely administrative background conditions. They functioned as discursive practices and governing technologies through which a particular organisational order was produced and normalized [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. What became intelligible was not meal work as a shared care responsibility, but meal work as a set of purchasable and measurable contributions.\u003c/p\u003e \u003cp\u003eIn line with earlier organisational research, the hospital cannot be assumed to function as one coherent organisation experienced in the same way by all actors [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Instead, it may be better understood as multiple organisations within one. From this perspective, staff may be oriented primarily to their local work setting rather than to the hospital as a unified organisation. The present findings suggested that the kitchen, ward, and service were not simply coordinated parts of one foodservice system, but differently positioned organisational sites with unequal power to define what counted as legitimate meal-related work.\u003c/p\u003e \u003cp\u003eThe kitchen emerged as a strongly valued site of quality and improvement. Although food production work itself was relatively invisible at ward level, food as a product was highly visible and was repeatedly associated with patient satisfaction in interview accounts. The ward was the site where the politically approved service concept was operationalised into local arrangements. It therefore functioned as a gatekeeping site where service needs were prioritised and organised in practice, and where the relevance of other contributions was filtered through existing hierarchies.\u003c/p\u003e \u003cp\u003eWard-based service occupied a more uncertain position. Although visible in everyday meal-related work, its contribution was not consistently recognised and often had to be justified in terms of relieving healthcare work or reducing burden. Service could therefore be valued when it facilitated the meal process and reduced the workload of healthcare staff, but it could also be questioned as a cost or treated as an auxiliary function that had to justify its presence. This interpretation is also consistent with recent research on CRS in Swedish hospital wards, where unclear task allocation, limited integration into existing ward routines, and organisational separation between CRS staff and ward staff complicated collaboration and made the new service role more difficult to become accepted and established in everyday ward work [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the present study, a central lived effect of the foodservice reform was the uneven distribution of value and legitimacy across these three sites. The kitchen was legitimised through quality and patient satisfaction, the ward retained authority to define ward-based service in practice, and service itself remained only conditionally legitimate.\u003c/p\u003e \u003cp\u003eThe findings also indicated that meals should not be treated as a purely technical and logistical matter. Previous research has shown that physical tasks often become the visible measure of \u0026ldquo;work\u0026rdquo; while emotional labour remains harder to account for and is often carried by lower-status workers close to patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hands-on care tasks such as feeding patients and noticing problems may be undertaken by lower-status staff who nevertheless remain positioned low in the hospital hierarchy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Related research has also shown that embodied and emotional care, often expected of female frontline workers, remains necessary but insufficiently recognised, while technical and disembodied skills are increasingly valued [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Rather than suggesting that logistics are unimportant, the present findings indicated that foodservice reform alone does not secure patient experience or nutrition care when the relational dimensions of meal-related work remain weakly recognised.\u003c/p\u003e \u003cp\u003eThis argument can also be related to previous analyses of neoliberal restructuring in hospital care, where growing workloads, intensified demands, organisational control, and budgetary discipline may marginalise care practices [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The findings of this study also need to be understood in relation to the wider organisation of work in Swedish women-dominated welfare sectors, where labour remains strongly gender segregated and where New Public Management reforms have reshaped the public sector in recent decades [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Power structures in everyday work may remain difficult to articulate, partly because they are uncomfortable to discuss and difficult to influence [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In the present study, such structures became visible in how meal-related work was differentiated, valued, and justified across kitchen, ward, and service.\u003c/p\u003e \u003cp\u003eThe present study has several strengths and limitations. The case study design enabled an in-depth analysis of a hospital foodservice reform in its natural organisational context and was well suited to the study aim of examining how discourses, discursive practices, and governing technologies shaped meal-related work. The study therefore offers a conceptual contribution by showing how hospital foodservice reform can be analysed as a governance issue, rather than only as a matter of food systems or patient outcomes. Further, the foodservice reform was followed over several years through study visits, organisational update meetings, and interviews conducted before, during, and after implementation, and participants were purposively recruited from different parts of the hospital organisation. However, the study was also limited by its single-case design and by its reliance on purposively selected key informants, which meant that the findings were context-specific and that some perspectives on everyday meal-related work were less visible. Data collection was also affected by the Covid-19 pandemic.\u003c/p\u003e \u003cp\u003eIn sum, the analysis suggested that reorganising hospital foodservice involves more than improved food quality or efficient task redistribution. It also involves struggles over how work is defined, whose contributions are recognized, and how care is coordinated across organisational and professional boundaries. In this case, communication, inclusion, and recognition were not secondary implementation issues but part of the organisational conditions through which meal-related work could be enacted as care rather than as a peripheral support function. This suggests that research on hospital foodservice therefore needs to address governance, hierarchy, and inclusion alongside nutrition, efficiency, and satisfaction outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study shows that hospital foodservice reform is not only about food production, logistics, or patient satisfaction, but also about how meal-related work is governed, understood, and valued. The analysis made visible a set of assumptions that might otherwise remain taken for granted. The analysis showed that internal contracting and customer-oriented language framed meal-related work as something that could be bought, measured, and negotiated rather than treated as a shared care responsibility. While the kitchen was strongly legitimised through quality and patient satisfaction, the ward-based service remained conditionally legitimate.\u003c/p\u003e \u003cp\u003eThe findings also suggest that if ward-based service roles are expected to contribute to patient care, they cannot be treated as peripheral support functions. They need to be included in collaboration, recognised in everyday ward work, and supported by organisational arrangements that make their role clear and their working situation sustainable in practice. More broadly, the study highlights that hospital meals carry value beyond nutrition alone. Hospital foodservice should therefore be understood as an organisational and relational part of care, not as a secondary service surrounding it.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Criteria for reporting qualitative studies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCare Related Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eAn advisory statement expressing the ethical appropriateness of the study was granted from the Swedish Ethical Review Authority (Reg. no. 2019-05132). All participants provided informed consent to participate. Participants received both written and verbal information about the study, including that participation was voluntary and that they could withdraw at any time without giving a reason. Participants were also informed that data from the interviews could be published in research articles in anonymised form, with all identifying characteristics removed. All methods were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe qualitative interview data generated and supporting the findings of this study are not publicly available due to ethical restrictions and the risk of participant identification. Requests for further information about the data should be directed to the corresponding author (SR).\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research didn’t receive any funding.\u003c/p\u003e\n\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\n\u003cp\u003eS.R designed the study and was responsible for data collection, data analysis, and drafting the manuscript. E.K. supervised the study and contributed to interpretation of data, as well as drafting and editing of the manuscript. Both authors reviewed the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eOur sincere thanks to prof. Maria Carbin and prof. Agneta Hörnell for their insightful advice and constructive feedback. We would also like to thank the study participants for their time and invaluable insights.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHazzard E, Barone L, Mason M, Lambert K, McMahon A. Patient-centred dietetic care from the perspectives of older malnourished patients. J Hum Nutr Diet. 2017;30:574\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoss LJ, Mudge AM, Young AM, Banks M. Everyone\u0026rsquo;s problem but nobody\u0026rsquo;s job: Staff perceptions and explanations for poor nutritional intake in older medical patients. Nutr Diet. 2011;68:41\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOttrey E, Porter J, Huggins CE, Palermo C. Meal realities \u0026mdash; An ethnographic exploration of hospital mealtime environment and practice. 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NORA - Nord J Fem Gend Res. 2022;30:81\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;hman A, Keisu B-I, Enberg B. Team social cohesion, professionalism, and patient-centeredness: Gendered care work, with special reference to elderly care \u0026ndash; a mixed methods study. BMC Health Serv Res. 2017;17:381.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Food Service, Hospitals, Health Care Reform, Qualitative Research, Healthcare Governance","lastPublishedDoi":"10.21203/rs.3.rs-9167818/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9167818/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHospital meals are important for patients\u0026rsquo; well-being and recovery, but research on hospital foodservice has mainly focused on foodservice systems and patient outcomes rather than on how meal-related work is governed, organised, and valued in practice. This study analysed a hospital foodservice reform in a publicly funded Swedish hospital. A cook-serve foodservice system based on immediate preparation and service of meals was replaced with cook-chill production involving advance preparation, chilling, plating, and reheating before service of meals. Additionally, menus were expanded and ward-based service staff called meal hosts were introduced. The aim of this study was to analyse how the foodservice reform shaped professional relations between the kitchen, the ward, and ward-based service.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study design was a qualitative case study. The foodservice reform was followed 2017\u0026ndash;2022 through study visits, organisational update meetings, and semi-structured interviews. Key informants were purposively selected based on their closeness to the foodservice reform and represented different parts of the hospital organisation. In total, 18 interviews were conducted with 12 participants before, during, and after implementation. Data was analysed using Bacchi\u0026rsquo;s poststructural interview analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwo overarching discourses were salient: market-oriented discourse based on efficiency and customer satisfaction, and a discourse of enduring hospital hierarchies. Internal contracts, budgets, and the foodservice reform concept guidelines shaped how meal-related work was organised and valued. The kitchen was legitimised through quality and patient satisfaction, the ward retained substantial power over how ward-based service was organised, which remained only conditionally legitimate. Although ward-based service was visible in everyday meal work, it was not consistently recognised and was often valued mainly when it reduced the workload of healthcare staff.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eHospital foodservice reform should be understood not only as a matter of food production and logistics, but also as a matter of governance. In this case, meal-related work was framed as something that could be bought, measured, and negotiated rather than treated as a shared care responsibility. If ward-based service roles are expected to contribute to patient care, they need to be recognised, included in collaboration, and supported in organisational arrangements.\u003c/p\u003e","manuscriptTitle":"Professional boundaries of food and care: efficiency, satisfaction, and collegiality in a case study of hospital foodservice reform","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 20:16:41","doi":"10.21203/rs.3.rs-9167818/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"327062436681286383856329894721066988137","date":"2026-05-11T11:42:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188728518729882316241465710080864010517","date":"2026-05-09T07:36:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-24T05:06:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-23T07:52:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-31T03:59:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-30T12:15:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-03-30T12:09:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7e5ce87-c122-4bd4-936e-15a1d49524e8","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"327062436681286383856329894721066988137","date":"2026-05-11T11:42:40+00:00","index":81,"fulltext":""},{"type":"reviewerAgreed","content":"188728518729882316241465710080864010517","date":"2026-05-09T07:36:29+00:00","index":79,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T20:16:41+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 20:16:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9167818","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9167818","identity":"rs-9167818","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}