In the following, the results are presented as ‘thick descriptions’  of concrete situations associated to nursing home food culture, which will be theoretically contextualised. All names have been changed to protect the participants´ right to anonymity. The focus of this paper is on the residents of the two nursing homesFootnote 6.
The fear of unpleasant consequences if rules cannot be followed
It is my (i.e. the first author’s) 2nd day in Facility 1 when Mrs. Miran must wait unusually long before being brought back by an occupational therapist from group therapy in the basement to her ward on the 4th floor. On that day, the therapist, a community service worker, and I have the task of getting all 16 group therapy participants back to their wards. Since only one of three elevators is working, which offers space for a maximum of two wheelchairs and an escort, Mrs. Miran, twelve other residents with wheelchairs or rollators and I are waiting in the basement in front of the lift. Mrs. Miran keeps looking anxiously at her watch and squirming in the seat of her wheelchair. At some point she comments that there are only ten minutes left until lunch. The woman with the rollator nearby, Mrs. Schlink, then looks in her handbag for her watch, which she does not find. The man in the wheelchair next to her tries to relieve the pressure, noting that ‘those on the ward’ know where they are and ‘would not immediately send out a search party’. This is apparently not a convincing argument for the two women, because generally no food is set aside on their ward for late comers, and they would hence have nothing to eat. The man then remarks that missing the meal is not that bad, since lunch is generally inedible, and that he would prefer the afternoon snack anyway. Mrs. Schlink moves with her rollator to the staircase, intending to walk to the 2nd floor so that she will be on time for lunch. Mrs. Miran seems to find this idea persuasive and also moves towards the stairs with her wheelchair. She is already out of the wheelchair when the women realise that they will not be able to carry the rollator or the wheelchair up the stairs. However, Mrs. Schlink continues on her way, announcing that she will ask a ‘strong caregiver’ to fetch her rollator, because she can hold on to the handrail while climbing the stairs and does not need a rollator. My argument that I could run upstairs and quickly let the staff on the wards know they will be late does not persuade them to turn back. Only if I had brought their food downstairs would they have been convinced to abandon their plans, a nurse tells me afterwards. She had discussed the event in detail with Ms. Miran in the following afternoon hours.
After ten minutes of stairclimbing, however, Mrs. Miran feels herself weaken and allows me to help her back into the wheelchair via the 3 steps she had climbed in the meantime. After another ten minutes I can accompany Mrs. Miran into the elevator to go to the 4th floor. She asks me to take her directly to her room, where she usually has her lunch, because she hopes that her lateness has not yet been noticed. Once in her room, she asks me to find out if the food has already been distributed. Shortly after I leave the room, the nursing assistant that is responsible for lunch approaches Mrs. Miran and asks her where she has been and why she was not in her room when the food was distributed. Now there would only be leftovers, which she says can be warmed up in the microwave. However, neither Mrs. Miran nor I are offered the chance to explain her tardiness. Rather, she is left with the onus of being unreliable and uncompliant, and she feels uncomfortable. I also feel guilty about not delivering Mrs. Miran to her room on time. Eventually, we look at each other speechlessly and find no words for the situation. In addition, the therapist who organises the group was held responsible for the fact that, although Mrs. Schlink arrived on the 2nd floor in time for lunch, she was on foot. The therapist was later even blamed for neglecting her supervision duty and told that she was lucky nothing else happened to Mrs. Schlink, apart from having to go to bed at noon because of the exertion.
From my ethnographic participation in this event, I, being a rookie in this setting, learned some implicit rules and was taught that I had better follow them to avoid being sanctioned as well. The rules concerning mealtimes and their modalities are given high priority, and not respecting these rules can be sanctioned in the event of non-compliance - not only by residents, but also by staff members who perform tasks for and with the residents (here, e.g., the therapist). Being late for meals or not appearing in an appropriate manner will be reprimanded. The scene showed very impressively how nursing home culture is shaped and structured by food. Right at the beginning of my fieldwork stay, I experienced what it meant not to follow the implicit rules and, as a newcomer, I inevitably had to develop a guilty conscience. The collective commotion in front of the elevator, the extraordinary measures the two women jointly undertook to manoeuvre their way out of the situation, the restrictions that residents have (here, due to limited mobility), show very clearly the necessity of adhering to the rules. Therefore, the residents always seem to be on their guard. As described above, residents even tend to actively adapt and choose the lesser of two evils – Mrs. Schlinks’ attempt to climb the stairs from the basement to the 2nd floor instead of waiting for the elevator exemplifies this in an almost absurd way.
A fear of unpleasant consequences of institutionally inappropriate behaviour is present for many residents. Besides asking questions about not eating, threatening with infusion or oral nutrition supplements or informing family members have also been observed – potential sanctions related to not following – or not being able to follow – rules associated to eating. The above example, however, also illustrates traits of the total institution with regard to spaces of agency offered to residents with the aim of allowing them autonomy and self-determination, such as activity groups. Nursing homes provide their residents social and recreational activities in which the residents can participate upon their choice. However, these activities offered are not comparable to the things residents used to do themselves. They lose a great deal of control when they enter a nursing home, since they do not have as much freedom and independence as they had before. So they have no choice but to abide by the prevailing rules and regulations of the nursing home and the staff. As part of the latter’s possibilities, attempts are made to create as pleasant an atmosphere as possible, but the prevailing institutional conditions make this much more difficult.
Thus, most residents prefer not to accept the offer of activity programmes, in which participation is voluntary. In contrast, in an ergo- or physiotherapeutic individual hour, residents and the nursing staff accept that participants might be late for lunch because therapy prescribed by the doctor has priority. This illustrates very clearly the dichotomy of somatic nursing and caring in a residential environment.
Overcoming eating impediments
Adhering to rules was also observable with respect to individual eating behaviours, as exemplified by a scene observed a few days later. In the common roomFootnote 7 of Facility 1, those residents who do not take lunch in their room sit at their usual places and wait for the soup. Only the clattering of the dishes can be heard, the residents do not talk. After the table has been set with napkin and cutlery 30 min before and the residents have been given a bib, the soup is put on the table for them. Some residents spoon up the soup on their own, others are helped. A care assistant sits at a table with four residents and assists two residents in eating. Another care assistant sits at a table with six residents and assists three of them in eating. For example, they thicken the soup, guide a resident’s hand holding a spoon to their mouth, remind the residents to continue eating or feed them directly. There is no talking, not even when reminding residents to eat, which is done by touching their arm or hand and by eye contact. At another table there are three residents who do not need any support, eat independently and would be able to express their preferences and needs; however, nobody is talking.
While in the common room everything is quiet, the adjacent corridor is busy, where the nurse and a third care assistant are distributing the food to those residents who eat in their roomsFootnote 8. Out in the corridor, there are short conversations among staff and between staff and residents, although the latter cannot be heard in the corridor; what is said does not leave their rooms.
The ward physician, followed by the ward manager, enters the common room. They go directly to Mr. Holand, who is in his 60s and much younger than the other residents on the ward. After a stroke three years ago, he only communicates by making sounds; his movements are extremely slow. He is therefore dependent on a wheelchair and on someone to assist him eating. At the moment, he sits alone at a table in his wheelchair, without assistance, wearing only an undershirt with his trousers and looking apathetic. The ward physician and the ward manager stand before him and discuss his state of health and his eating habits in public. He has ‘got worse’, they state, since he barely eats anything anymore, even when assisted by a carer. Neither of them can explain why this is suddenly the case. The doctor suspects that it could have been another stroke, so she decides that a blood count is needed. Thereupon, the ward manager sends a nurse to retrieve the necessary utensils for taking the blood sample. The doctor then takes a blood sample from the resident on the spot. She pushes the soup aside to put down her utensils. She says to the resident that they have to take his blood now, stretches his arm, puts the tourniquet around his right upper arm and tightens it. Then she inserts the needle, and the blood runs into the 4 tubes one after the other. She releases the tourniquet on his upper arm, pulls out the needle, puts a plaster on it and leaves, followed by the ward manager. Mr Holand still does not move. He has not even touched his soup. A resident sitting in his immediate vicinity, who has only recently moved into the facility, observes what is happening and then forgets to eat her soup. She is immediately admonished to do so by one of the table caregivers. In response she pushes the bowl of soup away from herself without saying a word. The other residents, by contrast, seem to be little affected by the event. No change in the atmosphere is noticeable at the more distant tables.
Obviously, the situation of residents being disturbed by medical interventions during meals and staff making residents’ personal medical matters public has only peripherally affected the old-established residents, as such things seem to be part of everyday life in the nursing home. But it could also be an indication that they have kept quiet in order not to attract negative attention. Possibly also because not eating could then be interpreted as a deterioration in their state of health , and therapeutic consequences could be deduced from this, which the scene described illustrates to everyone. Thus, the residents try to avoid attention to their poor eating by eating in an adapted way.
In the situation described, Mr Holand was (half) publicly made into a patient by having his health condition diagnosed during mealtime. On the one hand, the environment in which this happened is inappropriate, because it was actually about eating. On the other hand, one would assume that a diagnosis of health condition should be comprehensive and take place in a private setting. At this point, the importance of exercising control over food intake in the nursing home became clearly visible to everyone present. It was demonstrated in full clarity that therapeutic consequences are to be expected if food is not eaten. It should also be noted that only the new resident reacted with shock, the other residents either looked away in order not to have to deal emotionally with what was happening or behaved in an adapted manner in order not to attract attention. They adapted their behaviour and their needs to the institutional context. The dichotomy of patient/resident that is inherent in the institution of the nursing home  becomes very clear at this moment. On the one hand, there is an attempt to respond to the resident individually, and on the other hand, the resident becomes a patient when the professional actors in the nursing home feel they must intervene in order to fulfil their task properly.
Organising routines around mealtimes
As has been shown so far, the institutional context thus rigorously structures lunchtime for the residents, through rules about where, when and how to eat, but also through the gaze of somatic nursing care that intersects with and sometimes clearly overrules social and emotional aspects of mealtimes. This centrality of eating in the nursing homes studied is not restricted to lunches, but seems to be of systematic relevance: All the activities in a nursing home day, whether those of the residents or the (nursing) staff, are aligned with the five to six mealtimes.
Routinely, a list is drawn up of who among the nursing staff on a given day is responsible for what tasks in the distribution of meals: breakfast is to be served from around 8 a.m. for all residents, and the fork lunch (a snack comprising fruits, yogurt, pastry) around 10 a.m. for some residents. In their morning break at about 10.30 a.m., staff are reminded who has to deal with lunch at noon. As an implicit rule, 30 min after food has been served, it is cleared away again.
Usually, nursing staff take lunch in the break room after serving the residents food. Those who are still busy feeding residents take their meal a little later. For them, the food is portioned and held by those colleagues who are not ‘busy with eating stuff’ that day. During the staff lunch break, it is negotiated who must distribute the afternoon snack at 2 pm. Staff responsible for this are exempt from distributing supper at 5 pm and can leave earlier. During the lunch break, it is also planned who has to deal with breakfast the next day, so that there are no discussions on that during the morning handover. Serving breakfast is not one of the popular tasks of the day because it is time consuming. Staff are instructed to ask each resident what they would like for breakfast, although that is the same for most residents every morning. There are lists for this, which must only be worked through in the morning. However, it is more time-consuming if breakfast is also timed to coincide with the resident’s awakening or time preferences and must then be coordinated with the colleagues responsible for personal hygiene in the morning. Some residents prefer to have breakfast dressed; others insist on being allowed to have breakfast in bed at a certain time. This attempt to organise meals individually, and thus accommodate residents, requires coordination with both residents and nursing colleagues. In contrast, lunch has to be strictly timed, partly because the food carts are equipped with a timer that allows them to be opened only at 11:30 a.m. The carts are then picked up by an external company at 1 p.m. sharp. This may be why the institution tries not to be institutional at breakfast.
Eating in a nursing home is a tightly organised affair, and meals rigidly structure the daily routine of the people working and living there. Residents are to some extent obliged to come to terms with these structures, but they also develop strategies to deal with constraints through tight institutional rules.
How difficult it can be for residents to structure and organise their day in the institution of the nursing home around mealtimes was also explained by Mrs. Jenner, who lives in Facility 1. She has managed to fit into the institutional context without having to abandon her needs entirely by establishing a strict routine, which is recognised by the staff. As she likes to sleep in, she wants her breakfast to be served last, around 9.30 a.m., in her room. Then she needs until noon to get ready for the day with the help of the nursing staff. She takes her lunch in the common room. Afterwards she retreats to her bed until the snack. After the snack she insists on watching her programme on TV, and after supper she always talks to her daughter on the phone. Finally, after a late-night-snack, usually yoghurt or an apple, she goes to bed. It is extremely important for her to follow her hard-earned routines, which amounts to preserving her autonomy in an institutional context where basically everything is predetermined. These strict everyday routines of Mrs. Jenner’s make it impossible, as the nursing staff explained, to put Mrs. Jenner in a group, even though she is ‘still in such a good mood’ that she is one of the few residents physically fit enough to participate. Mrs. Jenner explained to me that she had neither time for the ‘lessons’ nor to chat with me, although she would have liked to tell me about her ‘wonderful’ grandchildren. It took her a while to arrange her day around the mealtimes in such a way that the nursing staff would also agree to it. The most difficult thing for her was not being able to set mealtimes according to her needs. The ‘solution’ that she has found is not yet perfect, but she can live with it and come to terms with the structural constraints by strictly focusing on organising her personal routine around mealtimes. It seems paradoxical that she fights for autonomy from the structural guidelines by setting strict rules herself to make other things possible.
Playing by the institutional rules
The strict timing and the frequency of food servings is also reflected in residents’ comments on how they experience food and meals in the nursing home. Mrs. Miran explained to me that she would be asked many questions if she did not eat her lunch to the satisfaction of the nurses: You didn’t like it again? Why didn’t you eat anything again? Would you like to eat something else? Mrs Miran’s remarks are confirmed by my observations of daily routines: Nursing staff are always vigilant and attentive to the amount of food eaten, as they must document this in the resident’s file. Their primary task in this context is to ensure the provision of somatic nursing care. With regard to food, this includes ensuring nutrition, monitoring the state of health, detecting and assessing irregularities to prevent emergencies or taking appropriate and timely measures. And all this must be properly documented to ensure nursing process, safety, quality, and reimbursement of costs. Furthermore, staff also endeavour to promote the well-being of the residents, which they often strive to achieve through food. Thus, carers keep a close eye on the eating behaviours of the residents. Both the nursing and the caring gaze notice any deviation from the ‘normal’ and investigate it by means of questions. Residents seem not to be comfortable with this watchful gaze.
To avoid questions from caregivers and thus regain more control over their own food intake, residents have developed various strategies. If lunch is not at all tasty, residents switch to having a snack between meals. A late breakfast is also an excuse not to have lunch. But, as some residents explained, sweet snacks are not a good substitute for lunch. Therefore, in Facility 1, bread with sausage or cheese was also offered as an afternoon snack.
Mrs Kainz increasingly opts for snacks between meals, as she can never be sure what lunch will be like. However, if lunch was not to her liking and she let it go back almost untouched, the comments of the nursing staff would be unpleasant. In addition, she would have to wait until there was something to eat again, because in principle she very much likes to eat. Then, she remarked, one could ‘keep one’s head above water’ with the snack at 2 pm, but the sweet pastries were not a smart alternative, because for her only savoury dishes are considered a ‘full meal’. This could also be a slice of bread with sausage or cheese. In Facility 2, where she lives, however, there is only a sweet pastry for snacks and not bread with a savoury topping. As Mrs Kainz does not have visitors, she cannot organise any alternatives to the foreseen meal plan and the selection of additional meals in the facility if she does not like what is offered, as is the strategy of Mr Armbauer, for example. His daughter comes to visit him once a week and brings all the food that he ‘misses’ in Facility 1. Besides home-cooked soups, which are warmed up for supper for Mr Armbauer – if the personnel are willing to do so –, family baked goods, puddings, yogurts, juices and sausages are brought by his daughter. These are kept in the ward fridge, labelled with the resident’s name, and are handed to Mr Armbauer on request – again, if the staff is willing to do so. Because he is looking forward to these special treats, he makes sure that he leaves ‘enough space’ for it during the day’s mealtimes. Therefore, he does not take a snack in the afternoon and only eats enough of lunch so that no questions are asked.
Another resident strategy to escape the gaze and potential questions of carers is to eat in one’s own private room. Mrs. Schiefer and Mrs. Horacek share a room in Facility 2 and have succeeded in getting permission to eat meals together in their room, allowing them to avoid gazes and constant caregiver questioning as to how much was eaten or not eaten and why. Mrs. Schiefer is diabetic, obese and suffers from an intestinal disease. She is therefore given a light diet, which she is not keen on. Her roommate Mrs. Horacek gets an enriched diet because she is a ‘poor eater’, as the carers point out. Mrs. Horacek was therefore often asked by the carer why she had left food on her plate. In reaction to this, she started to ‘make the food disappear’ but was ‘caught’ by the carers when she put it in her nightstand. To get Mrs Horacek out of this embarrassing and awkward situation, Mrs. Schiefer offered to eat her food. Mrs. Schiefer greatly enjoys being able to eat ‘good things’ again and to feel satisfied. Sometimes neither of them likes the lunch; then Mrs. Schiefer disposes of it in the toilet, because she is more mobile. In this case, Mrs. Horacek fetches a snack in the afternoon, which is then eaten by Mrs. Schiefer, because she is still hungry after the unsatisfactory lunch.
I was also able to observe how two residents swapped individual food components in the common room during lunch when the nursing staff were busy with other residents. One resident took the meat and the other the vegetables. When I asked the two residents about my observation later in the afternoon, they were embarrassed at first and asked me not to pass my observation on to the nursing staff, because they have developed this strategy to let as little food as possible go back and thus avoid questions. This strategy allows them to comply with the institutional rules, but still not completely abandon their preferences.
Beating the institution at its own game
Getting attention by not adhering to mealtime rules, however, may not only be avoided, but may also be used strategically to one’s advantage. Due to the rigid routines at mealtimes, the emotional attention at this situation often comes up short for the residents.
Mrs. Bauer, who is visited by her family only on her birthday and at Christmas, said that she sometimes felt forgotten. One day she told me about a resident whose name she did not want to reveal. This resident thought it would be wonderful if nurse Sonja had time for her alone. But since time for emotional attention from carers is scarce, the resident in question, after careful observation, found the solution for herself. She simply refused to eat, so that a carer – ideally nurse Sonja – would focus on her, because that is what carers ‘have to do’ and cannot ‘pretend’ they have a more important task. When I guessed that she was talking about herself, she reacted with a negative hand movement and smiled. Mrs. Bauer’s story clearly shows the extent to which residents feel lonely and need attention; but it also shows how they creatively deal with the nursing home culture and its constricting structures, for which they develop their own strategies.
The story above shows that if residents do not have any relatives or do not receive sufficient attention from them carers dedicate more time to those residents. Thus, it seems that carers invest in residents who receive hardly any visitors through their appreciative attitude, which is reciprocated by the resident with affection or docility. These informal exchange relationships involve an individualised give and take between carers and residents, which creates a sense of community [39, 40].
Striving for autonomy and privacy
As has been shown, residents work out strategies to cope with restrictions in their everyday life and to influence their scope of action for themselves. Thus, they have the chance to arrange their lives within a framework of restricted structures and capabilities in order to maintain or enlarge their autonomy, in a space where they do not have to justify themselves for their behaviours or preferences.
Eating meals in a private room, for example, gives the residents control, because the caregivers are ‘guests’ and for once not the controlling authority. Thus, the meal situation in a private room can be arranged by the residents themselves, at least to a minor extent, and is not orchestrated and monitored by the carers as it is in public. Mrs. Calek’s strategy illustrates this.
While I am handing out the snack at 2 p.m. in Facility 1 and bring Mrs. Calek a lukewarm coffee with lots of milk and a brioche croissant, she talks about her great success at being allowed to eat in her room and says that she does not need anything more for the day. She tells me she finds it very difficult to eat due to her impaired physical mobility, but she does not want to ask the nursing staff for help, not wanting to make them any busier. And so, she feels very uncomfortable about her inability to carry out this recurring activity to her satisfaction. Since she feels so embarrassed about needing help when eating, she has had to ‘fight’ for many weeks to be allowed to eat in her room. At each meal in the common room, she had been reminded by comparing herself with other residents that she could no longer ‘do it’ the way she should. Therefore, she prefers to eat on her own and very slowly, which means that she ingests less and less food, since after about 30 min the food is cleared away to ensure the general flow of tasks and timings. She would never admit that she needs a little more time to eat, and therefore stops eating when her dishes are cleared away. She does not want to be ‘one of the other residents’ who are so ‘miserable’, because she thinks that she does not yet belong in a nursing home. To avoid becoming ‘miserable’, she is taking gymnastics classes to keep fit. Mrs. Calek thus not only uses the institutional offers to prevent deterioration, but furthermore has managed to create a little privacy to compensate for her emerging deficits. However, it is hardly possible to offer her even more comfort within the timeframe, although she would benefit greatly if the food were not cleared away after 30 min. On the other hand, it is through the institutional context that she has the opportunity to maintain and develop her remaining competencies and skills during gymnastics lessons.
On the one hand, Mrs. Calek stays in her room at mealtimes to hide her deficits, because it is important to her to distinguish herself from the other residents who have, in her perception, a poorer general condition . With this strategy, she also tries to escape the vigilant gaze of the carers and its consequences, and also to minimise the danger of co-residents pointing out to the nursing staff that Mrs. Calek is no longer acceptable because she cannot eat autonomously in the collective meal context.
Like Mrs. Calek, some residents tend to group their fellow residents into categories, often distinguishing between three groups characterised as follows: (1) those who are still quite independent and can act autonomously within the institution; (2) those who need more help but are not yet fully dependent; (3) those who are fully dependent, mostly due to their physical condition, and no longer negotiating on autonomy. On the other hand, strategies for hiding deficiencies, as practiced by Mrs. Calek, also entail that due to a lack of knowledge by the staff, no consideration can be given to associated needs. Fitting into the social context, and thus belonging to the community, is essential for Mrs. Calek, because only if she can eat in a cultivated way without spilling and stick to the time allowed for eating meals, will she not be excluded from the community. Thus, she decided to withdraw from the community as a precautionary measure. She took this step ‘voluntarily’ in order not to be publicly excluded and not to have to endure the feeling of rejection.
Autonomy can also be strived for if food from ‘outside’ the ward is consumed, whether it is brought by relatives or self-organised from the snack bar or mini supermarket in the facility or in the immediate vicinity by mobile residents, with the staff’s agreement. However, no help can be offered to them for this; they must be able to manage it completely independently. Mr Friedrich, for example, has negotiated with the nursing staff that every Wednesday and whenever he does not like the offered lunch, he goes to the nearby snack bar outside and buys a kebab, which he pays for out-of-pocket. As the nursing staff remarked, since this arrangement was made, Mr Friedrich has been much more balanced, more satisfied, and only in specific circumstances has he become quick-tempered. Like Mr Friedrich, some residents try to form alliances with employees, which nevertheless depend on their goodwill. Sometimes they invest in building a closer relationship with a specific caregiver, who is then usually more tolerant about sidestepping the rules and not asking questions. The resident’s behaviour, which is to some extent deviant, is then tolerated.
As a rule, eating together in a ‘family’ environment – small to medium-sized groups around a table, usually the ward or residential group – is considered to be the norm in nursing homes [8, 41,42,43]. Eating in a central restaurant or cafeteria – as Mr Friedrich practices it – is an alternative option that signals freedom, but also requires a certain prosperity because residents have to pay extra for it. This option is, however, usually only chosen by residents if a visitor is announced for lunchtime.
In principle, the residents always look forward to visitors and want to make the visitor as comfortable as possible within the possibilities they have. At this point, the role of host, which can no longer be exercised by residents in the nursing home, appears to be a felt limitation to autonomy. As Gouldner  already pointed out, residents have no equivalent form of nurturing social relationships and expressing gratitude in the sense of the ‘reciprocity norm‘.
Furthermore, conclusions can be drawn by the site where food is served to certain residents, which can be understood as a cultural imprint of the institution on individual residents – in contrast to the negotiated small space of autonomy expressed in Mrs. Calek’s story above. Eating in one’s room is, if prompted by the staff, usually more of a ‘banishment’. Either because the resident does not eat properly enough in the group, disturbs the others, is not socially acceptable or wants to be alone because (s)he feels disturbed by the others. But it can also be an expression of weakness or need for help if (s)he does not eat in a ‘normal way’, does not eat at all or needs special assistance with eating.