Hospital housekeeping

by Charlotte A. Aikens

CHAPTER IX.

Diet Lists and Blanks

For the housekeepers’ guidance in preparing meals for the patients, a diet list showing the number of patients to be provided for and the classes of diets required, needs to be prepared. The duty of preparing this list usually devolves upon the head nurses in charge of the wards and the lists should be sent in either at night or early in the morning of each day. Special articles for individual patients will usually be prepared in the diet kitchen, and may or may not be placed on the diet sheet sent to the general kitchen. In large institutions where there is a pantry on each floor in which special diets are prepared, special requisition blanks are used in many hospitals in procuring the supplies. The amount of eggs, milk and beef juice and the various articles that are expensive and perishable, are estimated by the person in charge, and the requisition is signed by the superintending nurse before it is sent to the kitchen or store room. Such a requisition blank is usually about the size of a doctor’s prescription blank, and they are most convenient when prepared in blocks similar to letter pads.

The housekeeper will, of course, superintend the carving of meats and the dispensing of food from the main kitchen. This is one of the most important of her duties and many a dollar can be saved or lost by neglect or attention at this point. Proper carving of meats results in a substantial saving in the course of a year. Dr. W. Gilman Thompson says that an “undesirable tendency among American hospital dietaries is to include too much meat. Not over four ounces of cooked meat (without bone) should be allowed in the meal for men.” Unless specially ordered meat should never be served more than twice a day in a hospital and once for the average patient is sufficient.

Serving of Food

In the serving of food to the patients, provision must be made for serving cooked food that is intended to be hot, really hot. If this is to be accomplished successfully, it must have special attention and special facilities. If there is no diet kitchen or nurses’ pantry on each floor, and the trays are prepared in the main diet kitchen adjoining the general kitchen and sent on the dumb waiter, it means that plates must be heated thoroughly and every article of hot food covered with a hot plate or saucer. The food must be really hot when served on the plates, and delay at the other end of the line guarded against. This method is the only one that can be pursued in small hospitals, or where mistakes in construction have resulted in there being no facilities for serving food convenient to the wards. It is hardly necessary to say that each tray should have on it a ticket bearing the name of the patient for whom it is intended. Neglect of this precaution might cost a life, as for instance if a convalescent typhoid patient (famished with hunger as they usually are in that stage) who was allowed only custard or broth, had served to him a tray laden with fruits, meats and vegetables. Such accidents are not unknown, and may happen in any hospital where laxity about the serving of food exists.

Where there is provision on each floor for setting trays and serving food the same care needs to be exercised about heating the dishes. The food will be served in bulk from the main kitchen, usually in large covered vessels, which should be hot before the food is put in. A steam table in the diet kitchen will suffice to keep them hot till the serving is completed. In winter it may even be necessary to heat the cups, for what is more insipid than a cup of lukewarm tea or coffee?

Equal care needs to be observed to serve cold things really cold. Ice may be a luxury to some people, but the free use of ice in a hospital is an urgent necessity. Not only is it needed to preserve the food, but it has its place in adding relish to a meal especially in hot weather. When a patient is hot and restless and uncomfortable even the clink of a piece of ice in a glass is refreshing and will help to create a desire for the milk itself. It ought not to be necessary to add that cold food should be kept as far as possible from the hot food on a tray, and yet having more than once found a nurse carrying a tray with a dish of ice cream covering a bowl of steaming hot soup, or the butter crowded as close to the teapot as it could be, it may be that such reminders are not out of place. If only everybody lived up to the best they knew; if only one could be sure that what was taught would always be acted out, the housekeeper’s anxiety about the serving of food would be greatly lessened. As it is, “line upon line and precept upon precept” is needed, and in addition that “eternal vigilance” that is said to be “the only price of safety.”

Tray Setting

In the setting of a tray there is a right and wrong method, as in everything else. It is not sufficient to have the dishes and the tray cloth spotlessly clean, but the method of arranging the various dishes should have in view the patient getting the food with the greatest ease. A moderate size tray is preferable. The very large trays are cumbersome and awkward and it is difficult to arrange the small trays to advantage. In the center of the side of the tray that will be placed nearest to the patient should be the plate, with the knife, fork and spoons, arranged in their proper places on either side. At the right hand should be placed the teacup and saucer, and on the left the bread and butter plate, or the individual butter dish. Back of the teacup is placed the small tea or coffee pot. Thoughtless nurses often reverse the position of the teapot and teacup, making it necessary for the patient to reach over the teapot to the back of the tray every time he wants a drink. In the center of the back part of the tray, or the part farthest from the patient, the little sugar and cream vessels should be arranged, and in the left-hand corner of the same side the dessert. The pepper and salt bottles and other small articles may be arranged as space will permit. It is well to have a regular custom established of emptying the sugar vessels and washing them after each meal. Crumbs are dropped in or they become smeared with a wet spoon, and unless the regular emptying and washing after each meal is insisted on, the housekeeper can never be sure they are properly clean. Salt and pepper bottles should be examined daily, and the outside washed after each meal also. It is so easy to overlook this small matter and send empty salt bottles on the tray. The food may be served hot and really be appetizing, save that it needs more salt to suit the patient’s taste. If a bell has to be rung, and a nurse summoned to get the salt, the meal may have cooled and the appetite for it have waned, before it arrives. These may seem small things to dilate upon, but in reality they are the real test of the quality of management. A chain is no stronger than its weakest link, and real success in a hospital demands attention to these apparently trivial details. These trivial details are large to the patient and have much to do with keeping him happy and comfortable. It is not sufficient to provide good food and prepare it carefully. It is only what the patient really eats and assimilates that is a factor in his recovery, and the best meal may be spoiled by lack of attention to the details of serving. The idiosyncracies of patients are nowhere more in evidence than where their food is concerned, and while they are sick, these idiosyncracies and tastes should be considered as far as possible with their highest interest in view.

Another very important point to observe in serving food is not to serve too much at one time. In dealing with a capricious appetite, the sight of a quantity of food often repels when a small portion of the same food daintily prepared and attractively served would be eaten with a relish and an appetite for more created. At the same time no cause should be given for the criticism that a patient did not get sufficient to satisfy him, when his doctor allowed him to have plenty. In planning for regular diets, the fact needs to be kept in mind that a larger quantity of food, proportionately, will be consumed in the men’s ward than in the women’s wards, and sufficient to replenish the supply should be sent from the kitchen.

Bills of Fare

A settled bill of fare for the different days of the week is never a good plan in a hospital. The patients will soon learn the rotation of the different dishes. Old patients will tell new ones, and the matter will come up for discussion. Frequently before the food is served, some patient who has heard objections to some food stated has decided she does not want it, when if it had been taken unexpectedly to her it would have been eaten without question.

Dishes

The prettiest, daintiest dishes the house can afford should be provided for the private rooms. The constant breakage of dishes and especially of dainty china, which goes on in a hospital makes it out of the question to provide this kind of ware for the wards, and here beauty must give place to durability. But a few dainty cups, especially for the women’s wards, will be greatly appreciated, for there are refined, sensitive people in the free wards, as elsewhere. These special cups can be used in serving hot effects. Indeed it is astonishing how few nurses know attractiveness to the food which is in itself an aid to digestion. Care must be observed to avoid partiality in this matter, for patients, like children, are quick to discern symptoms of favoritism.

Glasses are now so inexpensive that every hospital can afford to supply a sufficient quantity for all the patients.

A writer in Table Talk thus describes from a patient’s point of view the invalid’s tray in a certain hospital and shows not only what delightfully dainty effects may be secured in serving the commonest articles of food, but how the memory of those effects remained long after the hospital experience was ended:

“A couple of weeks spent in an up-to-date, twentieth century hospital, has opened my eyes on many points connected with nursing, and especially in regard to the setting forth in an appetizing way of the tray for an invalid.

“At breakfast, dinner and supper these trays were artistic creations of the highest order. One dinner tray was a study in golden greens and white as to china and food, with the needed touch of color given by wreathing the salver with racines of flowers in soft old pink, a flower whose old-fashioned name I could not remember, but whose color and fragrance took me back through more years than I care to count to a sweet, old New Jersey garden.

“There was a golden brown chop in a circle of riced potato; crisp, yellow-green lettuce leaves, ivory white at the base; strips of white and gluten bread spread with golden butter and piled log-cabin fashion on a pretty fluted dish of green and white china; pale green squash; a quivering mold of yellow custard and a pretty teapot in green and gold, with fragrant amber tea and a tiny pitcher of yellow, thick cream.

“A supper tray which stands out pre-eminently in my memory, by reason of its exquisite tones of color, contained a plate with four luscious oysters on cracked ice, the bivalves laid in the form of a star, and between the rays yellow wafers and discs of lemon. There was a plate of lettuce sandwiches in strips an inch wide by three long; a mould of farina, with its attendant pitcher of cream, a glass dish of apple sauce whipped to a foam with white of an egg; triangles of white and gluten bread buttered and cut in the thinnest of slices; a pitcher of cocoa and three Reve D’or roses.

“Sometimes dainty sprays of Cecil Bruner roses lay among the tempting viands, and fell in delicate profusion over the edge of the tray. Again, little clusters of violets peeped over its rim and perfumed the whole atmosphere, or the ruddy glow of crimson strawberries would be accentuated by the deep red of roses of Sharon nestling in their glossy, dark green leaves.”

Hints on Serving

An ordinary fruit, vegetable, or meat may be quite transformed by the manner in which it is being served. An orange may be cut through crosswise and served with a very small dish of powdered sugar and an orange spoon, or it may have the whole fruit cut in carpels or sections from pole to pole and the skin drawn back from each enough to loosen it, and then again drawn into shape. If a baked potato form a part of the meal, cut a slice from the upper side, take out the potato with a small spoon, mash with butter, cream, and salt, whipping light with a fork; fill the skin again, and stand in the oven long enough for the little cone of potato exuding from the top to take a golden brown tinge.

Fruit foams are digestible and dainty for invalids. Any sort of stewed fruit—apricots, apples, peaches, or prunes—should be whipped smooth while warm, and when thoroughly smooth beat in the white of an egg whipped to a stiff froth; serve in thin glass, a pretty cup, or low Japanese bowl.

A patient may be beguiled into eating nutritious food simply through the manner of its preparation. To speak of raw beef sandwiches would doubtless destroy the appetite of a delicate person, but if you will prepare them as follows he will eat them without knowing, probably, what he is eating: Lay a thin slice of round steak on a clean board, and with a rather dull knife scrape off the meat, leaving the tough fibers remaining; do the same on the other side, laying the scraped beef on a dish. Spread two slices of very thin bread with the beef, seasoning plentifully with salt; lay on these two slices of plain bread, and cut into very small triangles, squares, or strips. Arrange these prettily on a fringed napkin laid on a pretty dish, and garnish with very small inner leaves of lettuce or with watercress.

Another way of serving beef which is digestible, palatable, and nutritious, is to mould the beef, scraped as above, into small olives; heat a small frying pan very hot, sprinkle with salt; lay in these olives and shake over a hot fire for a minute or two until the outer surfaces are heated; turn onto a hot dish and garnish with strips of buttered toast.

Now in a general hospital where a hundred or more or less trays have to be prepared for each meal, it is out of the question to devote as much time to artistic serving as could be wished, but one thing is certain, if nurses are not impressed with the importance of taking pains to serve food attractively, and taught how to do it while in the hospital, they cannot be expected to secure the best results in serving food in private practice. Even a thing as simple of preparation as a slice of toast gives room for the production of dainty and artistic and wholesome meal more attractive. Butter should be rolled in little balls between wooden spatters and can be prepared hours

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how to prepare a slice of buttered toast so that it will be just right. A good deal of the time the toast served in hospitals is either burnt, half done or soggy, buttered over much or in patches and served in slices so that the patient cannot possibly manage to eat it without getting his hands well greased. It would cost no more either of time or money to toast it a golden brown, put the right amount of butter on it, and serve it cut in small squares between hot plates.

The time element is a very important point to be considered in serving food and requires careful calculation. Custards as a rule are better served quite cold, and should be cooked a sufficient length of time before the meal to allow for cooling. Baked potatoes are delicious and easily digested when cooked just right and promptly served, but what is more unappetizing than a baked potato that has remained after cooking in a slow oven till it was soggy and half cold?

Tea is another article that is spoiled if prepared too long before it is served, and this list might be multiplied indefinitely. There is no question but that this lack of forethought in calculating the time that should elapse between cooking and serving of food is responsible for many insipid, unattractive, indigestible meals in hospitals. When so much of the food has to be prepared in bulk, the problem is much more difficult than in dealing with an individual patient, and only goes to show the necessity of having not only first class facilities for prompt serving, but first class trained brains to calculate and first class hands to handle it if the best results are desired.

If the one in charge has had personal experience in dealing with invalids, many little touches will suggest themselves to her that will tend to make the invalid’s

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in advance of the meal and allowed to stand in water. Even a dish of bread and milk may be made a dainty meal if the bread is cut in half-inch dice and piled lightly on a plate. Milk toast may be accepted as a delightful treat if a little thought is given to its preparation and serving. As for all toast the bread should be thoroughly and evenly browned before a moderate coal fire. The toast, cut in neat squares, with the crust removed, may then be placed in a deep saucer (the daintiest and prettiest the establishment affords) and covered with a small plate which with the saucer should first be heated. When the tray cover is spread, set on it a small knife and fork and teaspoon, a little silver teapot of hot milk, a ball of butter and a salt shaker. If the patient is able to butter his own toast and pour over it the hot milk he will enjoy doing it.

When a single dish is to be served use a small round tray or a large plate covered with a doily rather than the regular tray used for meals. Avoid putting so many dishes on a tray that it will seem crowded. It is better to use a second tray for serving dessert or fruit than to pile too much on one tray and have it lack in order and neatness.

Cracked cups or china and broken-nosed teapots are distinctly out of place on any invalid’s tray and in these days of inexpensive dishes are inexcusable in any hospital. Special care should be used to avoid filling cups and glasses to the brim. When this is done, it is impossible to avoid an overflow if it has to be carried any distance, the neat appearance is spoiled, a portion of the contents is lost and it is difficult for the patient to handle without spilling.

A nurse who has an eye for harmonious effects in colors will not be guilty of setting a tray with a green cup and saucer and an old fashioned blue plate. A sense of the fitness of things will also keep her from placing together a cup and saucer that were never intended for each other. Such blunders in setting a tray are indicative either of ignorance or carelessness.

It is always a mistake to leave food beside a patient any length of time after the patient has had time to eat it. If he has no desire for it when it is first presented, the chances are small that the desire will come if the food is allowed to stay in sight. Besides the exposure to the floating dust made up of the undesirable elements of a sick room will render the food unfit for use at another time. Food substances are the soil in which bacteria flourish.

A spray of maiden hair fern or any of the dainty green effects is always suitable for decoration, as are many flowers. The use of flowers on a tray should be restricted to a single blossom with a touch of green, or a full bloom flower of the dainty varieties. Large bouquets on an invalid’s tray are in bad taste, as are many flowers that elsewhere would be appreciated.

Every hospital experience ought to be a practical lesson to the patient in how to serve food. A taste for the dainty and beautiful, for wholesome and simple things, may be created there that will permanently influence the sick one to higher ideals of living. And certainly the manner of serving food is a pretty fair indication of the tone of the institution. Refinement or absence of refinement will be detected at a glance by one who has a keen appreciation of the aesthetic.

The best results in food service will never be secured in any hospital until some one person is appointed whose chief business is the preparation of special diets and the oversight of serving. In many large or well-regulated hospitals this matter is in the hands of women specially trained in dietetics, and there one has a right to expect better service than in institutions where one overworked woman must attend to that and a dozen other things, or where the responsibility of serving food is divided among many. If the person in charge has had in addition to the training in dietetics practical experience as a hospital nurse, still better service may be expected. A genuine sympathetic interest, or as some one else has termed it, “an affectionate interest,” in the people for whom the food is prepared, a keeping in mind the Golden Rule in serving and preparing food, as in other departments of the hospital, is fully as important as a knowledge of the science of nutrition. The soul life of the individual can find abundant opportunities for its expression in the diet kitchen as in the ward. There is a field here for specializing which is fully as worthy of a nurse’s attention as some of the other lines of nursing.