in the patient’s shoes: the experience of diet ......b.sc.(hons) speech and language therapy in...

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B.Sc.(Hons) Speech and Language Therapy

In the patient’s shoes: The experience of diet modification from the perspectives of speech and language therapy (SLT) students

Samantha Edwards April 2017

Dissertation submitted in partial fulfilment of the requirements of Cardiff Metropolitan University for the degree of Bachelor of Science

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Acknowledgements

Firstly, I would like to thank my project supervisor, Ria Bayliss, for her invaluable support

and encouragement throughout the process, as well as her enthusiasm in the project.

I would also like to express my gratitude to the participants who gave up their time to take

part in this study; without them this project would not have been possible.

I would like to extend my gratitude to my family and friends, for their encouragement and

faith in me, also to Dan, for his support and patience throughout all four years of this degree.

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Abstract

Background: Research into the various factors underlying non-adherence with dysphagia recommendations is limited. Non-adherence is a complex issue that can challenge clinicians managing the condition, as it has been found to result in adverse outcomes. The social and psychological consequences of dysphagia may have a direct impact on patient adherence, as may the consequences of a common management option; diet modifications. Increased understanding and awareness of these psychosocial issues has been previously recommended, yet novel ways of encouraging this amongst students has not yet been explored.

Aims: This study aims to explore the experience of diet modification from the perspective of SLT students and to draw out themes regarding non-adherence. This will help to further our understanding on the impact that diet modifications can entail and some of the potential reasons pertaining to non-adherence. It will also help to determine whether patient enactment tasks such as this can increase the understanding and awareness of the patient perspective amongst SLT students.

Method & Procedures: This study adopted a mixed-method design. Participants modified their food intake for four days per the national texture descriptor guidelines, recorded their food intake into food diaries, and reported adherence to the guidelines. Quantitative data were gathered via analysis of the food diaries, in which both the adaptations made and the levels of self-reported adherence were evaluated. This allowed for themes to be drawn regarding non-adherence. Qualitative data were gathered via semi-structured interviews that were analysed using interpretative phenomenological analysis. This allowed for data to be gathered on the experience of diet modification.

Outcomes & Results: Results indicated that the levels of self-reported adherence to the modifications were quite high amongst all the participants. Despite this finding, there were instances of both intentional and unintentional non-adherence to the modifications, which occurred because of challenges faced during the application of the modifications as well as the impact that they entailed. Several themes were drawn from the data regarding the experience of diet modification and highlighted that diet modifications can place burden on an individual’s social and emotional functioning, as well as on their overall lifestyle.

Conclusions & Implications: Findings provide insight into the impact of diet modification on the lives of those recommended them, as well as some of the potential reasons pertaining to non-adherence. Furthermore, the findings demonstrate that enactment of the patient experience can increase the awareness and understanding of the patient perspective amongst SLT students and lead them to identify strategies to assist patients manage some of the practical challenges. This may be of benefit when considering the future training of SLT students in the holistic management of dysphagia.

Keywords: dysphagia; diet modifications; adherence; SLT students

(International Journal of Language & Communication Disorders)

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Table of Contents

1. Introduction 1

2. Literature Review 2

2.1. Dysphagia overview 2

2.2. Texture-modified diets 3

2.3. The impact of dysphagia and diet modification 3

2.4. Adherence 5

2.5. Speech and language therapy students 7

2.6. Summary 9

3. Methodology 11

3.1. Introduction 11

3.2. Design 11

3.3. Participants 12

3.4. Materials 13

3.5. Procedure 14

3.6. Analysis 14

3.7. Ethical considerations 15

4. Results 17

4.1. Quantitative data 17

4.2. Qualitative data 24

5. Discussion 36

5.1. The experience of diet modification 36

5.2. The adaptations made 38

5.3. Self-reported adherence 38

5.4. Learning 39

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5.5. Clinical implications 40

5.6. Limitations 41

5.7. Future research 42

5.8. Conclusion 42

6. References 44

7. Appendices 51

7.1. Participant information sheet 51

7.2. Texture guidelines 53

7.3. Food diary 56

7.4. Participant consent form 62

7.5. Interview schedule 64

7.6. Ethical approval letter 65

7.7. Participant 1: Completed food diary (Disk copy only) 67





7.12. Master table of themes with verbatim quotations 87

7.13. Participant 1: Annotated interview transcript (Disk copy only) 92





7.18. Participant 1: Master table of themes 161


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7.23. Table showing merging of the participant themes 170

7.24. Confidentiality checklist 172

8. Word Count 173

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1.0 - Introduction

Dysphagia has been described as a disorder or difficulty with swallowing (Groher & Crary,

2010). It can have serious medical consequences, which include risk of: malnutrition,

dehydration, respiratory infections and death (Ekberg, Hamdy, Woisard, Wuttge-Hannig &

Ortega, 2002). Appropriate management of the condition can help to reduce the risk of these

complications, as well as the length of stay in hospital (RCSLT, 2009). For management to be

successful however, patient participation and adherence is required. If, for various reasons,

patients do not adhere to management recommendations, challenging clinical situations can

arise (Kaizer, Spiridigliozzi & Hunt, 2012) as non-adherence is associated with adverse

outcomes (Low, Wyles, Wilkinson & Sainsbury, 2001).

Non-adherence is a complex issue (Pascucci, Leasure, Belknap & Kodumthara, 2010). At one

extreme, some patients may refuse treatment entirely. This refusal may be uninformed, and

occur because of difficult, un-cooperative behaviour (Tippett, 2011). It may also be informed,

in which the burdens and benefits of the proposed treatment are balanced by the individual

(Tippett, 2011). Outside of this extremity, there may be some patients who intend to adhere,

but occasionally, do not. Some of these instances of non-adherence may be intentional, and

based on informed-decision making, but some of them may also be unintentional (Clifford,

Barber & Horne, 2008). Unintentional non-adherence occurs as a result of limited capacity or

skills to apply the recommendations (Clifford, Barber & Horne, 2008). As will be discussed

further, awareness of the key factors pertaining to non-adherence is essential amongst speech

and language therapists, who play a key role in the assessment and management of dysphagia

(Sura, Madhavan, Carnaby & Crary, 2012).

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2.0 - Literature Review

2.1. Dysphagia overview

Swallowing is the safe and systematic movement of a bolus from the mouth to the stomach

without penetration of the airway (Easterling & Robbins, 2008). It is a complex process that

occurs in four stages: oral preparatory, oral, pharyngeal and oesophageal (Logemann, 2007),

and involves automatic, co-ordinated sensory and motor patterns (Easterling & Robbins,

2008). For healthy individuals, the process is generally performed with little effort or

conscious awareness (Groher & Crary, 2010).

Dysphagia is a disorder of swallowing (Groher & Crary, 2010) that includes: “problems

positioning food in the mouth, in oral movements, including: sucking, mastication and the

process of swallowing (p.320)” (Royal College of Speech and Language Therapists, 2006). It

occurs as a result of behavioural, sensory or motor problems (Easterling & Robbins, 2008)

and is a sequela of various medical conditions (Groher & Crary, 2010). Conditions associated

with dysphagia include: cerebrovascular accidents, tumours, progressive neurological

diseases, autoimmune disorders, cardiopulmonary disorders and drug-related disorders

(Brockett, 2006; RCSLT, 2006). Exact prevalence of dysphagia is difficult to establish due to

differences found in timing of assessment, diagnostic methodology and the variability of

cases included in studies (Wright, Cotter & Hickson, 2008). However, it is estimated that

approximately 8% of the world’s population experience problems with eating and drinking as

a result of dysphagia (Cichero, Steele, Duivestein, Clavé, Chen, Kayashita, Dantas, Lecko,

Speyer, Lam & Murray, 2013).

Serious complications have been documented in the presence of dysphagia and include:

increased hospitalisation, poorer long-term outcomes (Smithard, O’Neill, Park, Morris,

Wyatt, England & Martin, 1996), malnutrition, dehydration (Huckabee & Pelletier, 1999) and

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aspiration (Langley, 1988). Aspiration refers to entry of material into the airway below the

true vocal folds and into the lungs (Logemann, 1983). Along with malnutrition, it is the most

important medical consequence of dysphagia (Singh & Hamdy, 2006) as it can lead to

respiratory infections (Langley, 1988) and at the most extreme, death (Nóbrega, Rodrigues &

Melo, 2008). To minimise the risk of these adverse outcomes, healthcare professionals have

developed various intervention strategies to appropriately manage dysphagia (Kaizer et al.,

2012).

2.2. Texture-modified diets

Diet modifications are one of the most common treatment options for dysphagia (Kaizer et

al., 2012) and involve the alteration of solid foods by either dicing, chopping, mincing,

mashing or pureeing (Steele, Alsanei, Ayanikalath, Barbon, Chen, Cichero, Coutts, Dantas,

Duivestein, Giosa, Hanson, Lam, Lecko, Leigh, Nagy, Namasivayam, Nascimento, Odendaal,

Smith & Wang, 2015). They are commonly recommended for those with oropharyngeal

dysphagia, oro-motor impairments or who are generally un-well and require softer foods

(National Patient Safety Agency, 2011; Langdon, Jardine & Cichero, 2013). Such alterations

serve several purposes. They ease oral processing by reducing the need for chewing (Groher &

Crary, 2010), enhance the ease of swallowing, and minimise the risk of aspiration and choking

(National Patient Safety Agency, 2011; Langdon et al., 2013). Depending on assessment results,

patients or caregivers will be provided with specific recommendations on the types of foods

and textures that are the most suitable (National Patient Safety Agency, 2011).

2.3. The impact of dysphagia and diet modification

It is not surprising that a life-threatening condition such as dysphagia can create significant

psychological consequences. Patients already have to cope with the diagnosis of a primary

medical condition, and subsequently encounter the additional burden of coping with a

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secondary disorder (Colodny, 2005). This secondary disorder entails physical challenges that

may dramatically change the entire mealtime experience. Instead of experiencing enjoyment

from meals, patients have been found to experience various negative emotions, such as fear of

choking on food, embarrassment if they do, and frustration from the need to strategize

mealtimes (Martino, Beaton & Diamant, 2010). As a consequence of these emotions, both

eating desire and food intake can reduce (Leow, Huckabee, Anderson & Beckert, 2010; Martino

et al., 2010), which consequently can create additional medical complications (Sura et al.,

2012). To further complicate matters, if the texture of foods require modification, their sensory

characteristics can change, which in turn, reduces their sensual and pleasurable appeal (Keller

& Duizer, 2014). This may cause dissatisfaction with the diet (Colodny, 2005). Additionally,

dietary modifications may prevent patients from eating certain food types, which has been

found to cause feelings of depression (Martino et al., 2010). In effect, these factors may partly

explain why food texture modification has been found to be associated with worse quality of

life (McHorney, Robbins, Lomax, Rosenbek, Chignell, Kramer & Bricker, 2002).

As well as psychological consequences, dysphagia can have a significant impact on

socialisation. In one study that explored the burden of dysphagia, patients expressed that they

avoided eating with others because of their disorder (Ekberg et al., 2002). Potentially, this could

be the result of feelings of insecurity regarding physical and social appearance found to occur

during mealtimes (Jacobsson, Axelsson, Osterlind & Norberg, 2000), or it may be because

patients prefer not to watch others eat different meals (Nund, Scarinci, Cartmill, Ward, Kuipers

& Porceddu, 2014a). It is therefore not surprising that studies have found that dysphagia is

detrimental to socialising (Leow et al., 2010; Nund et al., 2014b; Martino et al., 2010) and can

reduce participation in hobbies and interests (Nund, Ward, Scarinci, Cartmill, Kuipers &

Porceddu, 2014b). In addition, patients have been found to express changes to their spousal

relationships. Nund et al. (2014b) identified in their study that patients perceived to no longer

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feel like an equal adult and instead, perceived their spousal relationship to be more of a parent-

child relationship. In effect, these changes to patients’ socialisation and family roles are

substantial, and are likely to adversely affect their overall quality of life.

In light of this research, it is apparent that the psychological and emotional burden on patients

with dysphagia can be profound. Yet, due to the life-threatening risks that dysphagia imposes

on patients’ lives, for clinicians, the psychological consequences of the condition may not

take priority over the medical consequences. In a study by Martino, Beaton & Diamant

(2009), clinicians’ and patients’ perspectives were compared to generate salient items for a

new measure of impairment consequences specific to dysphagia. A disparity was found in

both the generation and ranking of impairment consequences between the groups. Clinicians

identified two aspects related to the psychological domain and ranked the medical

consequences of the condition higher than the psychological consequences. Patients identified

six aspects related to the psychological domain, and considered them as outweighing the

medical consequences. Whilst this was a small scale study that did not incorporate a real-life

clinical context, it provides insight into how the priorities of patients and clinicians can differ.

The researchers suggested that clinicians need to increase their awareness of the

psychological issues associated with dysphagia in order to address the social and emotional

challenges that are potentially even more salient for patients than the medical challenges.

2.4. Adherence

Due to the associated risks of dysphagia, it is concerning that the adherence of patients who

had received management recommendations, were found to be relatively low in one study.

Low, Wyles, Wilkinson & Sainsbury (2001) investigated 86 individuals and found that 21%

never adhered to management recommendations. Non-adherence was associated with adverse

outcomes, including higher rates of hospital admission for chest infection and aspiration

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pneumonia. Although the various reasons underlying non-adherence were not explored, it was

found that seven participants were intentionally non-adherent, and that six out of the seven,

died during the course of the study.

There may be many reasons used by patients to justify non-adherence to dysphagia

recommendations. To date, only one study has explored such justifications, and so, there is

limited research in this field. Colodny (2005) identified that a key reason was dissatisfaction

with both the altered consistency and the altered taste of modified foods, which in turn, had a

negative effect on quality of life. This suggests that the impact of the management

recommendations, may be a direct cause of non-adherence. The other key finding in the study,

was that patients denied their swallowing difficulty. Denial was assumed to be a temporary

coping mechanism by which participants attempted to deal with the psychological

consequences of their disorder.

What may also contribute to non-adherence to dysphagia recommendations, are potential

barriers that make the recommendations challenging to implement. Chadwick, Jolliffe,

Goldbart & Burton (2006) found key issues related to the practical application of eating and

drinking guidelines amongst caregivers. There were difficulties identified in mealtime

planning, in which finding a wide selection of safe foods was challenging, and in mealtime

preparation, in which achieving the correct texture in accordance with the guidelines was not

straightforward. Crawford, Leslie & Drinnan (2007) had similar findings, with one third of

caregivers deeming that the eating and drinking guidelines were the most difficult aspect of the

management plan to follow. Effectively, such challenges may cause patients implementing the

recommendations independently, to occasionally make mistakes, and thus cause unintentional

non-adherence. Alternatively they may cause patients to refuse treatment. Tippett (2011)

proposed that logical obstacles in patients’ lives may hinder their involvement in treatment and

cause them to refuse treatment, when in reality, it is wanted. Transportation, child care,

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proximity to care, work commitment, inconvenience, embarrassment, or compatibility with a

clinician were some the potential reasons proposed.

Within dietary and pharmaceutical fields, there is a growing body of literature in relation to

non-adherence, which may help to provide further insight into the different causes of non-

adherence amongst patients following dysphagia recommendations. The study by Clifford,

Barber & Horne (2008), found that intentional non-adherence to a new medication for a

chronic condition, was related to low perception regarding the need for the medication. This

in effect, provides insight into why patients may refuse treatment entirely. The study by Hall,

Rubin & Charnock (2013) investigated adherence to the gluten free diet amongst the coeliac

population, and found that intentional non-adherence was related to occasional perceptions

of tolerance to gluten. These findings provide insight into why some patients, despite

accepting treatment, may still choose to be occasionally non-adherent. Finally, the study by

Pascucci et al. (2010) provides insight into why patients may be at times, unintentionally non-

adherent. The study found that unintentional non-adherence to medication regimes was caused

by failure to remember to take medication.

2.5. Speech and language therapy students

Speech and Language Therapists (SLTs) play a key role in both the assessment and

management of dysphagia within a multidisciplinary framework (RCSLT, 2009). In order to

develop the knowledge and practical skills required to perform these duties, dysphagia training

begins at the undergraduate level (RCSLT, 2014). Along with formal teaching, all SLT students

are required to complete a nationally used competency framework that documents their

knowledge and range of practical competencies throughout their dysphagia training (RCSLT,

2014).

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Understanding and awareness of the social and psychological issues associated with dysphagia

is an integral part of the SLT role. The Health and Care Professions Council (HCPC), the

national regulator for SLTs, outline in their standards of proficiency that SLTs must recognise

the contribution of the psychosocial factors to swallowing status, as well as to evaluate the

effect of swallowing status on psychosocial wellbeing (HCPC, 2014). Furthermore, the Royal

College of Speech and Language Therapy endorse the use of Therapy Outcome Measures

(Enderby & John, 2015) when evaluating treatment efficacy (Moyse, 2016). The Therapy

Outcome Measures aim to capture the impact of the impairment on the activity, participation

and wellbeing of the individual, and so, encourage a holistic approach (Enderby & John, 2015).

Arguably, as the awareness and understanding of the psychosocial issues associated with

dysphagia is deemed to be integral, they need to be incorporated into SLT training. Whilst the

student competency framework considers this, as it requires students to demonstrate awareness

of all of the patients’ needs (RCSLT, 2014), the issue of non-adherence still remains. Therefore,

further training is necessary to increase students’ understanding and awareness of the

psychosocial issues, which, as has been described, appear to have an influence on adherence.

To date, relatively few studies have evaluated ways of helping to improve patient awareness

amongst SLT students. Two studies have looked at the use of involving adult service users with

learning disabilities in the teaching of SLT students (Harding, 2009; Balandin & Hines, 2011).

Both studies had promising results, and found that the use of clients as teachers was not only a

valuable teaching method for students, but also helped them to increase their awareness of the

patient perspective. Another study looked at the use of standardised patients (actors trained to

portray patients) with aphasia to teach interpersonal and communication skills to students

(Zraick, Allen & Johnson, 2003). Along with classroom lectures, the teaching from the

standardised patients resulted in statistically significant improvements in both aspects. Another

method, not previously explored in the SLT profession but explored in the psychotherapy

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profession, is enactment of the patient experience. Von Haenisch (2011) explored the effect of

personal counselling on trained counsellors and their professional development. It was found

that by simulating the patient experience, participants were able to not only value the patient

perspective, but also to identify important therapeutic techniques to incorporate into their

professional practice. Whilst SLT students are not able to experience the impact of dysphagia,

they are able to experience the impact of diet modification. This may help SLT students to gain

insight into the patient perspective and to develop key professional skills.

2.6. Summary

It is clear that dysphagia does not only entail serious, life-threatening consequences, but

significant psychological and social consequences. These consequences may in part, be due to

the physical swallowing difficulties that characterise dysphagia. However, the modification of

food textures, a common management option, may also partly contribute to these consequences.

Management of dysphagia needs to include the psychosocial issues as they do not only appear

to affect an individual’s overall lifestyle, but they may also partially cause non-adherence

(Colodny, 2005). It has been identified that SLTs need to increase their awareness of them

(Martino et al, 2009) as well as the impact that their treatment choices can have on patients’

quality of life (Swan, Speyer, Heijnen, Wagg & Cordier, 2015). This in turn, may help SLTs to

consider other management options which are more suitable for patients (Swan et al., 2015),

and potentially improve adherence.

The purpose of this study is to explore the experience of diet modification from the perspectives

of SLT students, and to draw out themes regarding non-adherence. This will further our

understanding on the lived experience of diet modification, as well as provide insight into the

factors that may contribute to non-adherence, which at present, is currently limited in the field

of dysphagia. This study will also help to determine whether patient enactment tasks enable

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increased understanding and awareness of the patient perspective amongst SLT students. This

may be of benefit when considering the future training of SLT students in dysphagia.

To achieve this study’s purpose, students will follow a texture-modified diet, record their food

intake into food diaries, and report their adherence. This will then allow for their self-reported

adherence to be evaluated, and thus draw out themes regarding non-adherence. In addition, by

enabling students to record their food intake into food diaries and report their adherence, it

should encourage reflection on the experience. Reflection is a process that allows individuals

to understand and learn through their lived experiences and to identify effective action that will

lead to what is perceived to be acceptable practice (Johns, 1995). In effect, this should facilitate

their learning.

The use of a mixed-methodology would be a suitable approach to fulfil this study’s purpose. It

gathers both quantitative and qualitative data (van Griensven, Moore & Hall, 2014), which

would allow for both the lived experience of texture modification to be explored and the self-

reported adherence of the participants to be evaluated. Advocates of the approach have argued

that it can provide more comprehensive evidence to answer a research question than either

quantitative or qualitative research alone (Creswell & Piano-Clark, 2007).

In conclusion, the aims of this study, are to:

1) Evaluate the students’ self-reported adherence to diet modifications

2) Explore how adaptations are made

3) Explore the lived experience of diet modification

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3.0 - Methodology

3.1. Introduction

This study adopted a mixed methodology, a methodology characterised by the collection and

integration of quantitative and qualitative data (van Griensven, Moore & Hall, 2014). In line

with the literature on mixed-methods research (Glogowska, 2011), the decision to adopt this

approach was guided by the research question. To address the aims proposed, both quantitative

and qualitative research methods were required. The quantitative methods enabled data to be

gathered on the students’ self-reported adherence and the adaptations that they made. The

qualitative methods enabled data to be gathered regarding their interpretations of their

experience.

Quantitative and qualitative approaches fall into different paradigms of research (Creswell &

Piano-Clark, 2007) and so, the combination of both types of data has been seen as somewhat

controversial (van Griensven et al., 2014), due to long-running debates regarding their

incompatibility (Glogowska, 2011). To counter this debated ‘incompatibility’, mixed

methodologists posited a different paradigm; Pragmatism (Teddlie & Tashakkori, 2009).

Pragmatism values both objective and subjective knowledge, and focuses on the importance of

the research question, rather than the methods used to obtain data (Creswell & Piano-Clark,

2007). This study was positioned within the Pragmatism paradigm, as the methods were

selected to provide practical answers to the research question (Teddlie & Tashakkori, 2009).

3.2. Design

This study adopted a parallel, triangulation design (Creswell & Piano-Clark, 2007; Teddlie &

Tashakkori, 2009). Parallel designs involve a quantitative and qualitative phase, in which both

phases address related aspects of the same research question (Teddlie & Tashakkori, 2009). In

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this study, the quantitative phase involved the modification of all food in accordance with the

National Texture Descriptors (National Patient Safety Agency, 2011) by the participants for

four days. All food intake and the participants’ self-reported adherence was recorded in food

diaries. The qualitative phase occurred shortly after, and involved the delivery of semi-

structured interviews to capture data on the experience. Drawing from the literature on

triangulation designs (Creswell & Piano-Clark, 2007), the quantitative and qualitative data were

analysed separately and merged at the interpretation stage. The qualitative data validated the

quantitative data, as it helped to explain why there may have been any changes to the foods

consumed, and why there may have been any instances of non-adherence.

The qualitative phase of the study was conducted using the principles of interpretative

phenomenological analysis (IPA). IPA is a detailed examination of the meanings that particular

experiences, events and states hold for participants (Smith & Osborn, 2003). It is a dynamic

process in which the researcher interprets the meanings generated by participants, in order to

make sense of their personal accounts (Pietkiewicz & Smith, 2014). Data is commonly collected

through semi-structured interviews, which allow for flexibility; any interesting or novel areas

that arise can be probed further by the researcher and existing questions can be modified

according to the responses generated by participants (Smith & Osborn, 2003). IPA was deemed

to be the most appropriate method to collect qualitative data, as it gathers rich and detailed

information which would enable a thorough exploration into the participants’ experiences of

diet modification and their learning from it.

3.3. Participants

In line with the theoretical underpinnings of IPA, purposeful sampling was used in order to find

a closely defined sample for whom the research question was significant (Smith & Osborn,

2003). The inclusion criteria for participants was that they were over the age of 18 and were a

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final year SLT student. The decision to include only final year SLT students was made as they

had already received teaching on the topic of dysphagia and so were suitable to record their

self-reported levels of adherence. The sample size was small, with a total of five participants.

Although it was recognised that this sample size would not typically be endorsed with

quantitative methods (Teddlie & Tashakkori, 2009), it allowed for an in-depth analysis to take

place for each participant’s personal account, which would have been difficult with a larger

sample size (Pietkiewicz & Smith, 2014). All five participants were female and between the

ages of 21-40, which was representative of the final year SLT student cohort.

3.4. Materials

Each participant was provided with a participant information sheet, guidelines on the texture

requirements to assist with the modifications, and a food diary (see appendices 7.1-7.3). The

guidelines were an exact replication of the National Texture Descriptors, as they provide the

standard terminology to be used by all health professionals (National Patient Safety Agency,

2011). The food diary allowed participants to record each meal and report whether all, some or

none of the food components were modified. This then allowed for quantitative analysis of the

food diaries. A participant consent sheet was used to obtain written consent from each

participant to take part in the trial, be recorded at interview and for subsequent use of their data

(see appendix 7.4). An interview schedule was created and based on key topics identified in the

literature search (see appendix 7.5). In the interviews, it was used to facilitate a natural

conversation that aimed to focus on key areas of discussion (Pietkiewicz & Smith, 2014). Each

interview was recorded using digital audio recording equipment to allow the researcher to focus

on the interview topics and participants’ responses. It also allowed for recordings to be

transferred onto a computer so that they could be transcribed verbatim. The use of Express

Scribe and a foot pedal were used to transcribe each interview on a computer.

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3.5. Procedure

Following ethical approval (see appendix 7.6), a recruitment email was sent to all final year

SLT students. Volunteers emailed the researcher’s supervisor to express their interest and an

individual meeting was arranged. In the meeting, dates of the trial were arranged on an

individual basis. The interview date for all participants was arranged to take place the day after

the final day of their trial to ensure that data were gathered immediately after the experience.

All interviews took place face-to-face in a private room in the university campus and lasted

between 30 minutes to an hour. Participants were sent a copy of their verbatim transcription

four days following the interview and were given a period of two weeks to withdraw or edit

any comments made, in line with the procedure outlined when obtaining ethical approval.

3.6. Analysis

Quantitative data were gathered via analysis of the food diaries. Percentages were calculated

for the following:

1) All, some and none of the food components modified in every meal

2) Adherence in each meal type

3) Adherent hot and cold foods consumed

4) Each adherent food-group consumed

Data were then analysed using descriptive statistics. As the measurements obtained nominal

data, the mode was used to determine the category with the most frequent cases (Fisher &

Marshall, 2009). Percentages of each adherent food group consumed was further analysed by

comparing them with the National Health Service (NHS) eatwell plate (NHS, 2016), which

provides guidance on the recommended proportions of the food groups to maintain health. This

allowed further investigation as to whether the participants were able to obtain suitable amounts

of each food group.

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Qualitative data gathered were analysed using IPA. Interviews were transcribed verbatim and

subsequent data analysis was undertaken following the guidelines in Willig’s (2008) IPA

literature. This consisted of:

Reading and re-reading of each transcript and producing notes in the left hand margin

to reflect initial thoughts and observations

Identifying and labelling conceptual themes in the right hand margin to characterise

each section of the text

Clustering the themes in terms of their relationship with one another and producing a

superordinate label for each cluster

Producing a summary table together with quotations to illustrate each subordinate

theme

Once this process was completed for each participant, the summary tables were integrated to

form an inclusive table of master themes that reflected the experience of the participants as a

whole. As specified in Willig’s (2008) IPA literature, themes generated from each participant’s

analysis were compared to ensure that all themes included in the master table represented

different concepts, and were not manifestations of other themes.

3.7. Ethical considerations

Ethical approval was granted from Cardiff Metropolitan University School of Health Sciences

ethics panel. Participants voluntarily took part in the study. An information sheet was provided

to each willing participant detailing the nature of the study, their right to withdraw and

confidentiality protocols (see appendix 7.1). Supplementary verbal information was provided

alongside. Each participant provided written consent to take part in the study and the subsequent

use of their data. In addition, verbal consent was recorded at the start of each interview.

Participants remained anonymous throughout the study, being referred to by their participant

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number in all paperwork, interview recordings and transcriptions. Recordings of the interviews

and the interview transcripts were saved on a private computer and analysis was conducted in

a private setting.

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4.0 - Results

The aims of this study were to:

4) Evaluate the students’ self-reported adherence to diet modifications

5) Explore how adaptations were made

6) Explore the lived experience of diet modification

4.1. Quantitative Data

The following section outlines the quantitative results obtained from analysis of the food diaries

completed by each participant over the four day trial (see appendices 7.7 to 7.11). Food diaries

were analysed according to three main themes: adherence to recommendations, relationship

between hot and cold foods and proportions of food group intake. Results will be discussed in

further detail under the heading of each theme.

1. Adherence to recommendations

The self-reported adherence for each meal was analysed for each participant. Table 1 shows the

total percentages of all, some and none of the components modified in every meal over the four

day trial:

Table 1

P1 P2 P3 P4 P5

All components modified 57.14% 87.5% 81.25% 93.33% 64.28%

Some components

modified

35.71% 12.5% 12.5% 6.66% 21.42%

No components modified 7.14% 0% 6.25% 0% 14.28%

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The table denotes that the self-reported levels of adherence were quite high amongst all

participants. The mode is the ‘all components modified’ category as it contains the highest

percentages. In instances of non-adherence, more often, some of the food components were

modified as percentages are higher in the ‘some components modified’ category than the ‘no

components modified’ category for all participants.

Table 2 shows the total percentages of self-reported adherence according to meal type over the

four day trial:

Table 2

Meal P1 P2 P3 P4 P5

Breakfast 100% 100% 100% 100% 100%

Lunch 0% 75% 75% 100% 25%

Dinner 50% 100% 75% 66.66% 100%

Snacks 75% 80% 87.15% 100% 75%

The breakfast category is the mode as all participants demonstrated 100% adherence. Following

on from breakfast, adherence according to meal type varied. Therefore, there was no significant

pattern in the results to suggest that some meals were more adherent than others. Participant 4

demonstrated the highest levels of adherence, with 100% in all meals except for dinner.

2. Relationship between hot and cold foods

The written food recordings marked as adherent were categorised into hot or cold by the

researcher to determine if there was any preference towards hot or cold foods over the trial.

Table 3 shows the total percentages of the adherent hot and cold food components consumed

over the four days:

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Table 3

P1 P2 P3 P4 P5

Adherent

hot food

components

51.42% 66.66% 42.10% 66.66% 52.38%

Adherent

cold food

components

48.57% 33.33% 57.89% 33.33% 47.61%

Table 3 shows that there was a tendency towards consuming hot foods during the trial, as this

category represented the mode. Participant 3 was the only participant showing a tendency

towards consuming cold foods.

3. Proportions of food group intake

The NHS eatwell plate (figure 6) was used as guidance by the researcher to categorise the

written food recordings marked as adherent into food groups. The proportion of each food group

consumed over the trial by each participant was compared with the NHS eatwell plate in order

to determine if the recommended proportions were consumed.

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Figure 1 shows the proportion of each adherent food group for participant 1:

Figure 1


Figure 2

Carbohydrates17%

Protein14%

Dairy17%

Fruit/Vegetables29%

Processed food23%

PARTICIPANT 1

Carbohydrates Protein Dairy Fruit/Vegetables Processed food

Carbohydrates23%

Protein16%

Dairy17%

Fruit/Vegetables27%

Processed food17%

PARTICIPANT 2


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Figure 3


Figure 4


Carbohydrates26%

Protein18%

Dairy9%

Fruit/Vegetables42%

Processed food5%

PARTICIPANT 3


Carbohydrates30%

Protein10%

Dairy10%

Fruit/Vegetables33%

Processed food17%

PARTICIPANT 4


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Figure 5

Figure 6 shows the proportion of food intake that should be consumed from each food group

according to the National Health Service (NHS):

Figure 6

Carbohydrates19%

Protein14%

Dairy10%

Fruit/Vegetables24%

Processed food33%

PARTICIPANT 5


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As far as can be analysed from the participants’ descriptions of their food, it was evident that

they did not consume the recommended proportion of every food group. However, most

participants did appear to consume recommended proportions of some of the food groups. It

was deemed that results could be indicative of participants’ regular diets and may not reflect

any specific challenges in obtaining recommended amounts of each food group during the trial.

A description of participants’ intake of each food group is below:

Carbohydrates:

Participants 3 and 4 consumed approximately the recommended amount which is a third of all

food intake. All of the remaining participants had a lower proportion than recommended.

Fruit and Vegetables:

This category was the mode of food group intake as it had the highest percentages of

consumption amongst the majority of participants. Participant 1, 2 and 4 consumed

approximately the recommended amount which is a third of all intake. Participant 3 had a higher

intake and participant 5 had a lower intake.

Processed foods:

Participant 3 was the only participant to consume the recommended proportion of processed

foods which is lower than a tenth of all intake. All other participants consumed higher amounts.

Protein:

All participants were relatively close to the recommended amount which is 12% of all intake.

Participant 4 was the only participant marginally lower than the recommended amount, the rest

were all slightly higher.

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Dairy:

Recommended dairy intake is around 15% of all food intake. Participants 1 and 2 consumed

slightly higher amounts and the remaining participants had slightly lower amounts.

4.2. Qualitative Data

During the interviews, all five participants discussed a range of topics related to their experience

of diet modification. Six superordinate themes were identified in the analysis of the interviews.

Within each superordinate theme were associated subordinate themes, evident in some or all of

the interviews. The most salient points from each subordinate theme are described further in

this section and are supported by verbatim quotations, represented by a numerical key. For

example, [4:13-4] represents data drawn from participant 4, and lines 13-14 of the interview

transcript (see appendices 7.13 to 7.17 for transcripts). Table 4 shows each superordinate theme

along with the associated subordinate themes (see appendix 7.12 for a table with verbatim

quotations).

Table 4

Superordinate Theme Subordinate Themes 1. Factors that influence the experience of

diet modification 1.1 Prior assumptions 1.2 Proximity to regular diet 1.3 Planning ahead and being prepared 1.4 Cooking skills 1.5 Perspective

2. Challenges in the practical application of diet modifications

2.1 Determining the suitability of foods/prepared textures

2.2 Increased planning, preparation and effort 2.3 Routine behaviours 2.4 Rejecting food

3. Challenges out and about 3.1 Preparation of food in public 3.2 Availability of suitable food in public 3.3 Reactions of others 3.4 Having to “explain”

4. Changes as a result of the modifications 4.1 Changes to lifestyle 4.2 Changes to social life 4.3 Changes to food choices

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5. Impact of change 5.1 Restriction 5.2 Lack of Sensory appeal 5.3 Lack of enjoyment from food 5.4 Lack of control 5.5 Emotional reactions

6. Learning from the trial 6.1 Increased understanding and appreciation 6.2 Future Practice

1. Factors that influence the experience of diet modification

It was evident from the analysis of the interviews that several factors directly influenced the

participants’ experience of diet modification. These factors either assisted them in adjusting to

the diet modifications, or made it more challenging for them.

1.1 Prior assumptions

Prior to the trial, participant 1 assumed that the practical application of the diet modifications

would be relatively straightforward. This was influenced by her experience in preparing

modified foods in her occupation. Participant 4 made the same assumption, perceiving that a

fork-mashable texture would be the easiest texture to apply.

“I thought that’s the least modified, it can’t be that hard” [4:13-4]

Both appeared to have been misled by their original assumptions as they conveyed a sense of

concern when they described their feelings at the beginning of the trial.

“I started to think, what can I eat, actually practically, I was like, oh my god, I can’t

eat anything!” [1:152-3]

1.2 Proximity to regular diet

Four of the participants discussed their regular diets throughout the interview. Participant 1 and

4 commented that the modified diet was in contrast to their regular diets, which seemed to make

it more challenging for them to come up with meal ideas.

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“it was kind of like the opposite. So I think that was what was a bit more difficult”

[1:693-4]

Participants 2 and 3 explained that the modified diet was similar to their regular diets, which

appeared to not only influence their ability to come up with meal ideas, but also their

appreciation of meals.

“I think it’s because all of these things are already in my diet.” [2:142-3]

1.3 Planning ahead and being prepared

The participants differed in terms of how they planned and prepared their meals prior to the

trial. It was apparent that participants who did more planning, experienced less difficulties when

coming up with meal ideas. Participants 1 and 4 maintained their regular routine which was to

not plan meals in advance. They perceived this to be ineffective, as they highlighted that

planning would have been more helpful.

“I didn’t prepare that much, which I think maybe I should have” [4:44-5]

1.4 Cooking skills

Participants 1 and 2 distinguished cooking skills to be important when following texture

recommendations. Participant 1 explained that she rarely cooked, and felt that she lacked the

necessary cooking skills to be able to modify the foods and come up with meal ideas. Participant

2 highlighted that her knowledge and experience in cooking regularly was an important factor

in adhering to the guidelines.

“because I’m really used to cooking…I know how long things take to be cooked just

right” [2:366-8]

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1.5 Perspective

It was evident that for some of the participants, their perspectives had an effect on their

experience and levels of adherence. Participant 3 explained that she tried to adopt a positive

perspective throughout the trial. This seemed to help her appreciate her meals and rate them

highly in terms of enjoyment.

“I tried to focus on things…that you do have and how much you appreciate them”

[3:328-31]

Participant 4 explained that despite difficulties, she wanted to remain resilient in order to prove

to herself that she could modify her diet.

“I did stick to it. But I think that was more on myself” [4:359-60]


2.1. Determining the suitability of foods/prepared textures

The majority of participants described feelings of un-certainty when selecting foods for meals

and during meal preparation. For participant 1, her un-certainty led her to over-modify foods.

“Sometimes you kind of think what I’m eating is actually puree” [1:137]

Participant 5 explained that one of her decisions regarding the suitability of a food was in-

correct, and created an instance of non-adherence.

“I slipped up, I had a McFlurry, which as I bought it I thought it would be ok” [5:74-5]

2.2. Increased planning, preparation and effort

It was evident that for most of the participants, adhering to diet modifications required increased

planning, preparation and effort in terms of both selecting suitable foods and in preparing them

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in accordance with the guidelines. For participants 4 and 5, the perceived effort to prepare meals

impacted upon their motivation, and caused them to either change meal plans or decide to not

eat.

“the effort involved with cooking them” [5:34-5]

Participant 1 appeared to experience additional challenges with planning and preparation due

to conflicting lifestyle factors, such as work commitments and travel. She felt that the increased

planning and preparation had an impact upon her engagement in other important tasks.

“I ended up thinking more about the food (..) than about doing other things (..) that I

needed to do” [1:301-2]

2.3. Routine behaviours

It was apparent that at times, some participants had forgotten that they were on a modified diet

and engaged in routine, automatic behaviours, such as eating non-adherent food that was readily

available. It appeared to be a challenge to disconnect from these routine behaviours during the

trial.

“I had a packet of Fruit Pastilles on my desk that were already opened” [2:79-80]

2.4. Rejecting food

During food preparation, participant 3 expressed difficulties in disposing some of the non-

adherent food components, such as potato skins. This appeared to conflict with her values, as

she perceived the rejection of food to be wasteful.

“I found it really hard to throw them away, because I hate wasting food.” [3:161-3]

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3. Challenges out and about

3.1. Preparation of food in public

It was evident that adherence to diet modifications was challenging when out in public due to

limited cooking facilities. Participants 4 and 5 highlighted difficulties when out and about as

they had no means of preparing food appropriately.

“out and about that I struggled with, when I didn’t have cooking facilities” [5:133-4]

3.2. Availability of suitable food in public

Related to the above theme, was the theme of ‘availability of suitable food in public’.

Participants experienced difficulties not only in preparing food in public, but also in sourcing

suitable, convenient foods.

“It was practically impossible out and about”[3:187-8]

3.3. Reactions of others

Most of the participants experienced different reactions from others when eating modified

foods. Participants 4 and 5 experienced positive reactions from their housemates. This appeared

to have a positive effect on participant 5, who explained that it helped her to feel more excited

about her meal.

“I think to have them excited did make me feel a bit more excited” [5:289-90]

Participant 2 described a negative reaction from her housemate. Despite this, it did not appear

to have a negative effect on her mealtime experience.

“Just the look of it kind of disgusted her” [2:291]

Participant 1 described a lack of reaction from others. It was evident that this did have a negative

effect as she felt unable to discuss it with others and gain their support.

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“more often, nobody commented” [1:570-1]

3.4. Having to “explain”

It became apparent from the interviews that there is a lack of understanding and awareness of

diet modification in society. Several participants expressed that they had to provide

explanations regarding the modifications when eating in front of others due to their

unawareness.

“no one had ever heard of it” [4:264]

It seemed that providing explanations were time consuming for participant 1. She accepted the

offer of a non-adherent food as she did not want to engage in what she deemed to be a necessary

conversation to explain why she could not eat it.

“sometimes you just can’t have the conversation, and you don’t want to be rude”

[1:780-1]

4. Changes as a result of the modifications

4.1. Changes to lifestyle

Participants experienced changes to their lifestyle in numerous ways. Participant 4 appeared to

be prevented from engaging in her regular routine, as she could not prepare a meal suitable to

bring out with her.

“I didn’t this week because I couldn’t think of something to bring in to uni with me”

[4:305-7]

Participant 2 described positive changes to her lifestyle. She commented that the diet changed

her mealtime routine, and prevented her from snacking. This in turn, made her feel healthier.

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“I was, mainly actually sticking to mealtimes… so it was probably actually forcing

me into slightly better habits” [2:336-8]

4.2. Changes to social life

Participants 4 and 5 discussed changes to their social lives. Both explained that mealtimes are

social as they cook and eat with others. The social aspect stopped during the trial, and the change

was attributed to eating different meals.

“well normally two or three of us make a meal together…but they weren’t eating the

same as me.” [4:225-7]

Participant 5 explained that one of her instances of non-adherence was due to a social event.

She felt that in order to be fully adherent to the diet, she would have had to have restricted such

events, but she did not want to do this.

“I think if I’d been really strict on myself I would have limited the social aspects of

it” [5:227-8]

4.3. Changes to food choices

Some participants expressed changes to their regular food choices. Participants 1 and 3

commented that they ate more processed foods than they normally would have, which for

participant 3, had financial impact. For participant 1 the changes were attributed to conflicting

lifestyle factors, and for participant 3, compensation for a perceived lack of flavour in modified

foods.

“I spent a lot of money on junk food basically that I try to avoid normally” [3:55-7]

Three of the participants also described challenges in including what they perceived to be

healthier foods, causing them to feel un-healthy. Participant 4 explained that she ate more

carbohydrates, rather than fruits and vegetables which she appeared to value eating.

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“it was quite difficult to get vegetables and fruit in, as much as I did beforehand.”

[4:168-70]

5. Impact of change

5.1. Restriction

Four out of the five participants discussed restriction within their interviews. It was evident that

they felt a sense of loss from no longer being able to eat the foods that they enjoyed, and craved

these restricted foods throughout the trial.

“I thought of other foods all the time.” [1:379]

5.2. Lack of sensory appeal

Three of the participants perceived a lack of sensory appeal when consuming texture-modified

foods. This was due to the limited chewing required when eating, and feelings of fullness after

finishing food. Participant 3 commented that the satisfaction from meals is gained from eating

a mixture of textures.

“what makes food satisfying, is a mix of textures really” [3:197-8]

5.3. Lack of enjoyment from food

Some of the participants conveyed a lack of enjoyment from eating modified foods which

seemed to manifest for different reasons. Participant 5 commented that mealtimes were less

exciting and became an obligation. It seemed that this stemmed from her perceived loss of

variety and spontaneity when choosing foods. Participant 1 described feelings of sadness at

mealtimes. Consequently, she chose to go hungry at times.

“I saw it as more like an obligation” [5:177-8]

“I went hungry some of the times.” [1:280-1]

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5.4. Lack of control

A few of the participants compared texture modification to that of other dietary changes, such

as restricting consumption of animal products. It seemed that participants discerned that other

dietary changes would be easier to adopt as they were based on personal motivation, and so

provided a sense of personal control.

“that’s more (.) motivating because you’ve chosen it yourself” [4:287-8]

As participants explained that they did not have their own personal justifications to implement

the modifications, they appeared to experience a lack of control. This perceived lack of control

appeared to make non-adherence seem more appealing to participants 1 and 4, as they felt that

non-adherence would enable control to be regained.

“it makes you want to go against it more, because it’s set by someone else” [4:293-

4]

5.5. Emotional reactions

Several of the participants conveyed an emotional attachment to food. It appeared that food was

significant to their social lives and life satisfaction.

“food is really emotional isn’t it?” [1:451-2]

“a lot of the social things that we do…it’s all to do with food” [5:205-6]

It seemed that due to this social and emotional connection, a few participants experienced

emotional reactions as a consequence of the modifications. Participant 1 described intensive

feelings that she discerned to have a physical effect on her wellbeing.

“there are almost like gut feelings” [1:831]

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Participant 4 conveyed a sense of discomfort when eating with others. She felt a burden to them

by asking them to adapt meals on her behalf. She also experienced feelings of jealousy when

they ate different foods to her.

“I felt like I was being a really fussy eater.” [4:234-5]

“I just felt a bit jealous” [4:347]

6. Learning from the trial

6.1. Increased understanding and appreciation

All participants agreed that the trial was a useful exercise and would recommend it to other SLT

students. It was felt by most that it allowed them to appreciate the patient perspective and the

difficulties that may be faced when following a modified diet.

“I think you don’t get that appreciation on a piece of paper.” [2:357-8]

“there’s no way really to understand the emotional side of being on a modified diet

and I think unless you actually do it” [5:375-6]

It was evident that the insight gained led to an increased understanding of the reasons pertaining

to non-adherence. Participants 4 and 5 explained that due to this insight, they would be more

empathetic if patients do not adhere to modifications.

“I think I would just be a lot more empathetic if people didn’t comply to the diet.”

[5:323-4]

6.2. Future Practice

It appeared that the increased understanding and appreciation of the patient perspective caused

a few participants to consider how they would provide diet recommendations in the future.

Participants 3 and 4 discussed delivery of detailed explanations as to why diet modifications

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are required. It was felt that this would help patients to understand the recommendations and

encourage adherence.

“I’d maybe take the time a bit more to talk to them about it and explain” [4:333-4]

In addition, participants 2, 3 and 4 identified that supporting patients with the practical

implementation of a modified diet would help to alleviate some of the potential challenges and

encourage adherence. Practical support included the joint development of meal ideas, and

advice on interpretation of the guidelines.

“I might like do exercises around like brainstorming” [3:739-40]

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5.0 - Discussion

The purpose of this study was to explore the experience of diet modification from the

perspectives of SLT students and to draw out themes regarding non-adherence to modifications.

In this chapter, the main findings from the present study are discussed, along with its limitations

and suggestions for future research. The clinical implications of the study are also deliberated.

5.1. The experience of diet modification

The semi-structured interviews allowed for an in-depth exploration into the experience of diet

modification from the perspective of SLT students. Of frequent discussion within the

interviews, were the challenges faced by participants during the practical application of the

guidelines. Consistent with findings from two previous studies (Chadwick et al., 2006;

Crawford et al., 2007), a key issue was determining the suitability of foods and prepared

textures. Whilst there are qualitative descriptions of the texture requirements within the national

texture descriptors (National Patient Safety Agency, 2011), exhaustive lists of adherent and

non-adherent foods are not provided, and so interpretation is needed. Participants in this study

had received teaching on the topic of texture modification, yet still encountered difficulties.

This highlights that the guidelines in themselves, may not be adequate in helping individuals to

apply texture modifications, and that further support is needed. Participants also expressed that

their mealtime planning and preparation time increased. This could have been a result of the

difficulties with the interpretation of the guidelines. It could also have been a result of their

limited experience in applying the modifications. Chadwick et al. (2006), noted that challenges

may lessen with time and with increased experience. Even so, these early difficulties may have

a considerable impact on those experiencing them. For one participant, the increased planning

and preparation time, prevented her from engaging in some of her other daily activities.

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Participants frequently discussed challenges in following the modifications when out in public

and when socialising. Challenges identified included: sourcing suitable foods when in shops or

food establishments, having to frequently provide explanations to others regarding the

modifications and having to ask others to adapt meals in order to accommodate the

modifications. Such challenges led two participants to change their social mealtime routines,

and others to become non-adherent to recommendations. Overall, the findings emphasise a lack

of awareness of dysphagia in society. They also indicate that diet modifications can place

burden on daily and social engagements. Other studies have demonstrated that dysphagia is

detrimental to socialising (Leow et al., 2010; Nund et al., 2014b; Martino et al., 2010). Findings

from this study extend the previous findings, by demonstrating that even without dysphagia,

diet modification in itself, can have a substantial impact on an individual’s social life and

lifestyle. Effectively, this highlights the need for awareness-raising regarding dysphagia and

diet modification in society. This is not only important for helping individuals to adhere to

recommendations, but also to allow them to engage in their regular, social activities.

What was also of considerable dominance within the interviews, was the impact that the diet

modifications entailed. Participants stressed the importance of food, claiming that it formed a

central part of their lives. However, the texture modifications resulted in a lack of enjoyment

from food for several of the participants. In line with earlier research (Colodny, 2005; Keller &

Duizer, 2014; Martino et al., 2010), this seemed to arise from the perceived lack of variety and

sensory appeal found in modified foods, as well as from the restriction of eating valued, non-

adherent foods. Consequently, some participants experienced emotional reactions to the

modifications. Several studies have shown that dysphagia can change an individual’s mealtime

experience and create emotional consequences (Martino et al., 2010; Leow et al., 2010). This

study has shown that diet modifications do the same. Findings therefore lend support to the

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claim made by McHorney et al. (2002) that diet modification can lead to a reduced quality of

life.

5.2. The adaptations made

Analysis of the food diaries revealed that participants did not consume recommended

proportions of each food group. However, most participants did appear to consume some of

the recommended proportions of some food groups. As food diaries were not provided prior

to the trial, is was difficult to ascertain whether this was due to the modifications, or reflective

of participants’ regular diets. However, data gathered from the interviews did suggest that

regular food choices changed during the trial. Certain, valued food choices, such as fruits and

vegetables, were not able to be made, and this was perceived to be due to the restrictions that

the guidelines imposed. Nund et al. (2014b) had similar findings, in which participants in

their study expressed that they ate foods that they did not previously enjoy. In effect, this

suggests that diet modifications can lead to changes to regular, food choices.

5.3. Self-reported adherence

For the majority of meals, participants reported that they modified all of the food components

in accordance with the guidelines. This could be indicative of participants’ willingness and

motivation to enact the patient experience and extend their learning. It could also be indicative

of the various factors that were found to influence the experience of diet modification. Planning

and preparation prior to the trial, cooking skills and the perspective held, were all found to assist

some of the participants in their diet adaptations, which in turn, may have influenced their

adherence.

All participants did however, report some instances of non-adherence. All participants were

intentionally non-adherent, and the reasons underlying this varied. One of the main reasons,

was the lack of enjoyment and sensory appeal experienced when eating modified foods. It was

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apparent that this lack of enjoyment, led some participants to occasionally place more

importance on their intrinsic satisfaction from food, than their adherence. This finding was

consistent with one of the findings from the study by Colodny (2005), and highlights that non-

adherence can be a direct result of the emotional impact that diet modifications entail.

Unintentional non-adherence was also demonstrated in the present study, and was found to be

due to the challenges in the practical application of the modifications. This has previously been

demonstrated in studies looking at medication adherence (Pascucci et al., 2010). This highlights

that non-adherence is not always a conscious choice made by an individual, and despite good

intentions, mistakes may be made either due to forgetfulness or due to misunderstanding.

Overall, the present study demonstrates that even when adherence is quite high, both intentional

and unintentional non-adherence can occur simultaneously, as was the case for some

participants. This in turn, re-emphasises the claim that non-adherence is a complex issue

(Pascucci et al., 2010), and even if the management options are accepted, they may not always

be followed.

5.4. Learning

Consistent with findings from the study by Von Haenisch (2011), the patient enactment task

used in this study was found to be a useful exercise to increase the awareness and understanding

of the patient perspective. The insight that participants appeared to gain, allowed them to

identify that a more understanding and empathetic approach is necessary when supporting

patients with dysphagia, due to the challenges that may be faced, and the emotional burden that

diet modifications entail. They were also able to gain an increased understanding of the issues

surrounding non-adherence to management recommendations. Understanding of the

psychosocial issues associated with dysphagia is important due to the burden that they can place

on an individual’s life, as well as on their adherence to management recommendations

(Colodny, 2005). Martino et al. (2009) called for an increased awareness of the psychological

40

issues associated with dysphagia amongst clinicians. In effect, the use of patient enactment

tasks such as this, would be useful to incorporate into SLT undergraduate dysphagia training,

as they appear to meet this identified need.

5.5. Clinical implications

Whilst the participants in this study were SLT students who did not have dysphagia, results

provide insight into the patient experience of diet modification.

The challenges experienced by participants in the practical implementation of the modifications

are likely to be reflective of the challenges that patients face when newly applying texture

recommendations. Yet, these challenges are likely to be even more prevalent for patients, as

they are unlikely to have received the same level of teaching, and have the additional concern

of preparing food that is safe to swallow. SLTs therefore need to ensure that they provide

adequate support and re-assurance to patients, to adjust to the modifications and to develop both

confidence and competence in applying the guidelines. This is important, as some of the

challenges identified in the study, were found to be a cause of some instances of non-adherence,

and in clinical practice, non-adherence is associated with adverse outcomes (Low et al., 2001).

By using participants without the presence of dysphagia, this study has demonstrated that in

isolation, diet modifications, can entail impacts to an individual’s social and emotional

functioning as well as their overall experience of food. This is an important consideration for

SLTs when working with patients with dysphagia, as the burden of following a modified diet

may further contribute to the existing burden of dysphagia that has been previously shown.

Swan et al. (2015) emphasised the need for clinicians managing dysphagia to be aware of the

impact that their management choices can have on an individual’s life. This study supports that

notion. Before recommending texture modification, SLTs should consider other treatment

41

options that may have less of an emotional impact in order to help maintain patients’ overall

quality of life (Swan et al., 2015).

Like the participants in this study, patients may also have instances of unintentional non-

adherence, intentional non-adherence or both. It is important for SLTs to understand the reasons

underlying both types, so that they can effectively help to manage them. Unintentional non-

adherence, may require the implementation of practical strategies to support patients to apply

the recommendations more effectively. Along with the patients themselves, the inclusion of

family members or caregivers may help with forming and applying such strategies. Intentional

non-adherence, requires SLTs to be understanding of the reasons underlying it (Colodny, 2005).

In this study, the instances of intentional non-adherence were occasional, and primarily due to

the burden of following the dietary recommendations. Patients experiencing similar, occasional

challenges, need to be encouraged by the SLT to discuss these challenges, so that suitable

solutions can be identified that may help to maintain their safety. Some patients may also refuse

the modifications entirely. In these situations, some may require the use of counselling

techniques to help them to cope with the emotional burden of the disorder, as this may be the

cause of their refusal (Colodny, 2005). Some may require additional training or education, if

the decision made is uninformed, and others may need other management options to be

suggested.

5.6. Limitations

Whilst the current study has supported and extended findings from other studies, some

limitations exist. Firstly, due to initial difficulties in participant recruitment, a pilot study was

not conducted. This would have been of benefit, as it would have enabled the food diary and

interview schedule to have been trialled before use in the main study, and amended if required.

Secondly, food diaries were not provided to participants prior to the trial to capture data on their

42

regular diets. Therefore, it was not possible to determine if the adaptations made during the trial

were similar to, or in contrast to, participants’ regular diets through analysis of the food diaries.

Thirdly, participants were recruited from one SLT programme. It was not possible to recruit

other SLT students from other university programmes. Finally, the study had a small sample

size, and so, results are not generalizable to larger populations.

5.7. Future research

It would be useful to replicate this study, taking into account the limitations discussed. Using a

larger sample size and SLT students from other university programmes, would allow for the

effects of training on the experience and levels of self-reported adherence to be compared. In

addition, it would be useful to conduct the trial over a longer period of time, in order to explore

whether the challenges in the practical application of the modifications lessen with time and

increased experience, as was earlier hypothesised.

Additionally, further research with patients with dysphagia would be useful to further explore

both intentional and unintentional non-adherence, the factors related to them, and how

frequently both types may occur. To date, only one study has explored the reasons for

intentional non-adherence amongst patients with dysphagia capable of self-feeding, and so

research in this field is limited.

5.8. Conclusion

This study has been able to extend our understanding of the experience of diet modification and

the reasons underlying non-adherence to recommendations. It has shown, that in isolation, diet

modifications entail impact to an individuals’ overall experience of food, social life and

emotional functioning. These factors form a key reason underlying intentional non-adherence.

It has also shown that practical challenges exist in the implementation of diet modifications,

43

which not only create instances of unintentional non-adherence, but also further impact upon

an individual’s lifestyle.

44

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Appendix 7.1 Participant information sheet

Supervisor: Ria Bayliss

Email: [email protected]

PARTICIPANT INFORMATION SHEET

Title of project:

‘What are the experiences of SLT students when consuming a texture-modified diet and what can

they learn from it?’

Ethics Approval number: 8217

Background of project:

The aim of this research is to both explore the individual experiences of Speech and Language Therapy

(SLT) students following a texture modified diet for four days and to measure their level of compliance.

A texture modified diet is one of the management options recommended by practicing SLTs for with

clients with dysphagia.

This research will highlight some of the thoughts and feelings experienced by SLT students following a

texture-modified diet. It will explore any challenges faced and any changes that have taken place for

each student. This will provide SLTs with further understanding of the experience of following a

texture-modified diet. This will help in their understanding of patient non-compliance. It will It will also

provide information on whether practical learning experiences such as this would be beneficial to the

future training of SLT students.

What will be required?

You will be asked to try and modify the texture of all of your food intake to a ‘Texture E/Fork mashable’

consistency (see guideline sheet) for four days. You will be provided with information on how to do

this and on suitable food choices. You will not be required to follow a set menu. You will need to follow

the guidelines included and to try and modify suitable foods of your choosing to the consistency

specified. This will not require the purchase of any additional equipment.

You will be asked to record all of your food intake in a food diary for the four days of the trial. This will

include the food consumed and the consistency of the food. Compliance to the modified texture will

be measured.

Cardiff Metropolitan University

Prifysgol metropolitan Caerdydd

School for Health Sciences, Llandaff

Campus,

Western Avenue, Cardiff, CF5 2YB

02920 205749

52

You will be asked if possible, to eat at least one of your modified meals with others who are eating

normally.

A one-to-one interview will take place with the researcher, who will ask several questions that require

you to give your views regarding your experience. The interview will take approximately 40 minutes to

complete.

Confidentiality:

All of your personal details such as your name, age and address will be completely anonymous.

Everything discussed within the interview remains entirely confidential. The interview will be audio

recorded and transcribed. The transcription will not take place in a public setting. Some of the

statements that you make may be included in the publication. These statements will be anonymous

and you will not be identifiable in any way. You will receive a transcript of the interview up to four days

following the interview. You have the right to retract or re-phrase any statement that you feel is un-

representative of you. Please contact the researcher on the email address provided below.

Right to Withdraw:

You have the right to withdraw from this research at any time up until two weeks following the

interview. You can do this by contacting the researcher’s supervisor, using the email address:

[email protected]. You do not need to give any reasons as to why you wish to withdraw.

Additional information:

The aim of the trial is to try and modify all foods to a fork-mashable consistency. Non-compliance to

the specified texture will not be detrimental to the study. Any issues of non-compliance will be

discussed in the interview and will provide the researcher with information on some of the challenges

faced when consuming a texture-modified diet.

Thank you for taking the time to take part in this research.

Further information

If you have any questions about the research or how we intend to conduct the study, please contact

Ria Bayliss on:

Contact number: 02920 205749

Email: [email protected]

53

Appendix 7.2 Texture Guidelines

What is a Texture E/Fork Mashable Diet?

National Dysphagia Diet Food Texture Descriptors (2012):

Food is soft, tender and moist but needs some chewing.

It can be mashed with a fork.

It usually requires a thick, smooth sauce, gravy or custard (see next point).

Any fluid, gravy, sauce or custard in or on the food is thick (*please see note

below).

No mixed (thick-thin) textures. No thin loose fluid.

No hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits.

No pips, seeds, pith/inside skin. No skins or outer shells e.g. on peas, grapes.

No husks.

No skin, bone or gristle.

No round or long-shaped foods e.g. sausages, grapes, sweets. No hard chunks

e.g. pieces of apple.

No sticky foods e.g. cheese chunks, marshmallows.

No ‘floppy’ foods e.g. lettuce, cucumber, uncooked baby spinach leaves.

No juicy food where juice separates off in the mouth to a mixed texture e.g.

water melon.

Check before serving/eating:

No hard pieces, crust or skin have formed during cooking/heating/standing.

Fluid/gravy/sauce/custard in or on the food has not thinned out or separated

off.

*Note – definition of ‘thick’ fluid:

Any fluid, gravy, sauce or custard in or on food must be thick – a light disposable

plastic teaspoon would stand upright if the head were fully but just covered.

In addition to the general description:

Meat

Pieces of soft tender meat must be served no bigger than 15mm. Or serve meat finely

minced. No hard bits of mince. Serve in a thick smooth sauce or gravy.

Fish

Soft enough to break up into small pieces with a fork. Serve in thick smooth sauce or

gravy.

54

Fruit

Juicy fruit should be mashed – drain away any juice that has separated.

Casserole/stew/curry

Must be thick. Can contain meat, fish or vegetables if prepared as above and overleaf

and fully mixed in.

Bread

No bread unless assessed as suitable by SLT on an individual basis.

Cereal

The texture of thick smooth porridge with no hard lumps (soft tender lumps no bigger

than 15mms are acceptable). Or the texture of fully softened wheat-biscuit breakfast

cereal with milk fully absorbed. Any milk/fluid must not separate off (i.e. no thin loose

fluid/no mixed (thick-thin) textures. Overall texture must be thick.

Desserts

The texture of thick smooth yogurt (fork mashable or soft tender pieces of fruit no

bigger than 15mm are acceptable) or stewed apple in thick custard. Or texture of soft

sponge cake with smooth filling, fully softened with thick smooth custard. Overall

texture must be thick. (If the texture of the dessert is single it could be served thinner

if the person is on thinner fluids – SLT to advise). No ice-cream or jelly if a person

requires thickened fluids (because these can change to normal fluid thickness in the

mouth).

Summary:

What to avoid

Examples

Stringy, fibrous

texture

Pineapple, runner beans, celery, lettuce

Vegetable and fruit

skins

Beans (e.g. broad, kidney, baked, soya), peas, grapes

Mixed consistency

foods

Cereals that do not blend with milk (e.g. muesli),

soup with lumps (e.g. minestrone), mince with thin

gravy

Crunchy foods Toast, flaky pastry, dry biscuits, crisps, crackers

Crumbly foods Bread crusts, pie crusts, crumble, biscuits

Hard foods Boiled and chewy sweets, toffees, nuts, seeds, pips,

brown rice, chunks of apple

Husks Sweetcorn, granary bread, peas

Chewy or sticky

foods

Marshmallows, cheese chunks, toffees

Salad foods which

do not mash

Lettuce, raw tomatoes, sweet peppers, spring onions

55

Helpful tips:

Mash in small quantities at a time

Add flavouring to improve the taste of foods e.g. use herbs, spices, soy or

Worcestershire sauce

Mash and serve meat, starch and vegetables separately. This will maintain the

colour and the flavour of the individual foods. It will also make them look more

appetising

Blend gravy and sauces well into the foods

Drain off any excess liquid before serving

Try to include a variety of soft, minced, mashed or pureed foods

Meal Ideas:

(These are for inspiration!)

Breakfast Soft, mashed fruit and smooth, thick yoghurt

Cooked porridge/Readybrek with milk

Weetabix soaked in milk

Scrambled eggs and cooked, mashed tomatoes

Smoothie

Lunch Soup (with no lumps)-there can be various options!

Skinless jacket potato and filling (eg. tuna mayonnaise, mashed

vegetables)

Well-cooked, chopped pasta with a thick sauce

Well-cooked risotto

Egg dish

Dinner Fish Pie

Corned Beef Hash

Casserole (with tender meat or cooked, mashed lentils)

Mashed tofu with well-cooked, chopped noodles

Cottage Pie (meat or Quorn)

Well-cooked, chopped pasta with a thick sauce

Well-cooked risotto

Snacks Soft mashed fruit (e.g. bananas, stewed apples, tinned

peaches)

Smooth thick yoghurt

Hummus

Plain cake soaked in custard

Custard pot

56

Appendix 7.3

Food Diary

Name

Dates of trial From: To:

How to complete the food diary:

This food diary needs to be completed every day during your four day trial. There is a separate table on each page for each of the

four days of the trial. The second page shows an example entry.

The meals included each day are: breakfast, lunch, dinner and snacks. If you skip one of these meals, please leave the row blank.

Please list all of the components of every meal (e.g. if you have ‘fish pie’, list all ingredients, such as: mashed potato, mashed

fish, cheese sauce). Please indicate in the last column whether all, some or none of the components in each meal were modified to

a fork-mashable consistency. If only some of the components in the meal were modified, please list the components that were not

modified.

57

Example entry:

Meal Description of food Which components in the meal were

modified to a fork-mashable texture?

Breakfast Weetabix soaked in milk

All/Some/None

If only some of the components were modified,

please specify which components were not

modified:

Lunch Pumpkin soup, bread roll and thick, smooth

yoghurt

All/Some/None



modified:

Bread roll

Dinner Fish Pie (mashed potato, mashed cod, cheese

sauce) with mashed carrots

All/Some/None



modified:

Snacks Mashed banana, mashed tinned apricots

All/Some/None



modified:

58

Day 1



Breakfast All/Some/None



modified:

Lunch All/Some/None



modified:

Dinner All/Some/None



modified:

Snacks All/Some/None



modified:

59

Day 2






modified:

Lunch All/Some/None



modified:




modified:




modified:

60

Day 3






modified:

Lunch All/Some/None



modified:




modified:




modified:

61

Day 4






modified:

Lunch All/Some/None



modified:




modified:




modified:

62

Appendix 7.4

PARTICIPANT CONSENT FORM Reference Number: 8217

Participant name or Study ID Number:

Title of Project: ‘What are the experiences of SLT students when consuming a texture-modified diet

and what can they learn from it?’

Name of Researcher: Samantha Edwards

___________________________________________________________________

PARTICIPANT TO COMPLETE: (please initial each box)

I confirm that I have read and understood the information sheet for the above study.

I have had the opportunity to consider the information, ask questions and have had

these answered satisfactorily.

I understand that my participation is voluntary, and that I am free to withdraw up

until the time specified above, without giving any reason.

I agree to try and modify the consistency of all of my food intake for four days

I agree to the interview being audio recorded.

I agree to the use of anonymised quotes in publications.

I agree to take part in the above study.

Name and signature of participant:

Date:

63

Name and signature of person taking consent:

Allocated Participant number:

* When completed, 1 copy for participant & 1 copy for researcher site file

Information sheet to be given to participants for support with food modification

64

Appendix 7.5 Interview schedule

1. What were your feelings about the four day trial before you started it? Prompts: Can you tell me why you felt that way?

2. How did you go about planning and preparing your meals during the four days?

Prompts: Did you feel that your planning and preparation changed compared to what you normally do?

3. What were your thoughts on following the guidelines that were given? Prompts: Did you feel that there were any particular challenges? What did you

do when you were un-sure?

4. Describe your feelings about eating the modified food during the trial. Prompts: Can you tell me why you felt that way? Did you feel that these feelings

were different from the feelings evoked when consuming a normal diet? How do you think you would feel if you had to follow this diet permanently?

5. What do you think your appreciation of food was like during the trial?

6. What were your experiences with complying with the texture modifications during the four days?

Prompts: What do you think were your reasons behind not complying? (N.B. if any issues of non-compliance) How did your compliance/non-compliance make you feel?

7. What did you feel about your lifestyle during the trial? Prompts: How about your social life? How about your day to day life? Can you

tell me more?

8. Describe your feelings when you ate with others eating non-modified foods? Prompts: Can you tell me why you felt that way?

9. What do you think were the reactions of friends/family to your modified meals?

Prompts: How did this make you feel? How do you think that they would have reacted? (if they were not present during the four days)

10. What do you feel that you have learned from this experience? Prompts: Do you think that this experience has changed your understanding of

dysphagia? How do you think that you can apply your learning from this experience when you are a qualified SLT? Do you think that this is a useful task for future SLT students to complete? (Please explain)

65

Appendix 7.6 Ethical approval letter

67

Appendix 7.7 Participant 1: Completed food diary

71


75


79


83


87

Appendix 7.12 Master table of themes with verbatim quotations

Superordinate theme 1) Factors that influence the experience of diet modification Prior assumptions

[1:147]: “I thought it was going to be easier in a way” [3:11-2]: “I really wanted to try it” [4:13-4]: “I thought that’s the least modified, it can’t be that hard” [5:12]: “I was quite worried about it”

Proximity to regular diet [1:166]: “I only eat crunchy food” [2:142-3]: “I think it’s because all of these things are already in my diet.” [3:528-9]: “I principally ate things that were basically fork-mashable anyway” [4:16-7]: “there’s not much I can eat, compared to what I normally do eat”

Planning ahead and being prepared [1:66-7]: “So practically it was easy because…you already had a system” [2:109-10]: “I already knew what I was gonna cook and how I was gonna cook it” [3:43]: “Monday I didn’t plan and it was much harder” [5:22-3]: “I did quite a lot of planning beforehand”

Cooking skills [1:675-6]: “maybe I’m just not a very good cook.” [2:89-90]: “I knew how to cook all these things”

Perspective [1:747-8]: “one of the things that might help people, is to feel they are different” [3:330]: “focus on the things that you do have” [4:261-2]: “I wanted to stick to it to kind of prove to myself that I could.” [5:294-5]: “I do have more willpower than I thought”

Superordinate theme 2) Challenges in the practical application of diet modifications Determining the suitability of foods/prepared textures

[2:113-4]: “I kind of already knew what was fork-mashable and what wasn’t fork-mashable” [1:406-8]: “So I felt very insecure, many times during the trial, that I was actually making the right food or eating the right thing.” [3:135]: “Although if it was soaked in gravy? I don’t know”

88

[4:518-9]: “I wasn’t actually aware of what was, what I could have and what I couldn’t have”

Increased planning, preparation and effort

[1:181]: “there was a lot more planning” [1:416]: “It’s also sort of physically tiresome” [3:614-5]: “it required a bit more prep” [4:45-6]: “I think it takes a lot more planning.” [4:61]: “I kept having like, ideas for part of a meal” [5:34-5]: “the effort involved with cooking them”

Routine behaviours [1: 297-8]: “I was thinking of placement, preparing things, moving back” [1:799-800]: “I caught myself nearly putting something in my mouth without even thinking” [2:257]: “it was just absent mindedness” [3:358]: “the chocolate, it was just totally accidental”

Rejecting food [3:118-9]: “it’s really hard to reject it.” [3:161-2]: “I found it really hard to throw them away”

Superordinate Theme 3) Challenges out and about Preparation of food in public [4:309-310]: “you can’t prepare that in uni”

[5:133-4]: “out and about that I struggled with, when I didn’t have cooking facilities”

Availability of suitable food in public [1:508-9]: “There’s choosing the food in a public place and then once you get the food, whether it’s appropriate” [2:46-7]: “If I was eating out (.) then I would have to be really careful” [3:187-8]: “It was practically impossible out and about” [4:320-1]: “You can’t rely on stuff being available to you if you want to buy stuff” [5:142-3]: “when you’re out and about in town (.) yeah I couldn’t really find anything”

Reactions of others [1:570-1]: “more often (.), nobody commented”

89

[2:291]: “Just the look of it kind of disgusted her” [4:248]: “they were always really interested” [5:282] : “often they were quite complementary about my food”

Having to “explain”

[1:525-6]: “I ended up explaining” [2:310-11]: “I quickly explained, “oh you know I’m doing this fork mashable thing” [4:270]: “All the time I had to explain”

Superordinate Theme 4) Changes Changes to lifestyle

[2:336-8]: “I was, mainly actually sticking to mealtimes… so it was probably actually forcing me into slightly better habits” [4:36-7]: “I normally go shopping every week, but I didn’t” [4:305-7]: “So I (.) yeah normally come in, but I didn’t this week” [5:58]: “I went to Tesco as opposed to Lidl”

Changes to social life [4:430-2]: “we didn’t do that this week because (.) I was on the mashed diet.” [4:225-7]: “well normally two or three of us make a meal together…but they weren’t eating the same as me.” [5:224]: “I didn’t really spend as much time with him”

Changes to food choices [1:638]: “I felt that I was eating unhealthily” [1:231-3]: “I just went to the ready-made section. That for me is a big thing ‘cos I never eat ready-made.” [2:335]: “it was probably a little bit healthier” [3:591-2]: “I ate less healthy food, I felt like I ate hardly any vegetables” [3:55-7]: “I spent a lot of money on junk food basically that I try to avoid normally [4:160]: “it was quite hard to eat healthily”

Superordinate Theme 5) Impact of change Restriction [1:382-383]: “There’s a whole world of

foods that were out of my reach” [2:162]: “oh I just want to have a packet of biscuits right now!” [3:603]: “I could murder a stir fry” [4:25]: “I can’t have like salads for lunch”

Sensory appeal of textures

[1:371-2]: “just the thought of having to eat everything the same texture.” [1:439]: “It always felt heavy and loaded” [3:197-8]: “what makes food satisfying, is a mix of textures really”

90

[4:192-3]: “Everything’s the same texture, isn’t it really? Which was quite hard”

Lack of enjoyment from food [1:280-1]: “I went hungry (..) some of the times.” [3:193-4]: “I’d rather not eat, than eat something I didn’t enjoy” [3:344]: “it needs to compensate I guess” [4:143-144]: “I didn’t enjoy the food that much.” [5:290-1]: “it was just boring mush on my

plate.” [5:161-2]: “I felt like every day I was having the same snacks” [5:273-4]: “it wasn’t what I wanted in that moment”

Lack of control

[1:467]: “It’s almost like losing your free will” [3:545]: “you do feel like a child” [4:287-8] “that’s more (.) motivating because you’ve chosen it yourself” [4:282-3]: “when someone’s telling you you can’t, it makes you want it more”

Emotional reactions [1:451-2]: “food is really emotional isn’t it?” [1:831]: “there are almost like gut feelings” [3:474-6]: “I’ve worked with a lot of people who’ve really, really struggled emotionally, psychologically to detach themselves from food [4:347]: “I just felt a bit jealous” [4:77-8]: “I was like, (gasps) I really want them!” [4:234-5]: “I felt like I was being a really fussy eater.”

Superordinate Theme 6) Learning from the trial Increased understanding and appreciation [1:403-4]: “my appreciation of people who

have to do it day in day out” [2:357-8]: “I think you don’t get that appreciation on a piece of paper.” [2:446-7]: “you can sort of gauge why there might be some non-compliance” [4:505-6]: “it just allows you to be (.) in their shoes” [3:568-9]: “how frequently it would be the best attempt, wouldn’t quite be there” [4:511-12]: “I think it’s easy to be like, oh they’re not following my instructions”

91

[5:323-4]: “I think I would just be a lot more empathetic if people didn’t comply to the diet.”

Future practice [1:848-9]: “I do not want to put someone on a modified diet unless it’s …completely unavoidable” [1:222-3]: “You need to, not just to be shown recipes (.) but to …be (.) shown how to modify your diet [2:119-120]: “just kind of explain, you know, these things are fork-mashable” [3:709-10]: “really, really stress the safety element” [3:739-40]: “I might like do exercises around like brainstorming” [4:333-4]: “I’d maybe take the time a bit more to talk to them about it and explain” [4: 474-5]: “I think I would focus more on …clueing them up themselves” [5:366-7]: “how you can actually adapt fork-mashable into your lifestyle”

92

Appendix 7.13: Participant 1 annotated transcription

I: This is an interview for participant one. Right ok, so before we start just to let you know that everything being said is entirely confidential.

P: Ok.

I: So it’s not gonna be shared with anybody. It’s only gonna be contained within the report.

P: Yeah.

I: But you’re known as Participant one, so your personal details are not gonna be in the study anywhere, so it’s confidential.

P: Yeah, I understand (laughs).

I: So, yeah firstly, thanks for modifying your food for four days.

P: (Laughs) That’s ok.

I: Brilliant.

P: It’s been a good experiment.

I: So I Just want to check just before we start (.), are you happy for us to record the interview?

P: Yeah. Yeah, yeah, yeah, of course. Yeah, yeah. Thank you (laughs).

I: So before we start, just tell me a little bit about what your feelings were about the trial before you started it.

P: Before I started. Ah. Before I started. Before I started the trial?

I: Yeah (.) before.

P: Ok. Before I started (.) I had an idea that it could be difficult to change the diet. I didn’t have any feelings about it if you know what I mean?

I: Yeah

P: It was just a kinda theoretical situation. Erm (..), yeah. I was thinking that, yeah. It has to be hard for people. It’s kind of like you don’t really see how is it hard. So it was very non-descript. You know, I didn’t have any practical ideas of what, you know, any ideas of the practical ins and outs of changing a diet.

I: Right ok

P: But, also I (.) I thought that (..) that the modified diet wouldn’t be too much of a bother. If you know what I mean? It would be just a case of getting organised, getting, you know, meal ideas (.) and you know? I thought it was quite manageable.

I: Right ok, ok. Do you have any reasons behind that at all?

P: No just because I (.) well I used to, well I’m a carer so when I used to work in the nursing homes, we are used to modifying diets for

Annotations

Expected change but no emotions relating to the potential changes

Leads you to assume that it was in fact difficult

Thought more about the practicalities, rather than reactions or emotions

Themes

Prior

assumptions

Prior

assumptions

93

people. So, it was kind of like something that we did almost automatically. We never really questioned, ‘how is the person feeling about it’? I mean we did, obviously, because you’re a carer and you care for people. If they told us (.) you know (.) but (.) you kind of don’t get involved in their feelings about their diet because you’re always trying to look for solutions. They don’t like something, you change it. You choose another thing. It’s almost like (.) you become like (.) very sure of what you’re doing with the diet, when it’s for another person.

I: Ok, yeah.

P: (Laughs). You know. It’s like (.) almost like, yeah. These are the guidelines (.) I can follow these guidelines, this is what you’re going to have, these are the options (.) and you have a choice but, you know (.) we kind of control the options. If you know what I mean?

I: Yeah. Yeah definitely. So do you feel that that sort of changed your expectations of this trial because of your past experience?

P: Yeah, completely. Completely yeah. Which is amazing. Which is why I think it’s an amazing exercise, because it’s very different (laughs) to live through it than it is to be on the other side of the equation. When the decisions you make (.) are not affecting yourself (laughs). You know what I mean?

I: Right. Yeah (.) no definitely

P: Yeah and also, erm, because when I used to see this happen (.), see people being supported with diets, so (.) me supporting people with diets (.), it was all in the same place. You had all of the things there. So practically it was easy because (.) you know (.), you already had a system (.) and you know (.) you had a menu. You know (.), it was kind of like almost on a roll. It was what you did everyday da da da da da.

I: Yeah

P: There were no really big changes. Changes that would kind of take the rug from under your feet. If you know what I mean?

I: Ok (.) so it was almost routine for you to do these procedures (.) to modify foods?

P: Yeah it was. Yeah. And for the patient, it was expected really. There wouldn’t be any times you know when food didn’t turn up because something failed. So there was always food available.

I: Ok (.) and do you feel that they were used to that as well?

P: Yeah. Yeah because in this particular type of client they wouldn’t cook for themselves. So yeah I don’t (..) I don’t have much (.), I didn’t really question how it would be a different experience (.) in what way really. Erm. If you were out and about, you had a job, you had things to do. You know what I mean?

I: Right

Annotations

Modifying diets was part of a job routine.

De-attached from the emotional side, involved more on the practical side

Viewed following guidelines in a methodical way. Like a process

The experience has changed the way P views diet modification

There was an established routine which made it easier

“take the rug from under your feet”= creates an image here. P was ‘taken aback’ by the experience

Diet modification was regular for patients

Perhaps P thinks that her clients’ dependency made it easier for them?

Themes

Prior

assumptions

Altered

perceptions

Planning and

preparation

Prior

assumptions

94

P: It was a residential setting (.) which is very different from having to run the rest of your life while having a modified diet. Which is quite interesting (laughs). Very interesting!

I: Yeah definitely.

(LAUGHTER)

I: So you’ve had this past experience of caring for other people on modified foods. So you’ve done the day to day sort of running.

P: Yeah (laughs).

I: So how did you go about planning your modified foods?

P: Well (.) that’s when you get caught isn’t it? Like (laughs), when you have to really look at yourself and your own hypocrisy. You know, it’s like (.) not in a bad way but we all do this don’t we? It’s like we think “oh yeah”, you know, if I did that, I would do that”. You have a pre-conceived idea of what you would do. And you go in (.) and it’s like, ‘’oh my god I’m not doing it” (laughs)! And why, you know? You kind of catch yourself (laughs) in like shameful situations when you’re like… Erm, I don’t know if I’m making too much sense but…

I: Oh no no! So what do you mean by shameful situations? Can you elaborate on that a bit for me?

P: Well, when you know you have to follow the diet but (.) you’re hungry (laughs) and you have nothing at hand and you have this moment when you have to choose between eating something that’s not within the diet (.) or be hungry. It’s kind of yeah (.), you kind of feel ashamed of been eating. I mean in this experiment, if I was ill, maybe things would have changed. If (.) I knew the food was really going to hurt me. But I think still there is an element of like feeling ashamed of yourself because you’re not following the diet. If, if you’re a complaint person. I’m quite a compliant person in general. So (.) if I was given this recommendation, this guideline, I would want to follow through. So it’s that thing of (.) almost like, you know (.), I’d rather go hungry than not follow the diet, and it’s really silly but for principle, you know what I mean (laughs)?

I: Yeah (.) yeah I do

P: You know and it’s not self-preservation really because you should not go hungry. But you get to that point. It’s like (.) yeah.

I: Where you feel like you should be doing something?

P: Yeah.

I: So you want to stick to that for your own (..) thoughts and feelings really? For your own (..) ideas of compliance?

P: Yeah, yes exactly. Yes and also because of the insecurity of not knowing (..) to what extent you can (..) kind of. (.)… It’s such a weird thing because you don’t really know to what extent it’s going to be a food that’s really, really bad for your diet or it’s something that’s just been modified wrong. (..). You know? It’s

Annotations

“interesting” repeated and stressed. Again highlights that P had an un-anticipated experience

“hypocrisy”= interesting use of noun. Clearly the experience was different to prior expectations

“shameful situations”= powerful description. P views some of her experiences as negative

Hunger can take over compliance. Is this due to practicalities of making suitable foods?

Choosing hunger over non-compliance due to P’s personality

“insecurity”- referring to whether the chosen food is suitable or not. P questioned her knowledge of the guidelines

Themes

Altered

perceptions

Prior

assumptions

Going

hungry

Personality

Going

hungry

Determining

the

suitability of

foods

95

this type of soft diet, fork mashable (..) that’s also…I don’t know if I’m jumping to another point?

I: Nope (.) carry on. That’s fine.

P: But also not being very sure about what kind of diet this is. You know?

I: Right ok.Yeah, yeah.

P: Sometimes you kind of think what I’m eating is actually puree (..) but kind of like wanting to stay on the safe side. Having puree rather than to go onto the other side of things when it’s too hard or too stringy, you know? So it’s sort of like airing on the higher end, on the most dangerous end. Or maybe too liquid (.) or maybe too mixed texture you actually go and air on the other side of having only mash. You know?

I: Right ok, ok.Yeah. So do you feel that there were challenges with following those guidelines? You mentioned some there.

P: Yeah I did, yeah. (…) I did and it was surprising because what I said before (.) I thought it was going to be easier in a way. I knew it was going to be (.) I knew it had difficulties but I thought the actual practical bit of preparing the menu, erm (.) and having food (.) regularly during the day, getting organised, was actually going to be easier than it actually turned out to be. Because when I (.) when I started to think, “what can I eat’’, actually practically, I was like, “oh my god, I can’t eat anything!” I went through the list (…) and you know what I meant when I said when, when you have routine, and you already have set menus in a residential home, it’s kind of almost like you have the recipe so (.) not the recipe, but you know, you bring ideas to the table but there’s (.) there has been a menu for ages. They just get the ideas from the menu and then you’re like, “oh”, you know, cottage pie then…And you’re all ready and all the system supports you making those menus. But when you suddenly have to change the menus that you always do (laughs)…

I: Yeah. So where you say, “I can’t eat anything”, you mentioned that. Is that from what you would normally eat?

P: Yeah. Yeah. Well my previous diet before this modification (..) I realised that I only eat crunchy food (laughs). Only like almost exclusively my food is crunchy, dry, on the go, so like Ryvita, some cheese, so sticky as well. I, I don’t have sauces. I, I don’t like sauces. So that was another level of like, “oh my god”, I have to eat everything with a really thick sauce, you know, to bind it together. And, you know, it was kind of a bit like, “oh my god, I’m not sure if I’m feeling well with this!” Because it was, you know, physically I wasn’t feeling bad but it’s like the psychological making you physically ill if you know what I mean?

I: Yeah, yeah.

P: And erm, (.) and I regularly, I, I cook a lot of vegetables but they’re always, they’re never really well (.) they’re never fork mashable. Ever. They have lots of skin because I cut big chunks

Annotations

Un-certainty re:

guidelines and

texture E

Due to P’s un-

certainty with the

guidelines and

“insecurity”, she

over-modified her

food to be safe

Felt surprised at

how she had

challenges, due to

prior assumptions

Is this because her

regular diet was so

different, or

because of her in-

securities in

following the

guidelines?

Realised that she

would have to

change her diet

almost completely

Creates an image of

her emotions being

so strong that they

affected her

physically

Themes

Determining

the

suitability of

foods

Prior

assumptions

Restriction

Regular diet

Intense

reactions

Regular diet

96

and I make these kind of like, very big chunky meals with pasta and everything separate with thin sauce in the middle, you know? So, there was a lot more planning than I thought it was going to be for a, for (..) just a regular schedule when you have to go out quickly to the supermarket because there’s not much time because I commute as well. So (.) yeah (…) in that respect. (…) sorry I think I’m going away from your first question!

I: No no carry on.

P: I think (..) erm (…) yeah. I think I lost my line of thought a little bit (laughs). Erm (…) yeah basically I think, I found that sometimes even actually, even when you already have all the ingredients and you’re going to cook and you’ve set aside a time for cooking. I had to set aside more time for cooking than I normally would (.) because obviously you’re used to your recipes and you do it almost automatically. And suddenly you have to stop and think, “ahh, I have to cut this in a certain way, take all skins away, make sure that this one that I’ve already cooked is mashed’’. But you have to keep it warm as well and then not in a way that it would make it peel over. You know. There’s so many little (laughs) little things that you have to do. I don’t know how to explain it. Basically I can give you an example. My first (laughs) my first dinner I came back from [town name] and it was really late in the evening and I was really hungry (laughs), so I had planned in my head (.) you know, for dinner, that I would make this and that, you know, I don’t know what is was that I had planned. I think I was going to get some chicken and erm and (.) not boil it but you know (.), cook it in lots of liquid. I had these plans to make a really nutritious dinner. And I got to [town name] at 8 in the evening and I was like, “oh my god I’m starving”, but normally when you’re starving you just grab something. And nothing that you can grab for this meal.

I: Right ok

P: There’s no snacks. Like, well (..) I say there’s no snacks, you know, I’m also wheat free. So that reduces a lot of the options that you can find in many of the places. And erm (.) I didn’t have fruit, I didn’t have a banana to mash, or did I? Hold on. I think I went to the supermarket (looks at food diary). No that was the second day. I went to buy bananas (laughs). But because on the first day I was like, “oh my god”, I went to the shop and I (..) yeah it was later at night and I literally spent an hour (laughs) in the supermarket…

I: Wow ok.

P: Thinking of a menu of things that I (.) because it’s almost like you need practise for this. You need to, not just to be shown recipes (.) but to (..) to be (..) to be (.) shown how to modify your diet now (…) kind of in a way that would allow for it to be fork mashable. Because (..) I don’t know. I don’t know how to explain. Because, if you can’t eat wheat you know (..) you know, pasta was out of the question. Erm you can eat gluten free pasta but when you over cook it, its like, “oh my god”, it’s horrid (laughs)! Horrid mass that you wouldn’t even touch with a

Annotations

Stresses “ a lot” to emphasise that planning time increased considerably

Other lifestyle factors influencing too- e.g. commuting

Stresses “more” to emphasise the increased cooking time

Listing everything you need to do when cooking, suggests she felt it a chore

“starving” is a powerful verb, emphasises how hungry she was

Stresses “snacks”. Difficult to get snacks out and about

Increased time in supermarket

P struggled to adapt her own diet. She then had difficulties creating a new diet

Themes

Increased

planning and

preparation

Increased

planning and

preparation

Difficulties

with finding

convenience

foods

Difficulties

with finding

convenience

foods

Practical

solutions

97

(laughs), with a fork like that eugh. And it gets sticky as well. It gets really gooey. I don’t know. So basically what I did, I just went to the ready-made section. That for me is a big thing ‘cos I never eat ready-made. I eat takeaway but ready-made for me is like, “eugh”. I try to avoid it.

I: So the quick, instant sort of meals?

P: Yeah yeah. All the things that are all ready. So I went for the mashed potato and all the mashes that are already made (.) in the plastic tubs (laughs). Because I was hungry, so I needed something quick and didn’t want to start peeling potatoes and boil them and like mash them and all that. So (.) I (laughs), so I ended up buying a lot of ready-made stuff.

I: Oh ok. Yeah (.) yeah.

P: That stuff that I thought would be helpful for the next few days. So I got big tubs of mash, different types of mash. One of them I thought was different types of vegetable mash but actually it was double potato (laughs) because (.) I bought mashed potato, plain, but I also bought another mash that was mashed potato with carrot and (..) er (..) swede. Swede?

I: Swede. Yep.

P: I wrote it like the band (laughs), Suede (laughs).

I: (Laughs) It looks like Swede don’t worry!

P: (Laughs) So. so basically I ended up relying on these shop bought stuff for two days actually (.) because I eat on my own, so it’s only for myself. So in the end, it ended up (.) lasting until the following dinner. Which (…) in a way (..) kind of made me feel a bit sad (…) you know?

I: And why was that?

P: Because there wasn’t much variety (..).

I: Right. In the supermarkets do you feel (…) or (.) where do you feel the variety was lacking?

P: Yeah, yeah. Well (..) I felt (…) oh yeah in the supermarkets definitely yeah. There was noth*. There were not many things that I could (…) unless I cooked from scratch. There were not many things that were convenient foods (.) that I felt… Maybe there are, but it was towards the end of the week after a couple of days, I had more ideas. But at that point I was feeling a bit overwhelmed. I was feeling like, there’s not really much (..) I’m sure I can make that applies with the diet. And I think, you know, I went online and I looked at other ideas and things but for (.) for quick (.), you know, when you resort to very quick meals that you make (…) most of my very quick meals are like I said, very crunchy (..), dry (…), you know (.), foods that were like all out of the list.

Annotations

“eugh”= sound

shows her disgust

with eating

processed foods. P

was not happy with

this change

She changed

because of the time

to prepare foods

Stresses “sad”. She

felt a lack of

enjoyment eating

the same again

Limited choices for

convenient foods

Difficulties with

getting convenient

foods led to feeling

“overwhelmed”

Themes

Changes to

healthy

eating

Changes in

healthy

eating

Difficulties

with finding

convenience

foods

Difficulties in

coming up

with meal

ideas

98

I: Mmm. So you’re talking about (..) a lot of time (..) restraints then, with this. Do you feel then that these time restraints had a knock on effect to other areas of your life?

P: Yeah, yeah. (Audible breath) yes actually, yeah. Yes because I’m travelling back and forth between placement, uni, [town name], so it’s you know, so (…) yeah. It did (..) and I’m sorry to say, you know (..), but yeah it kind of did because I went hungry (..) some of the times.

I: Right ok (…) ok.

P: Just because I couldn’t find anything. (..) Because most of the time in the week (..), sometimes I don’t even go to supermarkets, I just go to convenience stores and I just get some Ryvita and just something that I can eat there, on the go. Or one of those boiled eggs in like, Tesco Metro, or a bag of chips or something, crisps, things like that. So (…) it was kind of like (..), yeah I was going to the only shop that I could find at a certain time of the day, in the middle of (..), you know, next to the station.

I: Yeah

P: (Laughs) Or in the station and I didn’t have the amount of time to comply, or, well or the (..) or the (.) you know like the ability to modify it.

I: The utensils and things.

P: Yeah, yeah. Or the sauces. You know it was a bit like, and you almost have, I didn’t have the mental space because I was thinking of placement, preparing things, moving back. You know all these kind of things.

I: Yeah, yeah.

P: So it’s kind of like, basically I ended up thinking more about the food (..) than about doing other things (..) that I needed to do. So instead of going back home and doing uni stuff (…) I was thinking, “what can I cook for dinner?” Spending a lot of time thinking (..), “is this part of a modified diet?” (Laughs)

I: Ok yeah.

P: How am I going to cook this or not? (…) I don’t really like gravy (..) what can I do instead of gravy? You know all these kind of things. And then (..), so in that respect, it had a knock (.) knock on effect on (…), erm (..), and I think it’s just because of having no experience for your own food. Erm (..) if I had had my previous diet (..), if I had already had been making like, cottage pie, you know, like actually had a (..) dinner making routine then (..) maybe it would have been easier. Because then you just kind of, you just cook the same things that you cook normally (..) kind of like you try to change the ingredients so you make them in a different way. But, because I don’t (..) you know, it’s been months since I cooked from scratch really because I don’t have the time. I’m always on the trains and buses. So you know, in the end. Or the takeaway because you don’t control what it’s going to be like…

Annotations

Stresses “hungry”, this was a consequences of her challenges

P’s lifestyle and regular routine had a marked effect on her experience of diet modification

Ability is probably referring to utensils

“mental space”- implies difficult to think about diet modification when there are other conflictions

Increased time thinking

Mentions “knock on effect”- I presume to her lifestyle?

Has insight into how regular diet can affect experience of diet modification

Themes

Going

hungry

Confliction

with lifestyle

Confliction

with lifestyle

Increased

planning and

preparation

Impact to

lifestyle

Confliction

with lifestyle

99

I: True yeah

P: You know that kind of thing. Erm (..) so yeah in that way it did impact my work.

I: Mmm (….) mmm (.) ok

P: Mmm. Not massively. Just (.) you know, just (..) I guess just more than I can spare at the moment. But then on the other hand because it’s such a useful exercise (..), I took it as part of the course, if you know what I mean?

I: Yeah (.) yeah.

P: So it didn’t matter in the end (..) I’m not (.) I’m not complaining or anything. (..) Because it’s a useful thing. It is true it is really part of the things that I want to do (.) to, you know (.) to learn about these things. But in the case that I needed to have this diet (..) and it wasn’t part of my everyday routine, it wasn’t part of something I’m learning (..), then (.) the impact would be like way harder (.) well way bigger.

I: Right ok

P: I lost weight.

I: Right ok

P: Which in my case I don’t mind (laughs)! But you know, if I was ill (..) and I was going without food because I couldn’t find anything in the shop, and was scared to just have anything on the go. Which I did on the first day. I was running around uni and I was writing things between lessons and I had had a very good breakfast with porridge. Obviously you start on a “yay I’m going to make it!” And erm, I had nice porridge with milk and honey (..) and erm (..), but then I had to do things in the break, in between the lessons. So I was typing, typing, typing and then when I finished, I only had five minutes before the next lesson. So I went to the shop and to the café and I just ran around, you know, like a headless chicken thinking, “oh my god, you know, can I have this? Oh no, I can’t have this! Oh, can I have that? Oh no, I can’t have that! Oh my god there’s nothing!”

I: Yeah.

P: Really there was (..) really nothing. Because I couldn’t stop to get a jacket potato (..) because I only had five minutes (.) so I ended up having like a, protein flapjack.

I: Right (.) for lunch?

P: Which was absolutely not modified.

I: So going back to your feelings then. You mentioned that you felt psychologically (..) you know (.) it was impacting you psychologically?

P: You know I wasn’t prepared for that!

I: Tell me about your feelings eating modified foods.

Annotations

“useful”= adjective implies that P gained from doing the trial

Repeats “useful”

“bigger” is stressed. P has insight into how it could affect her if she had to follow diet modifications

Weight loss= physical impact as well

“typing, typing, typing”= repetition used to highlight how busy she was

Shows her panic

Repeats “nothing” to emphasise challenges with finding suitable food out and about

Non-compliance due to a lack of suitable foods

Themes

Confliction

with lifestyle

Going

hungry

Confliction

with lifestyle

Difficulties

finding

suitable food

out and

about

100

P: Yeah it’s so weird. I really wasn’t prepared for, yeah (.). I kind of just felt sad just looking at the plate (laughs).

I: Ok. So appearance do you feel then was?

P: Yeah more like, not really appearance. I didn’t really care much about the appearance to be honest. But it’s just, it’s just that, yeah it was just the thought of having to eat everything the same texture. That was a bit like, “ah”, it was like it felt like not eating much because it’s all like, yeah I didn’t feel it was very appetising and I felt a bit like, “ah”, you know (..), kind of like thinking about the other things that you can’t eat and that would go really well with this, that you’re eating.

I: Right ok. So when you were eating it, you felt like you were thinking of other foods?

P: Yeah all the time. I thought of other foods all the time.

I: How did that make you feel? What were the knock on effects of that?

P: Well yeah, I just felt a bit robbed really, you know. There’s a whole world of foods that were out of my reach (.) because I was kind of almost like (..), and I know this sounds really negative, and I’m sure that if, if I had to adjust to this, I would be making myself feel in a different way in accepting it. The first few days (.) it was a bit like (.), kind of like (.), it was mostly the negative things and you feel the change (.) and you can think this is for my own good, and in this case it was a little adventure and a learning (.) an opportunity. But because of the changes are quite large, you know, the impact is quite large really. If, because my diet was so different. I don’t know if I’m getting to the point. So yeah. I did feel a bit sad towards the middle of the trial. Towards the end, because I knew there’s going to be an end (laughs)!

I: So your feelings changed do you think?

P: Yeah they did because I knew that I was going to be eating my regular food today. So (.) that’s another thing you know, because (.) erm (.) yeah.

I: So do you think your appreciation of food was changed then during the trial, then from what you’re saying?

P: Yeah definitely. Yeah, and erm (..), erm (.), yeah my appreciation. Also my appreciation of people who have to do it day in day out, and how resourceful and how imaginative they have to be really. Part of the difficulty I think it was, was feeling that you’re doing the right thing. So I felt very insecure, many times during the trial, that I was actually making the right food or eating the right thing. So (..), yeah (..), I appreciate the effort level (.) that goes into modifying a diet more than I did before. And because of this effort, you know, once you get used to it and once you get a certain menu and routine, but in the process of creating a routine, it’s almost like tiresome as well (.) to be (.) yeah (.). You know when you’re tired, you don’t want to start

Annotations

Repeats about feeling “sad”, this was a key emotion for her

Difficulties appreciating food due to it being the same texture

Imagining other foods probably made it harder

Feeling “robbed”= strong verb to describe missing out on other foods

Concentrating on the negative did not help P to adjust- she has insight into this

Feelings changed throughout the trial

Appreciation for patients

Repeats about “insecurity”- this has made it challenging

Themes

Lack of

enjoyment

Sensory

appeal of

textures

Restriction

Restriction

Intense

reactions

Appreciation

of difficulties

Determining

the

suitability of

foods

Increased

effort

101

mashing food. You know it’s kind of, you just want to eat now and it’s late in the evening. You just look at your plate and you have to start mashing. It’s also sort of physically tiresome (laughs). I know this sounds really stupid!

I: No it’s really interesting!

P: Mashing is like, “oh god”, you know, like…

I: To mash everything?

P: Yeah, to cut everything in little pieces and mixing them, then you run out of gravy that you don’t even like, so you end up having the rest of the meal flakey because you just don’t fancy! So that happened one day, that I didn’t comply really fully because (.) the day before, I had added a lot of er, fish gravy to boil the salmon (..) and it worked well for the texture. It worked really well. But this meal I really didn’t enjoy.

I: Ok. Taste wise?

P: Taste wise, yeah. Because it was very salty because of the gravy. It was quite heavy as well. It felt heavy in my stomach (.) I don’t think it was heavy but it felt heavy in my stomach, so by the end of it, I was feeling a bit like, “oh god this is not what I would choose (.) really (.) to eat.” Kind of felt like, you know, washing it down with something, you know, like putting some thin stuff around, maybe something to matt you know? Kind of I had (.) with the mashy stuff with the kind of like gravy, this gloopy, not gloopy, but you know, this kind of thicker stuff. I kind of felt like I needed something fresh in my mouth and it never felt fresh. It always felt heavy and loaded. So I drank more. But (.) because of this trial (.) like you didn’t modify the drinks, but I kept thinking (..) if I had this diet and I had to have thickened drinks as well, then I’ll feel even sadder. Like almost dejectful if you know what I mean?

I: Yeah. Yeah.

P: Which is, I don’t know it’s always a battle because I don’t always want to be negative. I catch myself thinking, “come on, you know, look at the positive side of things (laughs), you know, you know you could be dead, or you could be, you know, having a chest infection if I was on this diet, this is for my own good”, and all that so (.) you can be positive but I don’t think I was prepared for the raw feeling (laughs) because food is really emotional isn’t it?

I: Yeah, yeah.

P: And the raw feeling of being in front of a plate of mashed stuff and going, “oh my god I really don’t fancy eating it!” Maybe if you end up doing the trial you’ll see that for yourself.

I: Yeah, yeah. So do you feel food is really important to your life?

P: Oh god yeah. Massively. For me it always has been. Even though like, because of the way things are now (.), I’m not much of a foodie because I’m just, you know, eating on the go.

Annotations

Interesting that not only was it more time consuming but preparation was “tiresome”

Stresses “even like”= P had to add things to make her food complaint that she didn’t enjoy

Repeats “heavy” to emphasise how she physically felt after eating the food

“fresh” contrasts with “heavy” and “loaded”. Strong imagery.

Tried to look on the positive side

Stresses “emotional”- makes a point that there is an emotional connection with food

Repeats about “raw feeling”. Emphasises how strong it was for her

Themes

Increased

effort

Physical

effects of

modified

food

Physical

effects of

modified

food

Emotional

connection

with food

Intense

reactions

Emotional

connection

with food

102

I: You’re in university!

P: Yeah, yeah and I’m always depending on something that’s convenient. But, even then, even the things that are convenient, I choose very carefully. Er (..) but for taste and for things that make me feel good. I guess also, you know what I think, reflecting about this, I think also there’s an element of erm (.), loosing your free will. It’s almost like losing your free will and erm (.), it’s really silly really.

I: No no. What makes you feel that?

P: Because there’s a list of things you can’t have. You know, just the fact that there’s a list of things you can’t have. I think it’s enough if you’re a little bit of a rebel (laughs) to make you go, “oh god why? Now I want them (laughs)!”

I: Ah so do you feel what you can’t have it makes it more…

P: More appealing really, yeah. Yeah it does. And then you start looking at the Ryvita with loving eyes (laughs). Even though it’s like a convenience.

I: Yeah. So do you feel that you appreciate the food you ate before the trial even more having done the trial?

P: Yeah, yeah, yeah. It’s silly, you know it was just four days. You know it sounds like very dramatic but, actually, yeah. This morning I couldn’t wait to have…well in fact I wasn’t complaint one evening. This is where I said about shameful (laughs)! I feel ashamed because it only took me three days to get back to Ryvita (laughs)! It’s so bad! But that was another day that I was really late back at home (.) and I had run out of the mashes (laughs). So I had already eaten all of the mashed stuff that I had bought and I spent the day at uni. Oh, and I ate with you that day. I don’t know if you remember?

I: Yeah

P: I ate lunch in the management building. I couldn’t really modify it. I can talk about it if you want?

I: Yeah go ahead.

P: Er, also again you know, I went for a (.) I went to the management building to get a jacket potato, got there and they had run out. So my plan was to have a jacket potato with erm (.) er, with tuna mayonnaise in it (.), which would have been great. Erm (.), but yeah, they had run out, so erm everything else they had (.), I didn’t think it was part of this texture. It wasn’t really. So (.), I spent quite a long time walking around looking at the food. I’m going to hold that thought because I wanted to say something about that. About the walking around looking at the food and spending a lot of time.

I: No, you can carry on. You know, discuss as you feel appropriate.

P: Yeah?

I: Yeah, yeah. Completely.

Annotations

Chooses food based on appeal

Felt a lack of control in being able to choose what she wanted and when

“loving eyes”= strong image to show how she missed the foods that she wanted

Views her non-compliance negatively, she is embarrassed by this

Had an idea of what would be suitable, but was relying on it being available out and about

Stresses “a lot”= implies it wasn’t easy when the first plan didn’t work out

Themes

Lack of

control

Lack of

control

Restriction

Intense

reactions

Difficulties

finding

suitable food

out and

about

103

P: But I want to go back to the (..) because there’s two issues here. There’s choosing the food in a public place and then once you get the food, whether it’s appropriate is what you thought would be appropriate or not. You know? So (.), erm (…), I can talk about the choosing for example. I found myself explaining to a lot of people that I was doing an experiment for uni (laughs).

I: Right ok. Is this for people in cafes?

P: Yeah. Because I did spend a longer amount of time than people normally spend looking at the food (.) and then walking around and thinking. They look at you kind of expectant for you to choose straight away. It’s kind of like you want to tell them straight away, but you can’t because you are looking at the different op* and thinking. There was lots of crumbly stuff with stuffing, not stuffing, but the things that they put (.), yeah the crumbly bits. Yeah, that I couldn’t have and there were a few options that, and none of the options I could have. So I was just walking around and you know, people in management, they just look at you. You know, they want to move the line. So I stepped out of the line and kept looking at the food. Then in the end, I ended up explaining.

I: Ok, ok. How did that go?

P: Yeah. It was, I mean, it was ok, they didn’t say anything. They just looked at me weird (laughs). They just went, “ah hmm” (laughs). Well it’s funny because I did the same. I always go to the same supermarket when I have time, that’s local to me. So (.), there’s one of the guys on the tills that knows me a little bit (..), I’m very predictable, I always buy the same things (laughs)! Because it’s easy, fast, you know. I always make the same things really. It’s really bad (laughs)! But in that supermarket, I ended up buying more or less the same things. This time, I bought like a lot of different, really weird things (.), like it didn’t make much sense, my shopping. And he kind of like (.), he looked and did a double take (.) to my food. So also ended up explaining to him. Which really, maybe it was just my imagination, you know? I was just feeling self-conscious and it might not even have a base on reality if you know what I mean?

I: Yeah, yeah.

P: I was just kind of, almost pre-empting (.) that people would want (..) would think there was something different, but actually I don’t think they did! You know what I mean?

I: Yeah. I mean did you have any reactions from anybody at all during your days? Did anybody react to you food? You mentioned about the shop, you know you felt that there was…

P: Yeah, I mean he just did a double take. And I (.), you know (.), I’m assuming this, but maybe he didn’t even, I dunno, maybe he just did it. Maybe it wasn’t to do with my food, I don’t know. But in that moment, I thought it was to do with my food because I was thinking about the food. So (.), maybe (.), it’s quite silly isn’t it because it was in my head?

Annotations

Needed to justify the time spent looking for food

All of these foods are non-complaint

Shows that there is limited awareness of dysphagia in society

“predictable”- i.e. her regular diet doesn’t vary much

Insight into experience. Perhaps as she was buying different food, she felt that it was noticeable to others

Thinks her reaction was “silly” as she is aware that it might have been her imagination

Themes

Difficulties

finding

suitable food

out and

about

Having to

“explain”

Having to

“explain”

104

I: But it was your feelings.

P: I still explained, and he (.) he found it really amusing. “Oh I’m carrying out an experiment”, and (.) it lead to a conversation, which was actually really nice as well. That’s a positive thing. You know, he was interested to know.

I: What was it?

P: About the diet. He was like. He was probably a bit bored as well (laughs)! But he was (..), like, “ah speech and language therapy, ah, ah, and you modify diets.” So that was also a teaching opportunity as well, about the role of the SLT. Which was quite nice. But erm, but yeah, the only person that said anything at all about my food when eating in public, was my PE. She realised that I was modifying it. She looked at it she was like, “oh you’re eating something interesting there (laughs)!” But yeah, what I found the times I ate with people, more often (.), nobody commented.

I: Nobody commented?

P: They did look. They realised, but nobody commented.

I: Can you think of any reasons why? What are your thoughts about that?

P: Well (.), I think two different things. When I was in management, I was with you and other two people in the class (.), and I think they realised that I was doing the trial and I think they didn’t want to ask because it was part of the trial. I think if you hadn’t been there, they probably may have asked (laughs)! Because you know, not to influence. You know, it’s normal isn’t it? But the other, more real situation, when I was eating at placement (.), erm (.), I don’t know why really. I don’t know why they (…), I don’t know. It was a team of professionals as well. So (.), they probably didn’t think there was something to comment on. Maybe they were thinking something, but it’s difficult to know isn’t it?

I: Yeah

P: Even when you see someone, and you’re used to having to make some changes (..) because of their health, you know? Unless (.), because they’re health professionals, you kind of don’t ask. You kind of give the person privacy. So I assume they didn’t ask because maybe they thought I had a health problem. Until I started to explain! Because my PE said, “oo, you’re doing something”, that I think she realised that it was, because (.), well not actually because, you know, we had eaten together before, and I was eating Ryvita, so, so she knew I was on a modified diet. And also, Sam, because I was eating the weirdest food ever (laughs)! Oh my god!

(LAUGHTER)

I: Can you tell me about that?

Annotations

“nice” and

“positive” stressed

here. Perhaps she

wasn’t expecting

this reaction?

Useful that she was

able to make

someone previously

un-aware aware of

dysphagia

Lack of reactions

Others didn’t want

to influence the

study results

Un-certainty

regarding lack of

reaction

P debates whether

health care

professionals may

not have reacted as

they wanted to give

her privacy.

Perhaps also they

had more

knowledge of

modified diets?

Themes

Having to

“explain”

Lack of

reaction

Lack of

reaction

Lack of

reaction

Having to

“explain”

105

P: It’s so funny! Actually it didn’t taste bad, but it was weird. I had leftover mash (.), from the night before (.), which I heated in the microwave (.), and I had avocado (.), mashed avocado (laughs) and hummus.

I: Ok. Altogether?

P: Altogether. So she was like, “mm that’s interesting!”

(LAUGHTER)

P: I was like, “hmm, you can say that!” “Is that tasty?” She was very polite! “Is that tasty?” I was like, “mm not really.” It wasn’t too bad. Yeah but that kind of gave some conversation.

I: So, I’m guessing by your reaction there, it wasn’t something that you would normally have? Avocado and hummus and mashed potato?

P: I would have avocado and hummus, but not with mashed potato (laughs). It was kind of like (.), but it was the only thing I had. Normally I had it with, yeah crackers or with salad. Oh I missed the salad so much! And I think that’s part of the emotional side. For me it was not eating the salads. Really.

I: What what about the salads? What was it that you missed, do you think? Was there a particular thing…was it taste or the crunchiness?

P: Yeah the crunchiness. I missed the crunchiness. And the fresh feeling in your mouth. It’s always like (.), you know (.), if you’re used to eating different textures together (.), like varying the textures one to the other (.), it’s a different feeling in your mouth. And salads in general, I think in general, it makes you feel a bit more you’re doing the right thing for your body. Because of all of our education about healthy eating. Even though erm (.), ironically this is healthy eating (.), the modified diet would be the healthy eating in that situation (.), but it’s difficult to change the chip from healthy eating. Erm (.) like lean, lean healthy eating, to eating for health reasons.

I: Ok. So just to clarify what you mean there. So do you feel that we have pre-conceived ideas about what healthy eating is? So like, like salads and fresh foods? And do you think that’s changed then on a modified diet?

P: Yes, yes. Yeah. I felt that I was eating unhealthily. And it’s probably because I wasn’t skilled. I didn’t feel skilled to make the meals healthy, you know? Because erm, maybe if I had done it for longer, then maybe I would have learnt how to prepare food that’s healthy but that’s also modified. But because I relied so much on potato, like mashed potato (.), which is not, it’s not unhealthy, but you know, if you eat it everyday, it is actually like, empty. Empty carbs really. It fills you up but it’s almost like you’re eating for mechanical reasons rather than for health reasons, just to get your body full. But erm, I (.), I tried other fast, convenience foods that could give me that feeling of “I’m eating healthy” (.) and erm (.), it was like tinned ratatouille,

Annotations

Views her combination as humorous

Received a reaction here. The other person seemed to think her meal combination was strange

Had this combination due to difficulties getting suitable food, possibly due to the challenges discussed earlier

Repeats “crunchiness”, missing the texture was key

Non-modified foods make you feel healthier.

P feels that salads are “healthy eating” due to education- interesting point

Modified foods created a feeling of being unhealthy

The foods she chose made her feel full, but not healthy

Themes

Restriction

Sensory

appeal of

textures

Changes to

healthy

eating

Changes to

healthy

eating

Physical

effects of

modified

food

106

which still is like tinned stuff. But (.), I assumed because it was tinned it was going to be soft and mashable, and I could just bung it in a pot quickly, warm it up and eat it with the mashed potato, that would be extra veg that I didn’t need to cook. Erm (.), but when I actually took it out of the tin, it was very, very hard. It had lots of skins, lots of pips, lots of stringy bits, you know? So in the end, I couldn’t (.) unless I had a blender, I could have eaten it as a puree. But (.) I didn’t. It was very mixed texture. It was like a soup really (laughs)! It was like a very thick soup.

I: Oh ok. So some things you thought you could have actually turned out to be non-compliant?

P: Yeah. Yeah. Oh my god most of the stuff, Sam. I chucked so much food. But then, it’s because it was the convenience food which is not really the same as cooking from scratch. You know actually (.), having your own ingredients there. But yesterday was different because I was at home, I had a day off from uni and I didn’t have to travel or anything. So I cooked my (..), my first dinner from scratch in the four days. And erm (..), and I cooked risotto (laughs) with meatballs, erm (..) and gravy (laughs). And erm (..), it was alright (laughs). It’s like you know, it’s difficult because if you don’t like gravy then you’re stuck. This diet is all gravy, isn’t it? Gravy, custard. So what do you do?

I: Yeah, (.) yeah, yeah.

P: You just have to put up with it! And erm, so yeah for me it was spoiling the risotto, but I had to do it because there was no other way of (..), I just couldn’t think (.), maybe I’m just not a very good cook. I just couldn’t think of a way of cooking risotto that didn’t have all the ingredients that I couldn’t eat. Normally, it would have chunks of stuff in it. So I ended up cutting up a courgette (.), only the inside without the pips, only the flesh. Cutting it really thinly and putting it in the pot for ages so it was really, really soft. And then cooking the meatballs a lot as well. And, I added lots of wine so I could reduce the amount of gravy that I had to use. So in the end it wasn’t too bad.

I: Ok (.) yeah, yeah. I just wanna go back because you mentioned about ‘good cook’. So, do you think that actually cooking skills and creativity come into this? Come into following a modified diet?

P: Yeah. Oh yeah. Massively. Massively. More than I thought actually. And it depends if (.), it depends if you’re picky about your food or not. That’s the thing. You know. If (.), or it depends if your regular recipes are closer or less, you know, more similar or less similar (..) to the diet that you’re now introducing. So for me it was miles away, it was kind of like the opposite. So I think that was what was a bit more difficult. I think if I were already eating the type of meal that’s, you know, like lots of people really eat, like you know, it’s quite normal to eat like macaroni cheese or yeah, or cawliflower cheese, or very boiled vegetables. You know lots of people eat like that anyway. Or boiled carrot, which I don’t like! You know, so that’s kind of like normal food for many people. So it’s kind of, it’s almost like you kind of have to

Annotations

Ready-made food purchased that appeared suitable but was not

Feels that cooking from scratch would be easier in terms of complying

“alright” is stressed. Indicates that there wasn’t full enjoyment

Difficulties if you don’t like some of the key elements of a modified diet- i.e. sauces

Repeats “massively”. Clearly P feels that cooking skills are important

Raises the point again that it is easier to modify your diet if your diet already lends itself to being modified

Themes

Difficulties

with finding

convenience

foods

Cooking

knowledge

and ability

Cooking

knowledge

and ability

Regular diet

107

make adjustments. Or lots of gravy, it’s quite popular here in the UK. So (.), and lots of custard. All the stuff. So that’s ok. If I already had a diet (.), yeah (.), it would still be difficult because you still have to think about things, but it’s not like if you’re not eating vegetables anyway the fact that you can’t’ eat vegetables. I mean crunchy vegetables. It’s not going to do anything for you, is it? That’s great I have an excuse! But erm (.), yeah (.), so I did (.), in this case, I did think (..), I didn’t feel skilled enough to change my previous diet to erm, a new diet. Even the risotto, I didn’t know how to cook a risotto. I had to look up a recipe and look for different recipes until I found one that didn’t have the ingredients that I couldn’t eat. Like mushrooms, for example. How do you fork mash mushrooms? I don’t think you can. So I left them out. Can you? I don’t know! I don’t think you can. I just assumed that…

I: I think that it you were making a really thick mushroom soup.

P: Soup yeah. But for the risotto, you couldn’t have really thick pieces of mushroom because it’s really chunky. And a bit like…

I: Yeah, yeah. Because you can’t have too much chewing can you? It needs to be a bit. And then…

P: Unless you cut it really fine.

I: Unless it’s really fine, yeah.

P: So in the end I didn’t put. So yeah, I found a recipe and I followed the recipe. Also, I didn’t count on how long it takes to cook risotto (laughs). Oh my god!

I: So the meals took longer then?

P: Oh my god, I was cooking for more than an hour! Really. And maybe that’s the way I live, always rushing (..), never stopping. An hour is like a considerable time cooking! It’s like, “god (laughs), can I spare an hour?” I was there with my paper reading and staring! You know (laughs)?

(LAUGHTER)

I: So to go back to your eating with others. So you said about their reactions. What were your feelings when other people were eating non-modified food. Did it have an effect at all?

P: When I was eating my modified food?

I: And others were eating non-modified food. So what was the experience like for you?

P: Eh. It was ok really. I didn’t really mind that. You know. I think because, because everybody has very different diets anyway. I didn’t really feel any, you know. I didn’t feel embarrassed, you know, I just thought that’s what I’m eating now. I don’t know. In that respect, I didn’t. It was alright. In fact I really wanted someone to mention it so we could talk about it! Because nobody asked and I was like, “‘ask me about this!” (Laughs)

I: It’s interesting that no one said anything to you. Yeah.

Annotations

Talks about “adjustments”

Difficulties with certain foods

Again mentions the increased cooking time

Stresses “oh my god”= P didn’t expect how long it would take

Eating with others was not a problem- however the lack of reaction was. Perhaps P would have felt better if she could have talked about it

Themes

Cooking

knowledge

and ability

Determining

the

suitability of

foods

Increased

planning and

preparation

Lack of

reactions

108

P: I think it, you know one of the things that might help people, is to feel they are different, but in a good way. It’s kind of trying to make (..) that situation to something more positive. You know? Sometimes being different is not too bad, you know? It’s just offering a new experience. A different (.), different way of looking at things.

I: So do you actually feel then that the acknowledgement would have made, made you feel differently?

P: Yeah. Yeah. It would have been normal really. I never understood why people, when they feel a bit awkward, don’t comment. Maybe that wasn’t the case, maybe in that way. Maybe, maybe I think if I was out in any other restaurant. Actually (..) hold on, let me think. Er, because it was the day (.) I think there was one of the days that I (…) (looks at food diary) ahh ok, yeah well. As for eating with people, or food when it involves other people (.), yesterday, and that’s something I kept thinking about (.), I went to buy fruit and veg in one of the shops by my house. The guys there, they always give you fruit when it’s ripe. It’s their way of connecting with you. They’re really lovely. They’re like, “oh we’re going to throw this away, try it, it’s amazing!” So the guy went, “oh look, I’ve got Sharon fruit and it’s really ripe, look, try, try!” So I didn’t want to say no (laughs) because it’s like aw, you know? So I ate it. But that was out of the modified. And that was another thing, it was like (.), you know (.), I didn’t want to make him (.), I didn’t want to refuse the food he was offering.

I: Right ok. Because it was a kind gesture that you felt?

P: Yeah, yeah. And also because it would have taken longer to explain (.) than to actually do it and move along. You know? Almost like you get to the (.), well it’s easier to adjust.

I: Oh ok. So the time constraints?

P: Yeah, yeah. Because talking about your diet may lead to a conversation in many ways and sometimes you just can’t have the conversation, and you don’t want to be rude and go, “oh I can’t eat that!” Full stop (laughs).

I: Yeah, yeah. So it must be challenging. So do you feel then, if somebody cooked for you, do you feel it would be a challenge in that scenario, just hypothetically?

P: Yeah I think so. I think that’s the danger area. Big time, big time. Yeah, because people love you with food don’t they?

I: Yeah

P: They just, you know, they want to give you things. They want to make you feel comfortable. And then, you have almost to make them feel uncomfortable for offering you something that they thought was nice for you. You know what I mean? So it’s, it can be tricky (.) and er (.), and I can imagine in many situations (.) when people really do not understand why the

Annotations

Mentions “different” four times here. P feels that by accepting you are different could help you to adjust

Didn’t want to refuse a kind gesture. It would break a social connection

Time consuming to explain your diet to everyone

Food is an important social statement

Goes against social etiquette to refuse a kind offer, especially when people offer food to build relationships

Themes

Accepting

difference

Difficulties in

refusing food

Having to

“explain”

Emotional

connection

with food

109

person needs a modified diet. That can be a tricky area. When (.),you know (.), they feel that the person would feel happier having this (..), whatever (..), that I made for you. You know? So yeah. That was quite, kind of interesting. And then another thing that I didn’t expect (..), the amount of times I caught myself nearly putting something in my mouth without even thinking (laughs)!

I: Right ok. Automatic behaviours. Yeah.

P: And I was like, “oh man, I haven’t modified this!” (Laughs) So many times. It was like, “oh”! (Laughs) Ok, hand to mouth, stop, leave it on the plate, take a fork, mash, you know? Banana, you know, you peel it. And normally, you know, you do automatic things. When I peel a banana, I take a chunk from the top and eat it. I always do that (laughs)! It’s like, “oh no”, on my plate, fork. But then you have to have the fork. You have to have the plate.

I: All of the utensils with you. Yeah, yeah.

P: So bananas are out of the question on the go. Unless you’re going to make a mess with your fingers (laughs)! God! (laughs)

I: Yeah that’s true actually. Yeah, yeah.

P: Yeah, same with yoghurts, Sam. You know what, most of the convenience corner shops, they don’t have thick yoghurts. They’re all like these very thin, watery ones. Which is quite (.), it’s quite good to know, you know?

I: Yeah (.) it is definitely. It is, yeah.

P: Yeah it’s when you realise everything in the shop, you just can’t eat. There’s nothing, anything absolutely in the shop that you can eat, now. When you’re hungry. So that’s another thing. Organisation.

I: Organisation. Yeah. Being key. I think just to sort of summarise, you’ve talked about a lot of learning throughout the whole experience. So what do you feel, just to summarise, what do you feel that you’ve learnt from doing the trial?

P: Well (.), I ‘ve learnt that it’s way more difficult than you think it is for the person and that there are feelings involved that are not really logical. And then, you can work with them (.) after (.), you can reflect or whatever, you can talk to other people, and kind of reframe them. But in a moment, there are almost like gut feelings like, you know, reactions really. There are reactions that I didn’t expect. And erm, er, I learned that you can put yourself in dangerous situations (..) for reasons that don’t have much to do with food, just for practical reasons. Like yeah, going without food because you know, you don’t want to, you know, not comply with the diet. Erm, or yeah, or accepting food from others, you don’t want to upset them more. That’s another thing. You know what, I kind of had it, I had an idea that that could happen, but actually kind of when you do it yourself, you’ll realise actually how it feels. And you know, I wasn’t put in any dramatic

Annotations

Considers an ethical scenario. Others may put quality of life over compliance due to their relationship with the person

Non-intentional non-compliance

Mentions another type of food that you would expect to be suitable but in reality are not

Describes her feelings as not being “logical”. She was unable to rationalise her feelings, they were just instinctual

Themes

Emotional

connection

with food

Absent-

mindedness

Absent-

mindedness

Difficulties

with finding

convenience

foods

Difficulties

with finding

convenience

foods

Intense

reactions

Going

hungry

110

situations, but, you know. That’s the thing you know, with this trial, it’s four days, so (..), it’s really (.) only very superficial.

I: It’s a small element to what somebody with dysphagia would experience.

P: Yeah, yes. And it made me think, and this is something that I think is very useful for this trial, for this experiment, it made me feel like I, I do not want to put someone on a modified diet unless it’s the (…) the (..), completely unavoidable. To do whatever is needed to, for the person not to have a modified diet. And it’s not, it’s not in the way that (..) it’s not like thinking (..) oh like they’re awful themselves. They’re not awful in themselves. It’s because of the feelings that they create. Because you know, food is tasty, you know? It’s nothing to do with how it looks, because it can look nice on the plate. It’s just that because that some people may react, some people may be super-shiny positive and not mind (..), but some people (..), if like me, you tend to be a bit like, eugh, despairing! I don’t know why. But you know, if you have that kind of like, erm, knee jerk reaction to change, then it might be hard. So yeah it’s made me think that in the future if I ever work with people with dysphagia, I would (…) I would really consider all the options. And er, I think I’ll be more empathic. Much more empathic I think.

I: That’s really good. And in terms of actually this task of SLT students (..) following a modified diet for a few days, how do you feel, do you feel that the task is a useful one?

P: Oh, I think everybody should do it. Honestly, Sam, I think (..) it’s an eye opener. We (..), we tend (.) as humans, we tend to think we know (..) until you don’t know (laughs). You know what I mean? It’s like they say, you need to live through it to know it. And even then it’s only my experience you know.

I: But that’s really important to you though and you as a therapist, isn’t it? To have, have that experience yourself.

P: Yeah, yeah and also, but also kind of be careful and not thinking, just because I went through this, everybody is going to go through this. But, but I have a notion when they tell me, oh my god, “I’m finding it really difficult”. I have a notion now (laughs). That why it is difficult. I can really sympathise. Actually yes, this is difficult. You know?

I: Yeah. So do you feel that this would be helpful for SLT students?

P: Oh god yeah. I wish it was part of the program. The thing is because ethically, it’s really tricky isn’t it? You have to give people the option of not doing it. But if the person was motivated, if the SLT was motivated, the student was well motivated (..) I’d recommend everybody to do it. And it’s faff you know, it does affect what you’re doing on the course, but then (..), that is part of the whole, you know, it affects everyone that has to go through it. So why is your life more important because you’re a student? Than other people that’s… And also, you know, it might be your future, touch wood. But, you know, in the future, you might have to be put onto a, you know, it’s almost like having one more

Annotations

Due to her experience, as a future clinician, she will try other options first

Recognises that her experience will not necessarily be the same experience for others. It depends on personality

Has built more empathy

Stresses “eye opener”. Implies that she has learnt things that she didn’t expect

Can relate to patients in the future

Feels that all students should have the experience

Themes

Diet

modification

as a last

resort

Intense

reactions

Appreciation

of difficulties

Appreciation

of difficulties

111

experience. In the same, we have placement, we have lots of experiences (..) at placement. Why not have this experience as well? It’s part of what we do. And obviously we can’t have a stroke, just to feel what the person would feel, but this is fully controllable. Even if it’s just for one day, Sam.

I: Just to have the sense of what it’s like. Yeah.

P: Well, no maybe two days (laughs). But thank-you, I really appreciate that you did this, because it’s something that’s really useful. So thank you for giving me the chance.

Key I= Interviewer P= Participant (.) = Pauses Underlined = Word emphasised in speech * = Word cut off

[] = Non-speech eg. Laughter, looking at something

Themes

Annotations

Repeats

“experience” here.

Experiential

learning was

important for P.

112

Appendix 7.14 Participant 2: Annotated transcript

I: So just before we start, just to let you know that the interview is going to be recorded, are you happy with that?

P: Yeah, that’s fine.

I: Brilliant, ok. You’re known as participant two so all of your details are anonymous and anything that you say will be confidential, so it’s contained in the study but it will not be shared with anyone. So are you happy to go ahead?

P: Yeah, that’s fine, yep.

I: So just to start, if you could tell me a little bit about what your feelings were about the trial before you actually started it.

P: Erm (.) to be honest, I didn’t really think about it much before I started it erm (.) ‘cos (.) I don’t know, I guess (.) yeah I didn’t really think about it. So it was kind of, by the time I actually got to the date of the study, it was actually more remembering that I had to do it, when the trial was going to start. So actually, it was almost like I started as if you’d just told me, “oh you’re gonna be on texture E from now on,” so it was actually really weird that it kind of felt more like er, what a real life situation would be, you’re now on fork-mashable from now onwards, change your diet (.) so... Kind of because of my poor memory (laughs) and because I read the reminder, came up on my phone, I was just like, “oh yeah!” so it was just like, I think my first feeling was, “hmm I’m not sure what’s in my cupboard that’s fork-mashable, so this could be interesting!” so yeah.

I: Right ok, yeah. That leads me onto my next question, so how did you go about day to day planning and preparing your fork-mashable meals?

P: Erm (.) well the time was actually quite good ‘cos I needed to go to Tesco anyway, so actually on the first day erm I went to Tesco in the morning, and I just filled the basket. I went around Tesco and I was just like, “yeah that’s fork-mashable, that’s not, I won’t buy that just yet.” Erm so actually preparing for it was actually ok. Erm so that’s kind of how I went about the first day is go to Tesco and er just buy the things that are fork-mashable, er (.) and I knew in my head what I was gonna buy. I also brought your, brought the (..) the meal ideas with me (.) and the kind of (.) the stuff that I ought to avoid and the helpful tips and stuff like that. I actually brought that to Tesco ‘cos I was just like, if anything to spark my memory. So like I already knew that I had risotto rice in my cupboard, I was just like, “oh yeah, what could I get for that?” so I got like butternut squash that I could put in and stuff like that so yeah, that’s why.

Annotations

P compares experience to patients’ experiences

First thoughts were of what to eat/make with existing food

Prepared by doing a big shop- seems to have found it helpful

Using the guidelines to select food

Combined ideas with existing food in house

Themes

Planning and

preparing

ahead

113

I: And the food choices, were they different compared to what you would normally eat, would you say?

P: Erm (.) in terms of what I bought, none of it was new. Erm so I was, these sort of things were already in my diet, so I didn’t have any kind of new foods, they were all just foods that I, I already eat. It was just, I kind, the only thing that was different was I had less food than I would normally eat. But yeah, what I actually bought, it was exactly the same. It would have been exactly the same. I would have just had a few more items in my basket. So (.) that’s it. That’s the only thing that was different.

I: Right ok. Can you tell me, you said that you had a little bit less food than normal? Could you tell me a little bit more about that?

P: Yeah, in terms of like, erm (.) I think the main things that I didn’t have in my basket that I would have done, was snacks and meat. Erm so er, the sort of tougher meats so erm (.) so the (.) chicken, beef or erm (..) things like that, I would normally buy, or like chicken kievs, and stuff like that I would normally buy. Erm (.) but for those four days I didn’t, ‘cos I knew that they weren’t quite fork-mashable, or it would have taken more prep to be fork-mashable. Erm and then snacks, I was just in Tesco and I saw all the biscuits and all the sweets that I would normally, and I was just like, “none of those are particularly fork-mashable!” (Laughs.) So yeah, it was kind of, yeah those were the only things that I didn’t have in my basket that I normally would have done, but everything else (.) was already (.) I already had in my diet, so.

I: Right, ok. So how was it in terms of actually following the guidelines?

P: Yeah the guide*, it was actually really easy to follow the guidelines. Erm (.) the (.) I don’t know if this will come up later, but the only thing I actually struggled with was the stuff that was already open (laughs)! So the foods that were already open, so erm the one (.) the one thing I erm (.) everything on here is filled out as ‘all’ (looks at food diary), except on the first day erm ‘cos I had a packet of Fruit Pastilles on my desk that were already opened. Erm and I was so good, I was, I had done breakfast and I had done lunch, I was doing work, and I was just absent-mindedly eating these Fruit Pastilles and I got through about ten, and suddenly remembered that they’re not fork-mashable! And so (.) yeah, but that was literally the only thing I actually struggled with, the rest of the guidelines were absolutely fine.

I: Oh ok, so when you were cooking and things…

P: Oh yeah when I was cooking it was absolutely fine. Erm (.) because, you know, I like to cook anyway so I knew how to

Annotations

Repeats “new”= emphasises that P did not have to change food choices

Bought less= is this due to restriction?

Opted to not buy snacks and meat. These are food groups that seem to not lend themselves to being modified

P had understanding of the texture requirements

Uses adjective “easy”- guidelines were not problematic for her

Repeats “open”= emphasises that this was a difficulty for her

Interesting that P describes compliance as being “good”

Non-intentional non-complaince

Stresses “how”= knowing how seems to be important

Themes

Regular diet

Adaptability

Absent-

mindedness

114

cook all these things, and it actually didn’t take up any more or less time than I usually do to prepare food. Erm because yeah, I had those timings in my head, so it was literally stuff like, put the broccoli on about five minutes earlier than I normally would have done (.) but I was still cooking at that time, so it was (.) yeah, so there was no real difference in terms of cooking or preparation. Erm, so yeah, it was (.) yeah it was fine.

I: Ok. And what do you think came into making those guidelines easier, you said that you got on ok with following the guidelines, what do you think was behind that?

P: It was the er, it was the meal ideas that you (.) had here. Er so things like (.) well-cooked risotto and (.) erm (.) the (.) what was it? (Looks at guidelines.) It was the er (…) there was something in there that said like erm (...) about vegetables and how (.) just you overcook broccoli and things like that so it’s more mashable and things like that. So yeah, it was those things, things that kind of, it gave you an idea of what you could have. So when I was cooking and preparing my meals, I already knew what I was gonna cook and how I was gonna cook it, erm but that’s possibly because I cook quite a lot. I have that in my head already, so yeah, and because I’m very familiar with erm (.) with, you know, dysphagia and (.) the different texture modifications, I kind of already knew what was fork-mashable and what wasn’t fork-mashable, so I already had that in my head. So I think that, having that understanding beforehand (.) really helped. Erm (.) but yeah, so actually like (.) yeah, so maybe like, having an understanding (..) or someone going through it with you, just to really, not just give you the suggestions, but just kind of explain, you know, these things are fork-mashable, these things aren’t so you kind of already have that in your head, so when you go to Tesco shopping, or when you’re cooking, or doing whatever, you already have that in your head so you don’t have to think about it too much.

I: Right, ok. And was it beneficial having the guidelines in Tesco with you? Like a kind of reminder?

P: Yeah, yeah, yeah, yeah, that was really good, yeah. Yeah, just as a prompt and just like, “oh yeah I can, oh yeah I can have risotto and oh yeah, I probably shouldn’t buy that particular type of cereal because, yeah, yeah,” erm so things like that. Yeah it helped.

I: Oh brilliant. Erm and yeah, could you just tell me a little bit about your feelings when you were actually eating the modified foods during the trial?

P: Erm (…) I don’t know it was kind of (..) like I didn’t really not*, I didn’t really think about it too much, it was just like

Annotations

Preparation time not affected

Having timings in head= P is confident in her cooking abilities. This seems to have helped

Ideas were useful

Having your ideas set out beforehand and knowing what you are going to do is useful

Knowledge of dysphagia was also helpful

P thinks about what would help patients by relating to what helped her- by clear explanations and preparation beforehand

Seems to have not affected P

Themes

Cooking

knowledge

and ability

Planning and

preparing

ahead

Knowledge of

guidelines

Explaining to

patients

115

(.) erm (…) I (..) I don’t know, like, actually I think my housemates were slightly more (.) affected than I was. In terms of like the one (.) erm meal that I kind of ate in front of my housemates was the yoghurt, the breakfast of mashed banana and yoghurt, my housemate was actually more disgusted by it than I was (laughs). Like I was fine eating it, I think it’s because all of these things are already in my diet. There wasn’t any kind of new or different feelings than (.) I would have already. If anything, the feeling of hunger just went because I was eating, so. There was no particularly new feelings that I noticed.

I: Right compared to what you normally eat?

P: Yeah because it’s food and I feel happy when I eat food so (laughs).

I: Yeah.

P: And it was all food that I liked as well.

I: So do you think that was important, choosing the food that you appreciate?

P: Yeah definitely, because I very much only eat the food that I like, but because I like quite a wide variety of food (.) and I do have a wide variety diet. So other than cutting out snacks (laughs). Yeah the one, yeah I missed snacks. Yeah I was just feeling a bit kind of (.) I guess that’s the only thing that I felt a bit annoyed about, I was just like, “oh I just wanna have, I just wanna have Jelly Babies and stuff like that,” I was just like, “oh I just want to have a packet of biscuits right now!” Yeah so, yeah, that was the only kind of, a feeling of annoyed or a little bit frustrated, was just like, “I wish I could have snacks!” But it was probably better for me, not having snacks. So actually, I think I felt like I was being a bit healthier than (.) if I hadn’t been on a fork-mashable diet, to be honest. Just in terms of just cutting out all of the extra snacks and stuff.

I: Yeah. Did you come up with any snacks that were fork-mashable at all?

P: Well I don’t know whether (.) I just need to clarify. Erm (.) bite and dissolve crisps (.) are they fork-mashable?

I: I think they’re fine, because you are allowed, I mean yeah, you’ve got to have some control to be on a texture E…

P: Yeah. But yeah it’s also because they dissolve, they don’t have the same crunch to it.

I: Yeah.

P: So the one snack that I found was actually Pom-Bears, because they are bite and dissolve crisps, which I have anyway (laughs)! To be honest, so there was no change, it was literally

Annotations

Interesting that others more affected than P

Feelings have not changed because the foods being eaten have not changed

Enjoys food, mentions “happy”

Choosing food based on what you enjoy

Stresses “wide”= emphasises that eating a variety of food can be helpful

Repeats emotion “annoyed”. P felt restricted in terms of snacks

Interesting insight- the restriction of snacks lead to feeling “healthier”

Un-certainty of texture requirement

Themes

Negative

reactions

Regular diet

Enjoyment of

food

Regular diet

Restriction

Feeling

healthier

Regular diet

116

just cutting out biscuits that were really crumbly, so like Digestive biscuits that I normally have, or like Oreos that I normally have. Erm (.) and (.) but I suppose if you have thickener, that’s how you could make those snacks fork-mashable.

I: If they’ve been soaked.

P: If they’ve been soaked and stuff like that, yeah. Erm (.) but yeah, just for me, er and the same with cereal as well (.) erm (.) normally I have things like Coco-Pops (.) or Cheerios, I sometimes have Shreddies, but I’d have Shreddies with sugar on the top, but I can’t (.) once the cereal, once Shreddies have got to the point that all the milk has been saturated, I then really struggle to eat that cereal, just in terms of the taste and the texture, I struggle to get it down. So actually, that was the one thing that I completely changed, was what I had for breakfast. Erm, so instead of having cereal, I had yoghurt mainly, and er sometimes with a banana, and sometimes without. Erm but that was kind of fine because I had yoghurt anyway, erm as kind of like a snack, but instead I just had it for breakfast.

I: So were you happy to change it?

P: Yeah, I was happy to change it. But I did enjoy my Coco-Pops this morning (laughs)!

I: Yeah, you’re back on your normal foods now!

P: I’m back on my Coco-Pops! And that was, actually that was the one thing that I was excited about, was having Coco-Pops for breakfast!

(LAUGHTER)

I: Brilliant! How do you think you would feel if you had to follow this diet permanently? I mean obviously this is a hypothetical question, but did you get any insight into that at all?

P: Yeah, I think I’d be ok with it. I think I’d just get used to it. Erm (.) so (.) like, things like having like Coco-Pops for breakfast or having extra snacks, it’s just a habit at the moment. Erm (.) so, but actually I think I’d be ok with being on this diet. Erm the one thing I would struggle with about being on this diet is (.) er (.) my meat intake. Erm, or more specifically my protein intake. I’d be a bit concerned that I wasn’t erm like (.) because I really enjoy like Sunday roasts and things like that, I would really miss that. Erm so actually, that would probably be the one thing that I would really struggle to conform with, or things like that. I would want to have (.) you know, small pieces of meat, soaked in gravy or something like that, but I would want that, so yeah. So I think

Annotations

Talks about “no change” but then mentions restrictions- i.e. biscuits, so there was some change

P talks about struggling to eat cereal in a fork-mashable texture. Distaste for the texture in certain foods.

“kind of fine”= suggests it was tolerable, but not exactly what would have been chosen

Even though P said she was happy to change, her excitement over a non-restricted breakfast suggests that she was missing certain foods

Idea that you have to change your habits to adjust to a modified diet, but over time you would adjust

Concerns re: meat and protein. Is this harder on a modified diet?

P talks about missing what would not be suitable. Uses verb “struggle”

Themes

Restriction

Restriction

Adaptability

Restriction

117

I would actually be ok with it, it’s just one or two things that I would be like, “oh,” I would just be a bit frustrated that I can’t have that.

I: And what was your appreciation of mealtimes like during the trial? Did you appreciate meals in the same way?

P: Yeah. Yeah exactly the same. I always appreciate my meals! (Laughs.)

I: That’s good. Ok, so you said to me about the Fruit Pastilles. Were there any other instances of non-compliance over the four days?

P: No I think that was it. Oh yeah, other than on day three (.) I have to say for lunch I did have cupcakes (laughs)! That was my lunch. Er but they were very moist cupcakes. The only thing that might not have been (.) compliant was the (.) er (.) bits on the top, but they were (.) mixed in with the icing. So I kind of put that as some, but it was so (.) small a part of the component, I wasn’t too sure whether that counted or not, so I erred on the side of it didn’t (.) but (.) that was. Yeah it was literally just Fruit Pastilles on the first day ‘cos I ate them (.) I’ve even put on the form, Fruit Pastilles eaten before remembering about texture E! So literally I ate ten and I was just like, “oh, hang on a minute!” Erm so yeah, that was the only non-compliance actually came from stuff that was already in my house and already open in my house. Erm , so I (.) that packet of Fruit Pastilles had been open like two days beforehand and it had been on my desk for those two days and I had been eating them (.) like on and off for those two days. So (.) yeah that was the only time it was non-compliant, it was just like, it was already there before the trial started so.

I: And was it sort of temptation to eat them, or was it just that you didn’t think about it?

P: No it was just absent mindedness, ‘cos like I had other packets of biscuits that I like (.) already opened, but I had no temptation to particularly eat those ‘cos I know they weren’t fork-mashable. It was just literally, like literally it was on my desk and I absent-mindedly ate them. Like if I had remembered beforehand, I wouldn’t have eaten them, erm but ‘cos I completely (.) blanked at that moment in time (laughs), like literally it was almost on automatic. It was only as I was eating them that (.) I then suddenly looked down and went, “oh, oh well! Put it down as some!”

I: No we all do it!

P: Yeah, yeah, yeah, exactly! And that’s the thing, it was just little things every now and again might catch someone out. Erm but it was, it wouldn’t be like (..) like the whole meal, and it wouldn’t be like (.) um a major, it would just be

Annotations

“frustration” over restriction

Seems un-certain whether a food choice was suitable

Interesting P justifies potential non-compliance by calling it “small”. Does she think that small amounts of non-complaint foods are suitable?

Calls her non-compliance “absent mindedness”. Perhaps this could be an issue amongst patients as well

P can see how her experience may form part of the patient experience

Themes

Enjoyment of

food

Absent-

mindedness

Absent-

mindedness

Absent-

mindedness

118

something, I think something really small or like, one that they just really want and they were just like, “you know what, just this once.” But that wasn’t really the case for me, it was literally just I forgot. That moment in time I just completely forgot. So, yeah.

I: And did you eat food out and about at all? Did you buy food out?

P: No actually. The thing is because it was over the weekend (.) and erm (..) and because I usually cook from home anyway, there’s very few inst*, there’s very few occasions anyway in which I eat out. Erm (.) so (.) no I didn’t, not during the trial anyway.

I: So it was mainly home cooked?

P: It was all home cooked, but that’s kind of normal for me.

I: That’s good. And you did tell me earlier about how your housemate reacted to your breakfast. Can you just tell me a little bit more about that?

P: Yeah, I had the mashed banana and the yoghurt and I was eating it in front of her, and I think it was just the look of it (.) erm, like, yeah. Just the look of it kind of disgusted her ‘cos it looked like something I’d already eaten (laughs). Which was how I described it! Which I was fine, it tasted good, it was just the look of it, was a bit kind of gross (.) to her. But I found that funny to be honest!

I: Ah ok, was it just humour that your felt, or did it have any other kind of impact?

P: No for me, it was just humour. Erm (.) but for her it was disgust (laughs). But yeah, erm, but yeah the rest of it, no it was absolutely fine.

I: Ok, did you have any reactions from anyone else at all?

P: Erm (.) when I was preparing my Sunday dinner, which was (.) the red wine risotto (.) and with (.) red onions, overcooked slash mushed broccoli and sausage meat with the skins taken off, so I actually took the sausage meat out of the skins, so that component was fork-mashable. Erm (.) but the skins obviously weren’t, so I was kind of de-skinning my sausages and one of my housemates walked in at that particular moment in time and just looked at me really weirdly as if, “why are you doing that?” so I quickly explained, “oh you know I’m doing this fork mashable thing erm and the skins aren’t fork-mashable so I’m just taking them off.” She was like, “oh ok!” so that was absolutely fine. So it was just a little, quick explanation of, you know, why I was (.) doing something so weird (.) which was skinning a sausage. It was just like, you know it’s not something you’d usually do, you’d

Annotations

P feels that patients may every now and again give into their temptations

Eating out and about was not an issue, but does not form part of usual routine

Stresses “look”= the sensory appeal of the food was altered

Appearance of food did not affect P, but it did her housemate. Suggests that it can create individual responses

“disgust”= strong emotive adjective

Description sounds like she was familiar with guidelines

P had to explain her actions.

“so weird”= P seems to have found some of the cooking processes unusual

Themes

Regular

routine

Negative

reactions

Negative

reactions

Having to

“explain”

119

just have your sausages and cut them up, but yeah other than that, there was no other reactions.

I: Ok. And how did you feel when you were eating with others eating normally?

P: Erm (.) absolutely fine because erm, I mean at my house we cook our own meals anyway, so erm, so, it was no different from you know, me just cooking something and eating it in front of my other housemates as I would normally. And because it’s all food that I would normally eat anyway, erm (.) yeah I didn’t have any kind of, there was nothing new. Erm (.) other than the, the disgust at my mashed banana, but other than that, there was literally nothing else. Erm and (.) er (.) actually my housemates were really, they really liked the er (.) as I was cooking the risotto, and as I was cooking, I cooked pancakes and stuff like that, they were actually really jealous of what I was eating. So you know, yeah it was fine.

I: Ok, and did you feel that your lifestyle was affected in any way at all during the trial?

P: Erm (.) only that it was probably a little bit healthier than just, just in terms of I wasn’t eating excess food, I was, mainly actually sticking to mealtimes. Erm (.) so it was probably actually forcing me into slightly better habits, eating habits and I think I was just a bit more conscious about (.) erm (.) yeah (.) I was just a bit more conscious about not having (.) things that were (.) that weren’t fork-mashable and the one thing that I could think of was actually around snacks, so, actually I was probably a little bit healthier.

I: Ok, that’s good. Same question again really, your social life?

P: Oh not affected at all, no. But I can understand why it would be affected. If I was eating out (.) then I would have to be really careful about what I was eating, it might be that I was leaving food on the plate, or might be having to specifically ask for how it was prepared. So I can see why it would be affected, it was just for me, ‘cos I’m cooking my own food, I was (.) it didn’t affect me in the slightest, so (.) yeah.

I: Ok, brilliant. Ok, and what do you feel that you’ve learnt from this experience?

P: Erm (..) I think I’ve learnt (..) I’ve learnt (..) hang on (looks at food diary). Yeah I’ve learnt I was absolutely fine going to Tesco with kind of the ingredients in my mind that I wanted to cook with that would be fork-mashable, and I was absolutely fine just going to Tesco and buying things for myself. I wasn’t conscious of it. Well I was conscious of what I was buying but I didn’t feel any (.) differently to how I normally go to Tesco. When I was cooking, I didn’t feel any differently to how I was cooking. Erm (.) but I can, I can see why it would affect people,

Annotations

Repeats “normally”= emphasises the point that P experienced nothing different from her usual routine

Others even experience jealousy- perhaps as P is confident with cooking- her meals appeared appealing

Helped her to develop a mealtime routine

Repeats “conscious”= P had to develop awareness around her food choices

Stresses “not”= emphasises that P did not experience any changes.

Has insight into potential difficulties such as eating in restaurants

Repeats “absolutely fine”. This really stresses the point that P felt confident in choosing and preparing suitable foods

Themes

Regular

routine

Positive

reactions

Feeling

healthier

New

mealtime

routine

Implications

for eating in

restaurants

Planning and

preparing

ahead

Regular

routine

120

because if they’re not used to (.) you know, if they are going out a lot more, and they’re not used to cooking for themselves, they would have to be really conscious about, you know, what it is they need to do . And because I’m really used to cooking, I know how long things take, I know how (.) long things take to be cooked just right and how much is over-cooked. Erm (.) so when it says like, well cooked risotto, I know what that means, when it says over-cook the broccoli so it’s fork-mashable, I know how that is er, just in terms of my experience with my cooking and things like that. Erm (..) yeah and I’ve also learnt how easy it is to slip up (.) and eat something that isn’t fork-mashable (.) just absent-mindedly and you know, because you just go into, I think with food, you kind of get into little habits and it’s kind of changing those habits and just, sometimes it just catches you out. So I can kind of see why people don’t conform (.) er to texture modification, just almost like absent-mindedly, just forgetting sometimes. Erm (.) but I can also see why some people might struggle because (.) like a lot of the things that came up were already in my diet, so if someone’s diet was completely non fork-mashable or that they had specific problems with like taste or texture of foods, ‘cos I know some people who have very, very specific erm kind of texture things that they absolutely can’t eat if they’re that texture. Erm (.) so I would completely understand why they would struggle more that I would. Erm (.) because I don’t have those kind of texture aversions or whatever. I don’t have those kind of taste aversions, other than rice pudding, which is one exception, but it’s kind of more the smell, yeah I just don’t like rice pudding. But yeah, so I kind of (.) I think I just got a kind of appreciation of (.) what it means to change diet. Erm (.) and I think that I would be completely ok with (.) erm (.) with fork-mashable to a certain extent, other than my Sunday roasts, which I just love. I love slow cooked meat. I’m sorry, I’m sorry to all the vegetarians and vegans in the world but I just love the slow cooked meat! Erm (.) and I would really miss it. But yeah, but actually I’d be, I could live and be healthy (.) you know, be fine with eating on this diet, so yeah it’s fine.

I: That’s good. Just with one thing you said there, I just wanted to ask you actually, do you feel that cooking skills actually come into this a little bit?

P: I think they do yeah. I really do because (..) yeah because if you were more reliant on going out for meals, I can see you’d be a little bit weary because so much isn’t fork-mashable or so much is like, like (.) gravy’s very watery in places, you know the vegetables are (.) probably more under-cooked than over-cooked in some restaurants or some food establishments, er (.) whereas at home, I’m in complete control of what I’m eating (.) and how I’m preparing it and I

Annotations

P has insight into potential patient difficulties. Some may have to change their cooking routines, or social routines –such as eating out

“slip up”- relates to non-intentional non-compliance

Changing habits requires practice

P can see that her experience caused her no difficulties as she didn’t experience too much change. Insight into how experience of texture modification relates to how much change the person has to adopt.

Talks about “appreciation”

Talks about a long term restriction of meat and how this would be difficulty

Positive outlook

Repeats “so much”= P feels that finding suitable food out and about would be challenging

Themes

Cooking

knowledge

and ability

Absent-

mindedness

Appreciation

of difficulties

Appreciation

of difficulties

Restriction

Implications

for eating in

restaurants

121

know what’s fork-mashable and what’s not (.) and I can be more in control of that. Erm (.) but because I’ve got those cooking skills already (.) that’s made a difference. Erm because yeah, I know the timings of what’s over-done, what’s under-done, what’s just right. I know how to cook some of these things, so I know how to cook risotto. I know (.) what flavours I like. I know how to make, incorporate those flavours into something that’s fork-mashable. I know (.) how much sauce is enough sauce that it kind of, it becomes fork-mashable. So I cooked a white sauce with salmon, so I cooked the salmon and I took off all the flakes, and I incorporated that into one of my meals (.) with a lot of white sauce (.) so I knew the quantities of how much white sauce I needed compared to how much I normally have. Erm (.) so yeah, things like that, I just knew already (.) erm, so yeah. And because I’ve cooked all these things (.) I know erm (.) I know what they taste like, I know what they look like, I know whether they’re fork mashable already. So yeah, it does make a difference I think, definitely.

I: Going back to your learning, how do you think you can apply what you’ve learnt to your future practice if you went down the dysphagia route?

P: Yeah, well if I went into dysphagia, I know that I (.) erm (.) I think it does make a difference when clinicians can say, “ oh yeah I’ve done (..) when I was a student I did a fork-mashable, I made all my meals fork-mashable for a time, so I know what it’s like.” And you just pick up lots of little handy hints, which you don’t necessarily get in the guidelines. Erm (.) so (.) things like, just cook broccoli for like five minutes longer than you normally would, things like that. Or like, erm (.) you know, you can cook pancakes, just drizzle them in honey, or like have, like (.) so they’re nice and moist and things, and just little things like that. And you’ve had that experience, and then you also as a clinician, you know, you can sort of gauge why there might be some non-compliance. Erm (.) and yeah that’s true of texture modification and that’s true probably of (.) definitely of erm, fluid modification as well. You just get an appreciation, and you just sort, you start to just (.) think, “oh that’s why they’re not complying!” it’s because they, you know, you just slip up, or “oh it’s because they really, really love their Sunday roasts,” and I can see why on a Sunday they would be really (.) annoyed that they can’t have something and that’s why they would get a little bit frustrated, but actually for the rest of the time, for the rest of the week, it’s ok. So yeah, and you, I think you don’t get that appreciation on a piece of paper. You do get that appreciation when you actually do it yourself.

I: That’s good. So following on from that, do you think it’s a useful task for future SLTs?

Annotations

Important to “control” what you’re eating yourself

“I know” is repeated four times here. It really makes it clear than P is confident, and she feels that knowledge is important

Important to “know” how food should look and taste- in order to determine if it is suitable or not

Feels that she can help patients by saying she has experienced it herself

Can provide patients with useful tips

Insight into patients’ difficulties

Seems to have a better understanding of the reasons behind non-compliance

Mentions emotions here- so P has more insight into the emotions that patients may experience

Themes

Cooking

knowledge and

ability

Relating to

patients

through the

experience

Explaining to

patients

Understanding

of non-

compliance

Appreciation of

difficulties

122

P: Oh yeah definitely. I think like, it would be good for SLT students to just (.) have a week when they modify their diet (.) to fork-mashable, obviously so they don’t have to buy blenders or anything like that, but like have a go at (.) changing their diet for like a week or like a couple of days or something like that, just to have that experience. So I think actually that would be a really good like (.) teaching tool. Maybe actually do it in dysphagia week (.) so actually fully immerse yourself in dysphagia, actually for that week, you eat a fork-mashable diet. Sorry, that’s just an idea!

I: No that’s a good one! Ideas are great! So you think part of when, students are taught dysphagia, to also try the fork-mashable diet?

P: Yeah.

I: Brilliant. Well that’s the end of all my questions. Is there anything that you wanted to add at all that I haven’t asked?

P: Erm (.) no, not really actually. No other than are bite and dissolve crisps fork-mashable? If you actually let them dissolve in your mouth, which I did! Other than that, no.

I: Oh brilliant, well thank-you so much for taking part in this study, thank-you!

P: Oh you’re welcome!



Annotations

Students to “experience” is useful

“fully immerse”= feels that engaging fully would be beneficial

Themes

123

Appendix 7.15: Participant 3 Annotated transcript

I: Thank- you very much for taking part in the study. Just to let you know, basically that everything you say is entirely confidential in the study, your name is not in there at all so you’re completely anonymous. Anything that you say will be in the report, it will not be shared with anyone. Ok? So are you happy to go ahead and be recorded?

P: Definitely. Yes.

I: Brilliant. Thank you. So, just to begin then, what were your feelings about the trial before you actually started it?

P: Erm, I was really really excited to do it as soon as I heard about it, I was like, I replied straight away. I really wanted to try it. Erm (..), partly because of the (…) erm (..), like if I was to work clinically in that area, I’d really like to have a bit more experience. Not that you can experience it, but insight into simulating the experience in some way, in a small way. And, also (..) erm, just to see whether I would find it a challenge to restrict my diet, because I think sometimes when you’ve already restricted your diet you forget how (.) erm, you think, “ah it’s so easy, why do people act like it’s hard?” And unless you try a challenge like that, you forget what it’s like to restrict your diet, so I wanted to have that experience again really.

I: Yeah, ok. You mentioned simulation there, so can you tell me a little bit about your thoughts on simulation?

P: I guess I was mindful (.) the whole time I was doing it, very mindful that (..) this wasn’t the experience of only, you know, being told clinically you can only eat these foods, or it’s dangerous for you, or you might die or, actually physically having discomfort or difficulty manipulating foods that were mixed textured. And obviously it’s only a short amount of time (..), erm, you know, in lots of ways it’s er sort of, I can’t think of a better word for simulated! It’s pretending isn’t it? It’s better than not pretending at all I guess, not trying it at all.

I: Yeah, yeah. Ok. And so, with the diet, how did you go about planning and preparing all of your different meals?

P: Well (laughs), erm, I would have to say, to be honest I didn’t really do that. Erm (.) I guess (..) to be honest, I’m glad I wrote it down because I don’t remember what I did on Monday but I did plan to go shopping on Monday, ‘cos I did Monday to Thursday. I did plan to go shopping on Monday evening. What did I eat on Monday? (Looks at food diary.) Yeah, Monday I didn’t plan and it was much harder. Actually that’s not true, on Sunday I had made some food which I knew I could eat on the Monday and like froze it in

Annotations

Repeats “really”=

shows enthusiasm

Interested in

gaining experience,

furthering

knowledge

P is interested in

finding out what

“restriction” is like

P is aware that she

can’t simulate the

experience of

having dysphagia

The idea that

‘pretending’ will

provide

experience?

Trying to remember

planning/preparati

on during the trial

Themes

Enthusiasm to

experience

Importance of

planning and

preparing

124

bulk. So I had it made. And then the other meals I hadn’t planned and it was really, it’s actually quite hard. Erm and then for planning for the rest of the week, I went shopping on the Monday night and I , I spent way more money than I normally spend (laughs)! And I, bought really processed food that I wouldn’t normally eat. I don’t know if there was an element of I saw it as a bit of a licence to (.), an excuse to eat quite processed foods. I don’t think you’d really have to do that but you know, obviously not everything in nature is fork mashable is it? So erm, yeah, I did buy quite... I spent a lot of money on junk food basically that I try to avoid normally. Maybe I saw it as an opportunity to indulge myself, which obviously wasn’t the point, but yeah (laughs).

I: Ah ok. So your food choices were different compared to what you normally eat, do you feel?

P: Yeah, so I bought things like, I bought some like vegan cheese, I bought some vegan butter, bought some like Alpro chocolate puddings. I bought a load of stuff I didn’t need that I would not normally…And yeah, the butter, the vegan butter in everything because (.) pureed food, you know, peas, are not palatable in the same way when they’re peas, so I did, I put both butter and a bit of stock in them actually. Yeah, so I found myself eating…And a lot more sugar as well. Or just any kind of sauce basically in everything. So (..) yeah.

I: Ok. Why did you buy these different types of foods?

P: I guess I thought to myself, I guess maybe the reason I saw it as an opportunity to indulge myself was because it felt like (..), it felt like a restriction or something that was gonna be unpleasant so I wanted it to be more pleasant for myself maybe. I don’t know if other people in that same situation, you know (.), would be likely to do that at least initially, or some people with a similar sort of personality style might. And I guess I was worried about it being unpalatable (.), which turned out to be true. I had a bit of a bad experience on the Monday because I erm, on the morning I (..) made myself some food. I was like, “ah it’s fine, I’ll just blend that food”, and it was horrible! It was so awful! It was so horrible that I gagged, it was really disgusting. It was just something I would normally eat, but I tried to make it more tasty (..) erm before I blended it, because I knew it wouldn’t be as nice, because it was blended. But then, I don’t know if it was ‘cos it was early in the morning and it was Monday morning as well, you know how you’re like more sensitive in the morning? But I did gag on it, so when I went to the shop in the night, I was like, “nah I’m gonna buy some like (.) nice treats kind of thing, to eat.”

I: Right ok, yeah.

Annotations

Had thought ahead by preparing in advance

Went shopping for the week= preparation

Bought lots of processed foods-not part of regular diet.

Verb “indulge”-implies P was trying to compensate for changing diet

P tried to make the food more “palatable” by adding additional ingredients- is this trying to compensate for the change?

Repeats “indulge”= emphasises how P viewed the experience

Interesting to try and make the experience more “pleasant”

Strong adjectives “horrible”, “awful” and “disgusting” = shows how unpleasant P found her first attempt at modifying food

Repeats “gag”, provides the listener with strong imagery on how unpleasant P found her food

Themes

Cost

implications

Changes to

healthy eating

Compensation

Compensation

125

P: All my other meals were great though, I really enjoyed all my other meals. Apart from that one on Monday morning!

I: (Laughs.) Right ok, and in terms of following the guidelines, the texture E guidelines, what were your thoughts on actually following them?

P: Erm (..), I’m not going to lie to you, I thought I had, was (.)… I thought I could remember and know what the guidelines were, but I didn’t. Thank you for including the information about it! So, did I follow it? (Looks at food diary.) I had this erm, white rice on Monday, which I remember, I think I asked you about it, or maybe I read it on here, erm that white rice was fine sticky, and it was a bit sticky. You know what I’m talking about, white rice?

I: When it’s soft?

P: Yeah. But as it...because I didn’t prepare it, I bought it, it looked good, but when I was eating it, I was like, “ah no it’s not quite there.” Do you know what I mean? It was still a bit bitty. And also, in the, it was like the vegetables were like slow cooked, so they were fine, but some of them had like, this skin. And I found it, I put this a few times actually in my little note bits, I found it really hard (..) to, and I remember this actually from when I stopped eating other foods, it’s really hard, when food’s already been presented to you, and it’s already on your plate, or you already own it, you’ve already paid for it, and it’s perfectly good to eat, it’s really hard to reject it. I forgot that. I forgot what that was like to be honest. Erm (.) other than that, Tuesday was fine. Ah on Thursday, no Wednesday, I forgot, I forgot, I was just all day, all of them were fine, like proper smooth, and then I just completely, absent-mindedly bought a chocolate bar.

I: Yeah. So just a moment of complete…

P: Yeah and I saw (.) one of our course mates and I was literally eating it and she was like, “you’re supposed to..” (gasps) and I was horrified! But I still ate it, I ate the rest of it to be honest. And then, erm, what was the other one? Oh yeah on, last night for dinner, the food I’d made (..) I’d baked it so it was hot (.), but then, literally a tiny bit of it was crispy and it was delicious! It was the best bit of the whole meal! That bit wasn’t fork-mashable.

I: Ok, so you had times when you were un-sure when you actually had the food in front of you?

P: Although if it was soaked in gravy? I don’t know. Erm I’ve been doing this for a week and it just shows how difficult it can be for a patient. But, it was crispy, but then I covered it in gravy. I don’t know?

Annotations

Useful to have the guidelines-not always easy to remember

Some foods may look suitable, but are not suitable on further inspection

Repeats “really hard” three times. P shows how significant it was for her to reject food, not only for cost, but when it has been “presented”

Gasps-shows how shocked P was when eating something non-compliant. Implies she wanted to comply.

“Delicious”- adjective used to describe non-complaint food.

Repeats “I don’t know”= shows P has difficulty interpreting guidelines even after trial

Themes

Determining

the suitability

of foods

Determining

the suitability

of foods

Rejecting food

Absent-

mindedness

Sensory

appeal of

textures

Determining

the suitability

of foods

126

I: Yeah. With the guidelines as long as it’s soft enough to be mashed with a fork. It’s hard to say without seeing it.

P: Without seeing it, yeah. To be honest, maybe I feel like I didn’t invest myself in the simulation of the experience properly because I mean, well different patients are different aren’t they? But, maybe if it was genuinely important for my health, and if I was, then maybe I would have been more like, mmm I don’t know, like cautious. Maybe I should have been more cautious. But to be honest, I was trying to think (.) how I would react to these guidelines if it was me. And I know that if it was me, I am a person that really evades what people tell me to do! Quite a lot. And I know that if I was in that situation, I mean you can’t never know, but I think I would follow the guidelines in so much as, but I probably wouldn’t be checking once my dinner was hot and in front of me. “Oh actually, I’m not gonna eat that little bit.” I know that I probably wouldn’t, or I didn’t I suppose when I’d tried it.

I: And why would that be? You said about your personality, is that your main reason, or any others?

P: Yeah. Maybe like the…. I mean the skins on all the vegetables and stuff I didn’t eat them (.) like all the root vegetables and stuff, when I made the food for myself, but I found it really hard to throw them away, because I hate wasting food. Erm, yeah probably my personality and I probably have a bit of a cavalier attitude towards like (..) er, like making decisions about my lifestyle, like valuing fun more than (..), yeah? So, maybe that’s erm (..) symptomatic of me as a person as well, yeah?

I: Yeah.

P: But that’s probably a lot of people isn’t it really?

I: Yeah definitely. Erm, so what, what were your feelings then when eating the modified foods?

P: Erm (..) mostly I really enjoyed it to be honest. Erm (.), yeah there was that one meal where it was really unpleasant. Most of the meals were just, you know, things I already eat anyway really. Erm, but maybe normally I would, there would be one crispy element to it, which I didn’t have or I replaced with something else. I think, to be honest, I think I’m pretty flexible about what I eat, you know (…), in general I think.

I: Do you think that that helped you? Being flexible?

P: That’s interesting, yeah. Erm (…) I think I’m used to restricting my diet really. So I don’t (…), like on Monday I was like, or was it Tuesday? Basically I ended up a bit busy

Annotations

Perhaps there is difficulty in fully complying with the diet when there is no risk?

P has insight into how she would react if she had to follow guidelines. Talks about “evading” instruction from others.

“hate”= strong emotive word

P values ‘fun” and quality of life

Did P experience enjoyment as she didn’t change the foods that she regularly ate?

Maybe being flexible helps

Themes

Control

Wasting food

Personality

Regular diet

127

in the evening when I didn’t think I was gonna be, and at lunchtime one time as well, and I thought, “ah I could get food you know, elsewhere, ” and I couldn’t. It was really hard to get cold food. It was practically impossible out and about, yeah. But then, it’s easy obviously to get vegan food, but you know, there’s been many a time in my life when I’ve not been able to eat anything and it’s like, “well you know it can wait until tomorrow.” I’d rather go hungry so (.), maybe I don’t mind. I think maybe, maybe probably a lot of times maybe I’d think, maybe I’d rather not eat, than eat something I didn’t enjoy, or didn’t want. That could be an issue for patients. I think probably a lot of people would do that. Just stop eating as much if they weren’t enjoying, if they really enjoyed…I mean the thing is, I think what makes food satisfying, is a mix of textures really. I think that’s erm (.) everyone’s got different ideas about it really, but I think that’s what makes food enjoyable. So I can definitely imagine people (.), a lot of people, especially if you like smoke or drink, or like coffee, I mean you could just…I did make a point of eating normal meals because I wanted to try a different range of stuff, but I could have very easily just (.) had coffee and had a fag and whatever and erm (…), just not.

I: Do you feel that’s what patients then, might do?

P: Some would wouldn’t they? Yeah. Especially, I suppose, the thing is most patients would be having thickener. I mean that would have been…I would have found that really hard if you were having thickened drinks as well. Yeah, so I mean that would, if you didn’t have the option of having a coffee instead, it would be hard, wouldn’t it?

I: If it was all aspects of diet?

P: Oh yeah, yeah. I mean, I did find that drinks to be like a really lovely, safe refuge from just, ‘cos you could just drink whatever you wanted. But if it had been thickened as well, I think I would have definitely been really dehydrated I think.

I: Right, yeah, yeah. I just want to go back because you said, you said about difficulties getting food out and about. Can you just tell me a little bit more about that?

P: Yeah. To be honest, I’m gonna have to look at my thing again because I don’t really remember what I do day to day, but… So (.) for example on Monday, I hadn’t planned food and I got erm, food at uni. And erm, the rice, and I was just hungry. I suppose that just contradicts what I said before, I was just hungry, I just bought it anyway. But I did think the rice looked good but it wasn’t really fork-mashable. But to be honest, had I, had I not been vegan, I think it would have been really easy to get hot food in the canteen. It would

Annotations

Talks about difficulties getting food out and about

Interesting that P would rather skip meals than eat something unpleasant or un-appealing

Textures are important-perhaps for the sensory aspect

Insight into how patients may choose to go hungry

Interesting way to describe drinks -“lovely safe refuge”. Perhaps as P experienced a sense of freedom when choosing drinks

P feels that as she was vegan, she was further restricted

Themes

Difficulties

buying food

out and about

Going hungry

Sensory

appeal of

textures

Going hungry

128

have been much easier. Erm and then in terms of the daytime (.)yeah I mean I just noticed when you go in like Tescos or whatever, there’s not sandwiches, salads. What other things could you get? You could get a banana couldn’t you? You could get a banana, you could get…

I: Some thick yoghurts I suppose?

P: Yeah you could get yoghurt. I mean it’s not very calorific though is it? That’s the thing, you miss out like, the carbs quite a lot don’t you? If you eat on the go, you miss out the carbs and you’re not really eating any calories. I suppose for somebody else who was basing their diet around like animal products, then you might still get the calories. I mean, you’d be low on fibre though wouldn’t you? Erm, and then what other…? And then in the evening, as well, I thought, erm (.), I did kind of consider, for a second, eating sort of on the go food, and I was like, “there’s not somewhere I can get a vegan takeaway which is fork mashable right now.” I mean it wasn’t a big deal, but I did think, I mean, I don’t know, I’m trying to think, if you weren’t vegan, what takeaway food you could eat. I haven’t really thought about this to be honest. There’s not (..), can you think of anything? I can’t.

I: It’s difficult. I mean I suppose, like, a curry, maybe but then, you’d have to make sure it was (..) thick enough (..), soft enough.

P: Yeah I mean like on chippy lane or something.

I: Yeah, it’s slightly…

P: Pizzas, kebabs. What else do people get down there? I can’t think of anything that you could.

I: You could probably take the fish out of the batter and make sure it was soft enough.

P: Take the fish out of the batter, and mix it with curry sauce or something. Obviously not something I would eat, so, yeah very hard to do that. I mean I don’t know how, I mean that’s a massive assumption on my part, I don’t know how many people are likely to be out drinking and only eating at like three in the morning or whatever, so.

I: But then younger people can have dysphagia.

P: Of course, yeah. I mean it probably doesn’t represent everybody but, everybody likes to have takeaway food don’t they? So, yeah that would be a difficulty. Yeah, it definitely would be difficult for them. It’s just annoying to feel like you can’t go out. Yeah, I mean, I think I’m used to it, but I think a lot of people find restriction a bit annoying, don’t they? In terms of food.

Annotations

Lists restrictions when purchasing food out and about

P talks about potential impacts to healthy eating if you chose to eat on the go, due to limited food choices available

Limited vegan, takeaway options

Restriction for vegans

P is talking about an impact on social life. Perhaps patients would restrict going out for food because of the limited choices available

Themes

Difficulties

buying food

out and about

Changes to

healthy eating

Challenges

with take-

away

Challenges

with take-

away

Challenges

with take-

away

129

I: Yeah, yeah. So, you mentioned that you are vegan, so do you feel that that helped you then in…

P: I’ve put here (looks at food diary), oh actually that’s a point, I can tell you that later. Well, I forgot what I said here about it. But I literally answered your question (.), I said, if you (.) it’s hard, I found it really hard (.) because there’s not, there wasn’t a reason why I needed to do it, do you know what I mean? It wasn’t like, although obviously there’s a reason in that I wanted to simulate the experience and it was your project, one of those things. But it wasn’t like (..), like I almost think I couldn’t do like a weight loss diet or something. It’s easier when you’ve got a reason to do it, you know. But there wasn’t really like, and also there wasn’t an actual risk to me, but maybe if I had that actual risk to me it would be different, but more scary obviously, not in a good way different but um…Do you know what I mean? But it wasn’t like, you know, I feel like anyone’s gonna die if I (..) ate a bit of crispy bit on my sausage or whatever, do you know what I mean? Does that make sense?

I: Yes. So, just to sort of clarify my question. So where you said you’re vegan and you’re used to restricting certain foods, do you feel that that helped you maybe? With restricting textures?

P: Yeah. I suppose I’ve got more of a, I’m used to every time I eat, when I haven’t prepared it myself, thinking about, “is this?” Do you know what I mean? There’s an element of familiarity to that yeah. But I think it’s different because you don’t (.), it’s easy to, if you’ve got a reason to do something, it’s easy. If you haven’t got a good motivation (..), it’s hard, isn’t it? In a way not really comparable, but yeah.

I: Yes, yes. I understand. Ok, and what do you think your appreciation of food was like during the four days?

P: Hm, I was looking at this earlier and I realised that I rated most of the food either nine or ten out of ten, so (..) quite good really. Erm, once I’d planned, I mean it might be because I put so much er (laughs), so much er flavour and everything, so I was like, “mm”. Obviously I try normally to avoid food, like unhealthy food, so maybe that’s why I got so much out of it! But part of me feels a little bit gutted that those little chocolate pudding things came in a little four pack, so I had one each evening, and I ate the last one last night and I was like, “oh I’m gonna miss this, like, this was enjoyable!” But yeah, erm, yeah, I genuinely enjoyed it apart from what I mentioned earlier, that one blended meal which was really unpleasant actually. It was porridge. Don’t do that. I don’t recommend it!

Annotations

Motivation to comply on this particular trial was challenging due to P not being at risk. No clinical reason to restrict foods.

Restriction is “easier” when you are motivated to do it for a certain cause

“gonna die”- strong imagery created here

P is familiar with restriction, but it is not the same experience. Motivated to restrict her diet for veganism, but no motivation to restrict her diet for texture modification

P stresses the word “genuinely” to show sincerity.

Themes

Control

Control

Compensation

130

I: So what do you think comes into making it nine out of ten, what you’ve put there? What comes into getting it to a higher rating?

P: I think it was (..) erm (…), I don’t know. I had food that was quite flavourful (..) and (.) I saw it as a treat, I tried to focus on things, the same things that you always do you when you restrict your diet really, focus on the things that you do have and how much you appreciate them. Erm (…) yeah, like not thinking about the other things, just appreciating the things that you do have. And erm (.), yeah I did put more flavour in all my food as well, and I normally try and avoid oil and salt and processed food and stuff, so it was a bit like, “mm this is great!” Yeah (laughs), it probably wasn’t the point of the project really, but I did…It was kind of necessary though because the first time I ate, the first few times I ate, I really did notice the difference between having peas on your plate and having blended peas on your plate. I don’t know what it is, but it’s just not the same experience. It tastes quite sickeningly bland. I don’t know if, yeah, it is quite sickeningly bland unless it’s…I don’t know why but it’s not enjoyable (.) unless it’s er, it needs to compensate I guess.

I: Ok, and you did that with the flavours.

P: The flavour, yeah. One of the things I ate was like er, it was like a macaroni cauliflower cheese (..) erm (.) and normally I would bake that so it would be like crispy on top, like some kind of like breadcrumb or cracker topping. Do you know what I mean? But obviously you couldn’t have that bit (.) and so it was just uniform, you know? And it’s not as enjoyable. So I did more, more, whatever I put in it, like mustard or whatever it was, you know, so it was more… Do you know what I mean?

I: Yeah, yeah. Ok, and what were your experiences with compliance over the four days? You did mention about the chocolate.

P: Yeah, the chocolate, it was just totally accidental! But then after I realised, I did still eat it, so then that’s deliberate non-compliance, isn’t it really? Erm, what else? What was the other thing that I didn’t comply with? Oh I tell you what I forgot to mention as well, I had a (.), I soaked (.) alpro, I soaked er oats and flax into my yoghurt (.) to have later because, I basically just felt like, and it’s a bit of another issue really, but I felt like it was really hard to include the things in my diet that made my diet healthy! Really hard and really challenging! So I just felt like I wasn’t really getting enough fibre or enough (.) just calories in really, erm (.) and just enough carbs in. It was hard to get, you know, enough in. So I was like, “ok, I’ll, I need to eat this flax, so I’ll just soak it in the yoghurt”, and erm I soaked the oats in there as

Annotations

Interesting that P viewed the food as a “treat”. Perhaps it is helpful to focus on the positives when eating modified foods and to view it as appealing, rather than focus on the negatives.

Did try and compensate by adding additional flavour. Change from regular diet.

“sickeningly”= strong adverb repeated twice. Emphasises how P viewed modified food without additional flavouring

Eating the same texture is not the same experience. Compensated by adding flavour

Un-intentional non-compliance, but made the decision to continue.

Stresses “hard” and “challenging”= shows that it was a real difficulty.

According to P, the modified diet restricted her ability to eat all of her nutritional requirements

Themes

Focus on the

positive

Compensation

Sensory

appeal

Absent-

mindedness

Changes to

healthy eating

131

well and there were some that were near the top that hadn’t fully soaked. So you know like if you soak it for a long time it will basically dissolve, but there was like a little bit that was a little bit bitty, and I was like, “if I was actually on a fork-mashable diet that could…” The thing is, it’s not (.), it’s not so much that, this made me realise this is really useful to me as the, erm, if I was to ever work in dysphagia, the reason it’s really useful to me should have been obvious, never occurred to me, is that, ok it might be difficult for people to cope with (.) lumps in their food (.), but if you’re not anticipating, if you already have that difficulty and then layer on top of that, you’re expecting smooth food, and then you’re not anticipating a lump, then the lump causes you more problems. Do you see what I’m saying? And that should have occurred to me before, but it didn’t occur to me until I was trying it and there was a bit of a lump in the food. And obviously I have normal, thank god, I’ve got normal swallowing abilities, and (..) we all have had that experience, the food’s not a texture you anticipate and it’s you know, “blugh”. And I had that experience, and I think, yeah, it makes you realise that, and I don’t know if there’s effect where you, you know, when you start wearing glasses (..), if you start eating the food that’s the right texture for you, and you’re not anticipating it, you probably struggle even more with lumps if there are any, don’t you? ‘Cos you’re not expecting it to be there. So that was interesting. Does that answer the question?

I: Yeah, definitely. I just wanted to go back, ‘cos you said that there were components in your diet that you said that you couldn’t have. Why was that? Could you just explain?

P: Yeah. So I mean, that was another thing, I don’t know if that counted, I didn’t think about it, but is taking tablets fork-mashable? It’s not is it? ‘Cos I still took my pills every day.

I: Yeah, I mean with this study in particular, obviously I wasn’t looking at medication. But erm, I think there would be doctors and other people involved to sort of look at that.

P: But it’s annoying ‘cos some things obviously if it’s your medication for you know, ‘cos you just had a stroke or something, then (.) but then, I take a supplement. So (.) are you gonna get (.), I mean you can buy supplements in non-pill form but it’s more expensive, it’s more difficult to get hold of. If you’re anything like me you’d probably stock pile them, you’ve got loads in your house, I mean you might not comply with that. The other thing that I eat every day is (..) erm (.) I (.) I (.) generally eat either hemp oil or (.) some kind of seeds that are really high in omega three every day. And (.) this (.), it was difficult as I had to use the oil basically in everything because it was difficult to get the flax

Annotations

Talks about her learning- an insight into what patients may experience based on her experience

Uses lots of word stress here to signify her point

“blugh”= sound used to show how P felt when eating a texture not anticipated

P questions whether people with dysphagia may be restricted in taking supplements for their health, or incur additional expenses to have the non-pill form

P views it as a potential cause of non-compliance

Themes

Un-anticipated

texture

Understanding

of non-

complaince

132

in instead, yeah. And greens, that was really hard to get. I didn’t eat any greens the whole time.

I: Right ok, ok. And that would be normal for you to eat lots of greens?

P: So normally I try to eat at least three cups of dark, leafy greens a day. So (.), I mean I blended (.), I mean I had a smoothie every day. I mean, I don’t know how you could do it healthily, if you didn’t have a blender, god help you, I don’t know how people do it. Like, you know, I think if you, if you were unable to acquire some kind of blender, I mean, I’d say good quality blender as well, it would be really difficult to enjoy. Firstly to have nice food, secondly to eat healthily. I think it would be really hard. I mean I basically ate nearly all of my fresh fruit and vegetables, non-root vegetable intake through smoothies basically. I don’t think it would have been possible otherwise to be honest. It would have been really hard.

I: Ok, so do you think because it wasn’t suitable as a fork-mashable texture?

P: Yeah.

I: Ok, so you blended to make sure…

P: I don’t know, maybe I misunderstood that but I can’t think how you could have eaten, or at least enjoyably eaten any (.), really any vegetables, could you? I don’t know, is there anything you could eat? There’s not really is there?

I: There’s things like carrots and broccoli that you can…

P: But really over-cooked. I had like over-cooked cauliflower in that macaroni and cauliflower cheese. That was fine. But I mean, cauliflower’s, and obviously I had lots of flavour on it, but nobody enjoys over-cooked vegetables, do they?

I: With this diet, it does have to be really, really soft, yeah. To make sure that you can mash it.

P: Really, really soft, yeah. But it’s not nice is it? I think if it’s blended into things, it’s much more enjoyable for me. Isn’t it?

I: Right ok, yeah, yeah. And, what did you feel about your whole lifestyle during the four days?

P: Mm (…), aside from (.) not eating things that I would have liked to have eaten (.), not really affected. But I mean, obviously four days isn’t it? But erm (…) not, to be honest, for me personally (..) not massive. But I can definitely see how it would for other people and I’m (.) aware in spending a lot of my time trying to encourage people to change the way they eat (..), I can (.), I’m aware that food can (.), the

Annotations

Restricted in eating some vegetables

“god help you”= signifies that P found it essential to blend foods

Struggled with fruit/veg intake unless blended

Stresses “any”= implies how significant P found the diet restrictions

Stresses “nice”. P did not enjoy the texture of vegetables on this diet

Not much impact

Insight into how it can affect patients

Themes

Changes to

healthy eating

Changes to

healthy eating

Changes to

healthy eating

Sensory

appeal of

textures

Sensory

appeal of

textures

133

idea of restricting food carries a lot of emotional weight for a lot of people. And (.) erm, people are extremely erm, resistant, and find it really upsetting to feel like they can’t eat things that they want to eat. Especially if people have ever experienced any kind of hunger or (.) food being used to punish or praise them as a child, people find it really, and I do appreciate that that would be (..) a challenge for a lot of people in a way that, I’m really lucky that food doesn’t really hold that role in my life. But yeah, I can definitely appreciate that you know, like, I know a lot of people and I care about a lot of people, and I’ve worked with a lot of people who’ve really, really struggled emotionally, psychologically to detach themselves from food. And I can really, and I don’t mean to sound, like un-empathetic by saying that it didn’t affect me hugely.

I: Well, it’s an individual thing though isn’t it, food. For everybody.

P: But I can see how it would be upsetting for others. One thing that did happen which made me laugh is that I like, my mother called me and she was like, “ah, what do you want,” it’s a bone of contention really to be honest, but she was like, “ah what do you want to have for Christmas dinner? Blah blah blah. What are you gonna make? Is it going to take up my oven space? Can it be something that everyone else eats? Blah blah blah blah blah.” And erm, I found myself getting really irritated by it, like, I want to have this, I don’t want to have that, and (.) I mean it’s something that I will probably argue about (laughs) anyway to be honest but I think, I did think, maybe I’m feeling extra cagey about this because, do you know what I mean? (Laughs.) Silly, anyway, but yeah.

I: So things like social life, and things like that, how were they?

P: Erm (…) to be honest, I don’t massively care (…), probably a personality fault of mine, as I don’t care what people think (.) about the things that I’m doing (laughs). So (.), I wasn’t really that bothered, but I can totally appreciate that other people (.) would.

I: Yeah. Brilliant. And what, what were you feeling when you ate modified food when others were eating normally?

P: Erm (.) again (..) wasn’t hugely bothered to be honest. I found it quite convenient really because (..), this is incredibly lazy, but I kind of ended up eating everything with a spoon. And like, when I had like soup or like, or what sort of meals, like for breakfast, I had like a can of chopped tomatoes and I like buttered and chopped up toast and like soaked it in there, so it was like, rather than having to like dip it and (.) yeah, you just kind of ate everything with a

Annotations

Talks about her understanding of emotional connections with food

Stresses “emotionally” and “psychologically” to signify how she has experienced other people’s connections with food. P has insight into how some people may find food restriction challenging

“blah blah blah”= shows possible irritation

P doesn’t explain why she felt “extra cagey”. Possibly, she felt more sensitive, or felt more emotional when talking about food on the trial?

P may be talking about the fact that she is resilient, so social life was not affected

Themes

Emotional

connection

with food

Emotional

connection

with food

Personality

134

spoon (laughs). So, to be honest, I don’t think it was hugely noticeable to anybody. But maybe it would be for other people. Er, (.) I mean I didn’t, what I didn’t do was you, know, everybody was having (..) I don’t know roast beef and jacket potatoes and I had the same thing but it was (.) blended and then really, I didn’t do anything like that. Erm (.) but to be honest, I think maybe a little bit of those boundaries of (.) refusing to eat what others are eating, eating other things around people, are a little bit broken for me, so, yeah. I’m not sure maybe, trying to remember if I’ve ever found that difficult, possibly in the past. But I can imagine it being difficult, I mean I know a lot of other people find that difficult.

I: Yeah, yeah. So did you have any reactions at all from anybody?

P: I ate a few meals, no. Most of the things, I think probably, the thing is about the food (..), I’d probably, apart from that porridge, I principally ate things that were basically fork-mashable anyway, so they didn’t look that unusual. Erm (...) didn’t really, if I had, I don’t think I would have really remembered or noticed, to be honest.

I: Do you think it helped that it didn’t look that unusual, for the lack of reaction?

P: Maybe? I mean I eat a lot of things that people don’t like the look of anyway! (Laughs.) But for myself, for my own personal enjoyment, I know that the look of something, if it doesn’t look very nice, it’s not appealing. So for example, that porridge didn’t look very nice and like sometimes if I have a smoothie, I don’t like to have red fruit because I put greens in my smoothie (.) and it goes brown, and it tastes delicious, but it looks horrible! And I don’t enjoy it, so, maybe more for my own reaction than for others. Maybe I didn’t spend enough time with others to really fully gauge (.) whether they would have got…It was a bit infantilising though obviously, you do feel like a child. Yeah it reminded me very much of (.), ‘cos I’m a nanny and you look after children, the way that you, the way that I was monitoring the food, reminded me very much of how I would monitor it for a child, for a very small, you know, for a six month old or something. Yeah, and I found myself feeding myself all the things that I would feed that baby, this particular baby who I looked after who was about, at the time, was like six months or something. And I was like, “ok I’ll have a sweet, cook a sweet potato and I’ll spoon out the skin and blend some peas up and…”, you know. All the things! And I’ve seen this meal before and it’s because I’ve fed it to, you know.

Annotations

P was not aware of anyone viewing her food differently. This could be because she received no reactions, or because she wasn’t looking for them as it didn’t bother her

Can see how it would be challenging for others= insight

Helped that the food was similar to food in P’s regular diet.

P is not concerned with what others think

Sensory appeal-the look of food is important

“infantilising” = interesting term to use. Felt as if she was being treated like a child.

Relates to past experience of feeding a baby and compares it to eating a modified diet

Themes

Regular diet

Feeling

infantile

135

I: So, do you think it took a lot more thought then, whilst you were preparing the food?

P: Not more than I would generally put into food really ‘cos (.), no not particularly, to be honest. But maybe it would over time, if I was doing it for longer.

I: Yeah, yeah, ok. What do you feel that you learnt from doing the four day trial?

P: Erm (.) I think I learnt that, how easy, easy it was in practice to slip up, I kind of predicted that to be honest, but (.) having a little bit of simulating that experience of how easy, and how frequently it would be the best attempt, wouldn’t quite be there. It would be you know, there would be an element of it that was not fork-mashable. And (…) and that if you (..) if you, yeah if you’re not anticipating the lump then it’s more problematic than if you knew there was a lump in the first place. That’s quite, that was quite a big (.) sort of realisation for me. Erm, what other things? I wrote down a bunch of stuff to be honest. Do you mind if I look at this, otherwise I’m not gonna remember? (Looks at food diary). Erm, that it was difficult, especially if you don’t like, I don’t like wasting food, it was really difficult for me to waste food. I found that really…in fact, when you asked me to do it, I planned when I wanted to do it, based on when I knew when my food was going to run out that I already had, ‘cos I didn’t want to waste any of it. So (..) that, if I lived on my own and someone told me, I would not be willing to waste the food, do you know what I mean? Do you know what I’m saying?

I: Yes, definitely.

P: So, that would come up for me. Erm, yeah, hard to leave food on the plate, hard to refuse it if someone presents it to you. I’m sure people would spend more money, at least in the interim stage of deciding what they liked and how to do it. I ate less healthy food, I felt like I ate hardly any vegetables, even though all I eat is vegetables. Erm (..) yeah, couldn’t get a sandwich or anything in a shop, that was a bit annoying. Easier to eat sweet food than savoury food. I wrote that down. It’s like, you know, on the go, whatever you could get, a yoghurt or a pudding is easier to get otherwise it’s a cold soup, you know some people would enjoy that, others wouldn’t. I’d really craved crunchy food a lot. I’d dreamt about it. Erm (.) like in fact, I can’t remember which, but I spoke to somebody else, and she said to me, “ah I’m really craving a stir fry today”, and I was like, “me too!” I’d literally woken up cycling in and was like, “I could murder a stir fry!” Like it’s that mixed texture, isn’t it? It’s like really crunchy! Erm (…) oh yeah, I said about having an argument with my mum, and (..) it’s

Annotations

Repeats “easy”- to emphasise how difficult it can be to fully comply

Repeats about finding a lump when it was not expected-this seems to be a key learning experience

Interesting that the trial was planned according to when food ran out. Clearly, it is important to P to not waste food.

Refusing food is challenging

Cost implications

Repeats about healthy eating-another important factor for P

Interesting that sweet food is easier to modify

“I could murder a story fry!”= strong use of phrase to emphasise how much P craved mixed texture

Themes

Regular diet

Understanding

of non-

compliance

Un-anticipated

texture

Wasting food

Cost

implications

Changes to

healthy eating

Restriction

136

really difficult to tolerate the waste. I hated throwing away the skins and stuff because that’s where all the nutrients are as well! Erm (.) yeah and just, the impact of motivation, like, there was no ethical motivation to do it, which made it harder than other things I restrict. Oh yeah and one day I woke up late, and it did require a tiny bit more, maybe I was wrong when you asked that question before, ‘was it more effort’. It, normally, I could just have a bowl of cereal or something but I (..) I didn’t because (.) erm, it required a bit more prep. Yeah, yeah I think everything else I’ve already mentioned it. Yeah, I’ve put here I think I could eat sleep and breathe root vegetables!

(LAUGHTER)

I: Over the four days? Ah that’s really good that you’ve put comments on the diary actually.

P: Well I knew that I’m really bad at remembering, so to be honest, I was like, “oh I’m not gonna remember otherwise!” But yeah I did, I felt like, I mean I like, it’s also autumn right now. So (.) comfort food is often smooth, hot food is more often smooth. Erm (.) there are a lot of, you feel like eating root vegetables (.) you can eat like stuffing and things like that if you want like… I don’t know whether I’d feel the same about it in spring and summer.

I: When it’s more salads and…

P: Yeah! It’s (..) hard, isn’t it? I think it would be much harder to do it in (.), maybe people struggle to do it at Christmas as well, or whatever, you know celebrations they have, Eid or whatever, when you have special food, harder to resist, that would be difficult. To be honest, I think that the main thing, I mean (..) I thought, when I first heard about dysphagia, at uni I thought (..), “I bet no one follows that advice, or I bet compliance is poor,” and (..) as a lot of people say, I said that, you know, “I don’t think I’d comply,” and I think… I don’t think I meant that in an unsympathetic way, like, “oh I wouldn’t bother doing that,” like I didn’t care about the fact it was a risk, I just know that I take a lot of risks. Do you know what I mean? I mean I do, I, you know, I don’t think I would comply that well to be honest.

I: If you had to follow a modified diet?

P: I think I would struggle to comply. I think I would struggle to comply with it. Not at all but consistently. And I think, I don’t know I haven’t looked at the evidence, but I would, I would be surprised if everybody manages to comply with every part of every meal, every day. Like my father has, he’s got like diet recommendations, because of his (.) conditions, and it’s not dysphagia related, but he, there are ways in which he complies and there are ways in which he doesn’t. And I think (..) it’s

Themes

Wasting food

Increased

preparation

Understanding

of non-

compliance

Understanding

of non-

compliance

Annotations

“hated”= strong use of verb. Again shows how significant it was for P to throw away food

Has now realised whilst talking that prep time was longer

“eat, sleep and breathe root vegetables”= strong imagery created here. Perhaps P is trying to show how there was a lack of variety in a modified diet

Different times of the year may have an impact

Talks about the cultural and social significance of food

P has insight into how she would comply if she was on the diet permanently

Repeats “every”- to show how she feels that compliance would not be consistent in patients

137

likely to be the case. Especially if you’re not aware of (.), you know, some people when they choke, and it’s unpleasant for them (.) some people that’s not the case is it?

I: And how do you think that you can apply this learning to your future practice if you went down the route of being a dysphagia therapist?

P: Erm (..) I (.) would (...), difficult to say. I have thought about that a bit and I have found it hard to say to be honest with you. I (..), I personally feel, I mean everyone’s different aren’t they? Everyone’s different. I feel like there tends to be quite a lot of emphasis on how you can make things you enjoy (..) fork-mashable (.) or make things thick or whatever it is, and (.) that (.) there’s that. But some of those things that are adapted are quite (..), not that enjoyable and it’s nice to, and I wouldn’t, not that I would tell people, “oh you should do this, you should do that,” but (.), I think just the idea that, “oh god I’ve got to blend all my normal food,” is not great. I personally got more value out of eating things that lent themselves to being mashable. But then obviously you don’t want people to give up things that they like best. But it’s a lot like, let’s say you were gluten free, or let’s say you were vegetarian or whatever, you know, there’s an argument that you can buy Quorn bacon, and you can buy…And there’s another argument that maybe you should eat more lentils and try, do you know what I mean? I guess (.) that you can draw that comparison. I mean I wouldn’t clinically, but you can draw that comparison a little bit. And (..) I suppose it would be really, I suppose if it was me and I was a patient, it would be really nice (..), like these guidelines (looks at guidelines), they they’re really useful because they give you, they tell you exactly about the texture. It was really nice to have this example menu type thing. But I think I’d really like to have like recipes. Maybe they do do that in clinical practice but maybe like recipe books or something? Maybe not even recipe books, but like meal idea books, with loads of pictures and like loads, so you can just see like an abundance of things that you can eat. Do you know what I mean? I don’t know, do they already do that? They probably do, don’t they?

I: There are leaflets with meal ideas and things but in terms of, booklets just dedicated to meal ideas, I’m not certain.

P: I would love it, I think if it was me, as a clinician, I’d feel much better about giving people the advice to do that. If (..), I felt like I could proper give them like a proper cookbook just ram packed full of , and not just like, blend your cottage pie, like, eat sausages without the skins on, proper meals that people actually like which aren’t like, twenty years… Because they do tend to be a bit retrospective, and I think,

Annotations

P has learnt that it is not necessarily pleasant to adapt your regular diet, and is better to change some of the food options so that they are more appealing when modified

Draws a comparison between becoming vegetarian and following a modified diet to show that there are two sides to the argument- adapt your regular food or change your foods

Providing patients with meal ideas

Confidence in providing diet recommendations would increase if she could provide patients with meal ideas

Themes

Adaptability

Practical

solutions

Practical

solutions

138

sometimes I think that people have a view of older people, especially (.) that all they want to eat is like (..) casserole, and like mashed potatoes. And I don’t know about you, but I don’t find that to be true in the people I know, you know? So (..) it would be nice to feel like you have an abundant, lots of things you can eat, I think. Erm (.) what else? Maybe just appreciation that it’s unlikely, but I guess maybe, I don’t know what the clinical advice would be, but maybe you need to (.) really, really stress the safety element. Because whatever advice you’re gonna give people they can (.) they can meet you halfway. Do you know what I mean? So maybe you have to be quite, hard line about it. Stress the dangers. I don’t know to be honest. I need to think about that more. That’s probably not a very good answer.

I: No, no, that’s perfect thank-you. And yeah, finally do you think that it’s a useful task for future SLT students?

P: Erm (…) yeah. I do, I think. I think I do. And I think erm (…) maybe even for longer.

I: Do you think that four days wasn’t enough time?

P: Yeah, not really because I could just not eat for four days. Do you know what I mean? I mean everyone’s different, but I mean you know, if I had to eat only apples for two weeks, I think I could. And everyone’s different but (.) I don’t know, I mean we probably did this in like year one, and I don’t remember it, but maybe it might be a good idea as an exercise in class to (.) maybe in addition to this, or as well as this (.), to ask people to write a meal plan of what they would eat for the next month or something.

I: On a modified diet?

P: On a modified diet, on a particular modified diet, for them personally. And for them to, I don’t know, spend fifteen minutes thinking or thinking about fifteen dinners and ten lunches and five breakfasts that they would generate to eat. Actually, to be honest, maybe that’s clinically, if somebody was struggling with dysphagia (.) or, I don’t mean struggling with dysphagia but struggling with adhering to a modified diet, or (.) finding it really difficult to (..) accept it, or think about what they’re gonna eat, I might ask, I might like do exercises around like brainstorming (.) erm, ideas about what they can eat. What meals they would enjoy. What things go nicely together. I don’t know if there’s any support, are there any websites or anything online where people share recipes on modified textures?

I: I found one actually, yeah.

P: Yeah, that would be nice.

Annotations

There are assumptions that older people prefer certain foods

Make it clear to patients as to why they are on the diet

P has an idea of what can help students in the future

Repeats about generating meal ideas- this is a clear learning point

Themes

Practical

solutions

Emphasising

safety

Helping

students

Helping

students

Practical

solutions

139

I: So future SLTs in terms of the training, do you mean like a brainstorming session?

P: Yeah or even potentially with patients. Yes, so for SLTs to be able to do that and maybe for patients to do that because it can be…I mean maybe I’m relating it too much to my own experience of restricting my diet, but that was important for me.

P: But no it’s about you and your experience.

I: Yeah. I think that’s something that I would encourage people to do (..) when they’re thinking about changing their diet. I think people have that experience whatever the change is, whether it’s not gonna eat bread anymore or not gonna eat sugar anymore, thinking, “oh my god what am I going to eat? How is this going to affect all my food? I can’t eat this, how can I change this, how can I change that?” And sometimes I think it’s useful for me, I advise people, I think people generally find it useful to think about, “what can I eat, what things do go together? What are extra things can I try that I wasn’t eating before?” Erm (.) so you’re not thinking about a restriction mind-set but you’re thinking about a new, positive…I might, I mean clinically, I might really stress the positives of it, and why it’s so good and how many lovely things there are. Just be really positive about it. And I know that sounds possibly a bit insensitive about the information that you’re giving people, but I think you do need to present changes people need to make in their life in a way that (.) not so much like, “oh this is gonna be great for you,” but, “food will be really enjoyable, there’s loads of lovely food.” Do you know what I mean? Especially if people aren’t used to restricting their food in any way, I think. Do you know what I mean? I don’t know really to be honest. I’m so sorry Sam! I’m just blabbering!

I: No that’s brilliant, that’s brilliant. No, it was about, do you think it’s useful for future SLTs?

P: I think it is, I think it is useful, I think it is useful. I think, I would be really interested to hear what other people’s experiences were as well. People who have different food preferences as well. Because there’s some textures that I basically never eat as well, that I wasn’t missing that other people might. Like the other day, not like during this, but recently I ate like a (.) toffee or something (.) and I was eating it, and I was like, “oh this is really weird!” Because I hadn’t had anything chewy, like proper, really chewy. Do you know what I mean? Like really tough and chewy, proper chewy for years, and I wonder if, some people eat steak or something every day and they’re us*, and my, my teeth were really tire*, I felt my jaw was really tired. I wasn’t used to eating things like that. And I wonder, I was missing crispy

Annotations

Believes people may feel panic when they are about to undergo change

Repeats “positive”. P feels that helping patients to view the positives would help them to adjust

Would like to collaborate with other students

Themes

Focus on the

positive

140

textures or crunchy textures (..) other people might really miss, I mean, people say that don’t they, they really miss the texture of meat, don’t they? So, some people might, I mean that’s a whole other ball game of things that people are cutting out. Isn’t it? Which I mean, I’m definitely aware, in a way I feel I couldn’t have this full experience that other participants will have had because I think (..) more of what they might of normally eat (.) was off bounds. Do you know what I mean? So in a way I feel like I’m a bad…I’d be interested to know how other people feel about it.

I: Ok. Just for sharing and finding out.

P: Yeah, just because it’s interesting and I imagine it would be a really useful learning experience for a lot of people.

I: That’s great. Ah, thank you for your participation!

P: Thank-you so much! Thank-you.



Annotations

Can see how people would miss different textures. Talks about this being different for individual-depending on their regular diet

Themes

Restriction

141


I: Thank-you so much for taking part in the four day trial. Just to let you know that this interview is going to be recorded. Are you happy to go ahead with that?

P: Yeah, yeah, that’s fine.

I: Basically everything you say is entirely confidential, and you’re known as participant four, so you are anonymous as well within the study. Is that alright?

P: Ok. Alright.

I: Ok, so if you could just start by telling me, what were your feelings about the trial before you started it?

P: Um, I think I was quite apprehensive (.) because (.) I think when I first thought about it, I was like, “yeah that will be fine because it’s only pre, it’s only texture E.” I thought that’s the least modified, it can’t be that hard, and then when I started thinking about actually what I would do, then I was like, “oh no, there’s not much I can eat, compared to what I normally do eat.” So it was when I, when I started thinking about the logistics about what I could eat for every meal, I was like, “ah no! There’s not that much, as much as I thought!” I thought it would be easier than it would be.

I: Right ok, so did that change happen closer to…

P: Closer to the time, yeah. I think when I sat down and thought, “ok, what am I gonna buy for this week,” food shopping, I was like, “ah, I can’t have like salads for lunch, I can’t have sandwiches for lunch,” and then thinking about what I could have. I think you forget how much of what you eat isn’t (.) fork-mashable.

I: Yeah, yeah. So, in terms of like your planning and preparation, how did you go about planning and preparing your meals, was there any kind of routine, or strategy?

P: What for, before I started or throughout the time?

I: Before you started or throughout. How was your preparation for the meals?

P: Um (..), so before, I didn’t, I probably should have gone on like a big food shop (.) before, that’s what I normally do. I normally go shopping every week, but I didn’t because (.) I don’t know, I think I just was like, “oh, I’ll just see what I feel like (.) nearer the time.” So I just kind of went on like, little shops, like every other day I think. Just bought, I bought like things that I know I would like, so like yoghurts and (.) things like that, that I knew I could bring out with me, rather than stuff to prepare in the house. And then, I

Themes

Prior

assumptions

Regular diet

Restriction

Lifestyle

changes

Annotations

Concern for un-

known experience

Pre-conceptions of

texture E

“oh no”= suggests a

temporary feeling of

panic

P lists what she

can’t have- did this

make it harder for

her?

Insight into how trial

could have been

planned more

effectively

Choosing foods

according to appeal

and ease of

preparation

142

don’t know what else I did. Probably, yeah I didn’t prepare that much, which I think maybe I should have. So I think it takes a lot more planning. I mean, normally I don’t plan my meals, normally. I just get home and I’m like, “oh, what do I want?” and make something from what I have, whereas I think I tried to do that with this plan, and was like, like, “oh god I can’t eat, I can’t eat anything!” (Laughs.)

I: Oh ok. So you tried to keep your lifestyle the same but then realised…

P: Yeah but it was difficult because everything I had…Or, I’d think of a meal, and then (..) um, or I’d think of part of a meal, so I was gonna make, I bought a butternut squash and I was like, “oh I can roast that and then mash that,” and I bought some like feta cheese, and I was like, “oh that would be nice!” and then, I was like, “that’s not really a meal,” and I couldn’t think of anything else to go with it! So I kept having like, ideas for part of a meal, and then being like, “oh, that’s just kind of like a weird side!” (Laughs.)

I: So what did you do, did you go with your first idea, or did you change your idea completely?

P: Um (.), I never had that in the end (laughs)! Because I just couldn’t think of anything to go with it! I should of just, yeah, I don’t know, then I didn’t fancy it really.

I: Right, ok. So how was it, following the actual guidelines? How did you feel it went, following the texture E guidelines?

P: Um (.), it was ok. Yeah, I think I followed them apart from one meal. I had some beans (laughs) ‘cos I was eating with my friends and we made um (.) cheese and potato pie because they knew that it was something that I could eat and they really like it. So they made, we all made it together, and they were all eating beans and I was like, (gasps) “I really want them!” so I had them as well. Because, that was a similar thing because, cheese and potato pie is not really a meal on its own. So (.) it was one of those things where, I was like, “well, what else does it go with?” I couldn’t think of anything to go with it that was fork-mashable, so then I just had it with beans. So I couldn’t stop myself!

(LAUGHTER)

I: Right ok. So in terms of knowing what was complaint and what wasn’t complaint, did you find…How did you find that?

P: I did, I think, I did have a few (..) questions. Mm (.) yeah I think it was good having the um (.) the sheet, because a few times I did like refer to that, to think (..) about what

Annotations

Emphasis on

“planning”= P feels

planning is

important

Realisation that it is

difficult to stick to

normal routine

P has found it

challenging in

creating meals-

finding suitable

foods to put

together

“Ok”= not overly

positive

Gasp indicates how

P experienced

temptation

Found it difficult to

resist temptation of

what she wanted to

eat

“questions”= un-

certainty when

choosing foods

Themes

Increased

planning and

preparation

Difficulties in

coming up with

meal ideas

Resisting

temptation

Determining

the suitability

of foods

143

was, so I wasn’t. I didn’t know if you were allowed bread if it was dipped into soup, so then I looked at the thing and it said no unless you had a specific, an SLT input. So I didn’t have that. So it was good to have that to refer to. But then (..) some things (.) you do kind of question, and when you’re cooking it, you’re like, “is that soft enough?” and, there was porridge and I was like, “is that, is porridge fine?” because it’s a little bit texturey isn’t it? And, “is that cooked enough?” I think it was more like, “is that cooked enough?” was my question a lot more. Because with like specific things that I could just refer to the sheet (.) but with, when I was preparing and cooking (.), and I was like, “do I need to…Is that sauce thick enough? Do I need to mash that or can I just eat it and it’s mashable in my mouth?”

I: Ok, and was there anything that you did if you were un-sure?

P: Um (..) I’m trying to think. Can I have a look at my food diary? To remind me of what I’ve been eating, I can’t remember (laughs)!

I: Of course you can!

P: Um (…) (looks at food diary) oh yeah I had courgette, I didn’t know if that was allowed, but I just, I mashed up a little bit with my fork and I roasted it (.) but yeah, that was the thing, I looked at the sheet and it wasn’t on there so, I don’t know.

I: So, did you find it harder then, with things that weren’t actually listed on the sheet?

P: Yeah, yeah. I guess actually yeah (.) ‘cos bread was, so when I checked that was (.) and then it gave me the answer. But courgette wasn’t. I guess you can’t list everything. But and I was like, “is it?” ‘cos it kind of has this skin but then it does go quite mashy when you (.) um (.) roast it for a while. Yeah that was the thing I was unsure of, was the courgette ‘cos I knew carrots were fine, I knew sweet potato was fine, because you can mash them completely, can’t you? But courgette, I was like, “I don’t know.” Yeah.

I: So do you think there was sort of a degree of interpretation involved with it?

P: Yeah definitely. I think you have to, yeah. And I think (..), I probably, because I’ve advised people we are, we do study it on the course and that type of thing, we probably have more of an idea than somebody that didn’t, than someone who was just put on this diet, rather than (.) me being an SLT student. So I think it’s probably harder, even harder, I found it hard (.) and whereas I think it would be a lot harder if you had no idea of (.) this diet beforehand. Like I’d heard of this before, I’ve seen the sheets before and (.) advised it before, whereas if you were just given that (.) after a stroke like randomly, I think it would be a lot harder. Mm.

Annotations

Tried to use the

guidelines as a

source of

information

Emphasises

“enough” twice. P

unsure of how much

modification is

required

Uses lots of

questions here

which again,

highlight un-

certainity

Difficulty with

interpretation of

guidelines?

Shows

understanding of

some suitable foods

P has insight into

some of the

difficulties patients’

experience. They

have less knowledge

than SLTs, and even

SLTs can find it

challenging

Themes

Determining

the suitability

of foods

Determining

the suitability

of foods

Determining

the suitability

of foods

144

I: Right, yeah (.) yeah. What were your feelings when you were eating the modified food?

P: Mm (.) I didn’t really like it. It was hard, yeah. I just felt like I didn’t um (.) I didn’t enjoy it, I didn’t enjoy the food that much. I had some things which I like eating. I like yoghurts and (..) um I think one night we had like cake and custard ‘cos I was like, “I’d really like something to have that’s nice.” But a lot of the time, I was just eating, like I had porridge most days I think (.) for breakfast, which had just got a bit boring. I don’t normally have the same thing every day. And then (.) I just had a lot of like (.)um (.) I don’t know, I was just mainly eating, I normally eat a lot of fruit and lots of vegetables, but I was just, the fruit side was a bit more difficult ‘cos I ate, I had bananas, and I had some like tinned peaches, and (.) that type of thing, but a lot of fruit like apples and oranges and (.) like kiwi or whatever. I don’t know, there were lots of fruits which I eat normally which I couldn’t eat, which was (.), and that’s my like go to if I need a snack. So it was trying it think of other things that I could eat really quickly. And (.) then (.) I think I (.) I don’t know, I felt like it was quite hard to eat healthily which wasn’t something I’d thought of before I started. But I normally have like salad for lunch, and then like lots of vegetables for dinner and like not (.), I don’t eat like that many carbs (.) um normally. Just like, not because I’m on a diet but because that’s the food I like eating but then (.) here I felt like I was mainly eating carbs. I could have like porridge for breakfast and like a potato, jacket potato for lunch and then like (.) some type of potato-y pasta-y thing for dinner and it was quite difficult to get vegetables and fruit in, as much as I did beforehand.

I: Right (.) ok (.) ok. So do you feel that your food choices then changed on this diet?

P: Yeah, definitely.

I: Ok. And you said about not really enjoying the modified food, was there anything in particular that you didn’t enjoy? What was it that you didn’t enjoy?

P: Um (.) I think I (.) it’s just different to the food that I normally eat. So I normally have like a lot of stir fries or rice or curry, which was all stuff I found, well maybe you could think of a way to make that texture E, but I couldn’t think of a way. So, I think it was just not the food I would normally choose, was probably the main thing. And then also though, it does get really boring having like (.) texture. I think that kicked in like day three possibly. I think the first days, I was like, “I want to have the food that I prefer” and then I think after a while I was like, “ah I really want something that has a bit of like bite to it,” ‘cos you’re just like, “ttt ttt.” There’s not much work!

I: Right ok. So the sort of sensory feeling?

Annotations

Emphasises “hard”=

stresses how

difficult it was

Emphasises “some”

when trying to see

the positive side,

but shows

resistance to

viewing the positive

Felt restricted in

eating some of her

normal foods

Emphasises

“healthily”=implies

healthy eating is

important

Difficulty in eating

fruit & vegetables.

Easier to eat carbs.

Compares normal

diet to a modified

diet

Different meals

were the biggest

difficulty

Talks about feelings

of boredom towards

eating the same

texture.

“ttt”= sound

emphasises lack of

sensual experience

when chewing

Themes

Lack of

enjoyment

from food

Lack of variety

Changes to

healthy eating

Lack of variety

Changes to

healthy eating

Regular diet

Sensory appeal

of textures

145

P: Yeah, but I think that took lon*. Yeah, the first couple of days I didn’t notice that as much and then, the last, last few, yeah it was the texture. Everything’s the same texture, isn’t it really? Which was quite hard.

I: Yeah. It’s all soft and mashable, everything has to be the same. Yeah. And in terms of like your appreciation, what was your appreciation of food like during the trial?

P: Whether I liked it?

I: Did you appreciate meal times?

P: No, no I don’t think so ‘cos I normally (.) um (.) I normally cook with other people and eat with other people and (.) I am like a big foodie. I really like food so I always think about what I’m going to have for dinner! I always think about, just always think about food. But I just feel like I wasn’t really, I wasn’t that bothered. Like I wasn’t that excited for dinner (.) and (.) I just um (.) like I think one day I didn’t, I think yesterday I didn’t have dinner, just because I didn’t, I just couldn’t be bothered to cook something on my own and then eat on my own and especially because I think it’s something that I knew I wasn’t gonna like that much, so I didn’t have the motivation to prepare it and make it. Because normally I love cooking, but I think it’s because I love eating as well! So I cook because I love eating, and I normally cook with other people and it’s really fun and then we all eat together. Whereas when (.) on one day I did cook with my friends, when I had the (.) um (.) cheese and potato pie, we cooked that altogether. And that’s when I had the beans ‘cos they were eating the beans. So that was fun to make it and then I was motivated to eat that (.) and cook it (.) but the other times I was just cooking on my own so (.) I just wasn’t that (.) excited.

I: So why did you stop cooking with others?

P: Because they weren’t eating the same as me. So I guess I could have cooked, well I normally cook (.) like the same meal with them. So we will all put in whatever we have and like make a big meal, well normally two or three of us make a meal together. Um (.) but they weren’t eating the same as me. So (.) so one day they did ‘cos they like cheese and potato pie, so they were all like, “we’ll cook that with you that will be fun!” But they won’t normally eat mashed food, so they weren’t cooking the same as me, so then they ate separately or doing their own things.

I: How did that make you feel?

P: Um, I don’t know. I felt like (.), they knew I was doing it because of this research but I felt like I was being a really fussy eater. Like they were saying, “oh what can you have? What can you..?” We’d think of something and they’d be like, “oh, you can’t have that!” and it felt like I was being annoying. Kind of (.) yeah like a bit of a pain, even though obviously I was only doing it for this, um (.) it felt like (.)

Annotations

Experience was

more difficult over

time

Repeats “texture”,

shows how

“texture” was an

influence to her

feelings towards

food

Emphasises “cook”

and “eat”, shows

how mealtimes are

a social occasion for

her

Skipped meals due

to impact on

socialising with

others while cooking

Lack of motivation

in cooking and

eating. Due to

altered appreciation

of food and cooking

alone.

“fun”= emphasises

importance of

cooking with others

Changes in meals

resulted in a change

in cooking routines

and socialisation

Separation from

others

“annoying” and

“pain”- strong

emotive words used

to depict how P felt

Themes

Sensory appeal

of textures

Food is central

to life

Motivation

Food is central

to life

Changes to

social routines

Changes to

social routines

Perceptions of

being “fussy”

146

they, they’d always be like, “oh what’s on your diet?” I felt like I was being really like, “oh I’m on a diet, sorry, I can’t have that” kind of person. Whereas, yeah (.) so (.) yeah.

I: Were there any particular reactions from people? Did you receive any comments at all?

P: Yeah. I’m trying to think of. Yeah one of my (.) so my housemates knew about it ‘cos they know the course I do and what, I think I’ve already told them about it before. So they were always really interested. So every day I came home they were like, “what have you eaten today?” and they would fill out my food diary with me! So they were like really positive and they did that meal with us altogether, so that was quite nice. But then um (.) the people that didn’t really know what I was doing (.) um (.) I think they kind of assumed I was on a health diet. They were like, “oh is it healthier to eat mashed food?” I was like, “no!” Um (.) and I said that it was for a dissertation. I think they just kind of assumed it was for like health reasons rather than (.) um (.) I guess it still is for health but in a different, well like losing weight reasons rather than (.) like health reasons. So I think that was the main, people assumed mainly. It was ‘cos of that and I had to explain to them (.) why. And I think, unless you had something that you know has been put on a modified diet, people don’t know that that’s a thing. Like no one had ever heard of it. Like I was like, “oh if you have difficulty eating, then you might be put on a diet, so you just eat puree and like...” I think maybe people had heard of pureed but not mashed. They just didn’t, it wasn’t something they’d ever heard of.

I: Ok, so did you feel that you had to explain to other people?

P: Yeah, all the time. All the time I had to explain ‘cos like, people will offer you food all the time, don’t they? Like if I’d go into someone’s house, they’d be like, “oh do you want this?” I don’t know, I found myself having to be like, “Oh no, sorry I can’t,” quite a lot. More than I expected.

I: And how did that feel, refusing food?

P: Yeah, it just makes you feel like you’re being really fussy and like difficult, when obviously it’s not your choice. And um (.) and (.) yeah, it was just annoying because normally I wanted the food. I guess I could have, but like, you feel like (.) it’s hard to say no to something that you want.

I: Sort of gives you a restriction.

P: Yeah, and I think when someone’s telling you you can’t, it makes you want it more. So (.) yeah I think it’s because…because if you’re on like, say you’re on a diet for, you’re trying to lose weight, there’s an end goal of it, you’re choosing to do that yourself, you set it on yourself, so I think in a way that’s more (.) motivating because you’ve chosen it yourself and you know that’s what you want. Whereas I know if you were put on this diet, there is

Annotations

Negative experience

of having to tell

others about diet

restrictions

Positive reactions

People were quick

to make

assumptions due to

lack of

understanding or

awareness of diet

modifications

Awareness of fork-

mashable diets even

lower amongst

others

Emphasises “all the

time”, implies it was

a burden

Negative feelings

associated with

turning down food.

Difficulty in resisting

temptation

Is this a feeling of

rebellion?

Harder to comply

when there is no

motivation

Themes

Positive

reactions

Having to

“explain”

Having to

“explain”

Perceptions of

being “fussy”

Lack of control

147

an end goal as well because you don’t want to aspirate on things, there is obviously a reason, but I think because someone else is enforcing it, and you’re checking up on these rules, it makes you want to go against it more, because it’s set by someone else, even though obviously you’re choosing to do it yourself. You’re like checking the rulebook like, “can I have this? Oh no, it’s so annoying!” Whereas (.) yeah if you were on a different diet, you set the rules yourself so it’s more like in your control.

I: Mm yeah. And what about your lifestyle during the trial, did that change in any way?

P: Um (.) I’m trying to think. I think I stayed (.), yeah I normally come into uni on Tuesdays because we have a day off but (.) I normally work better when I’m in the library, so I normally come in then, on a Tuesday, so then I can have the weekend off more. So I (.) yeah normally come in, but I didn’t this week because I couldn’t think of something to bring in to uni with me ‘cos everything normally I would bring in, a salad or a sandwich, um but the things I were having for lunch which was like soup or jacket potato, you can’t prepare that in uni. I could have bought stuff, I bought stuff a few days but I didn’t really want to, because I knew I could just make it at home for way cheaper. So I stayed home then on Tuesday, just because it was way easier to prepare stuff at home rather than to try and….One of the days (.) I came into uni, and I was gonna get a soup, and one of the soups was not fork mashable, it was like, curry chicken or something, and I was like, “oh no!” but then there was another soup in the other building that did, but I was like, “imagine if I come in tomorrow and there’s not a soup I can have.” You can’t rely on stuff being available to you if you want to buy stuff. So then I just stayed home and worked from home, which was different to my normal routine.

I: With that in mind, were there challenges eating out and about?

P: Oh yeah, that was the only time, well the only time I was out for food was in (.) uni (.) because I would have, I wouldn’t have eaten out for food because I would have had to have chosen something that I would not normally have chosen, and I think that if you’re paying for food, especially being a student, going out for food is like a big treat (laughs)! So, I wouldn’t have wanted to paid for food that I would have had to choose something that I wouldn’t normally have chosen, so I think I probably avoided, I would have avoided going out for food (.) this week. And in uni when I bought the soup, it comes with like a roll, and I was like, “ah I really want the roll!” but I didn’t have it because it was, I think it was the first day, yeah, and I was like, “I can’t break it already, it’s only been a day!” But that was annoying, because I paid, I technically paid for it, do you know what I mean? And then you want it then, so I think if you’re going

Annotations

No control over

food intake

“rulebook”=

interesting term

used. Feels the

guidelines are like a

set of rules. Again

highlights lack of

control

Regular routine

change due to

difficulty in planning

meals

Difficult to prepare

meals out and about

More expensive to

buy suitable food

out and about

Emphasises “can’t”=

shows difficulty in

eating out and

about

Uses “treat” to

highlight how eating

out is viewed

Insight into how it’s

difficult to pay for

something that you

wouldn’t necessarily

choose, but is the

only suitable option

Themes

Lack of control

Lifestyle

changes

Difficulties

preparing food

out and about

Difficulties

finding suitable

foods out and

about

Restriction

148

out to a restaurant, it would be annoying paying for things that wouldn’t be your first choice.

I: Did you eat with anybody when they were eating normally?

P: Yeah, when I was in uni.

I: How did that make you feel?

P: I wanted their food! I just felt a bit jealous. I get food envy anyway, whether I’m eating fork mashable or not, but it was (.) yeah it was annoying, because they were, all their food looked so much better. And when I had the cheese and potato pie, I just had to eat the beans as well because I was just so jealous of them having them ‘cos they were eating them and I was like, “ok I’m eating them too” because it’s annoying just having to watch other people eat stuff that you want to eat as well.

I: So you mentioned about the beans, were there any other issues of non-compliance over the four days?

P: I don’t think so, no (.) apart from maybe the courgette, if that wasn’t a thing. Um (looks at food diary), no apart from that I did stick to it. But I think that was more on myself, I was like, “I have to!” I’m quite competitive. I wanted to stick to it to kind of prove to myself that I could. So (.) I was quite like, I wanted to be able to do it and when I got, say when I got three days in, then I was like, “well, I’m almost there now, so I may as well carry on.” But obviously most people would be doing this for a long time, so they can’t count it down the same as I was. ‘Cos I was like, “it’s only four days, you can do it!” um, but yeah.

I: Hypothetically then, if you were to follow it for longer, how do you think you would get along, if say it was for a month?

P: I think I would have struggled a lot more. Yeah (..) because I ate a lot of the same foods, so I had a lot, like I had porridge every day and (.) I had a lot of mashed potato and stuff. So, I didn’t have much variation (.) which for four days I guess (.) is fine but for longer, I think I would have found it a lot harder. Yeah, and I don’t know if I was eating enough as well. Like so one day I didn’t have dinner, and then another day I did have dinner, but I like, (looks at food diary) ah yeah this day, I had normal food, so I had porridge then jacket potato and then (.) for dinner, I was like, “I really can’t be bothered” and it got to like, maybe like nine or ten, and I was like, “no, I just don’t want dinner.” I couldn’t be bothered to make something, I couldn’t think of anything to cook, I was just like, “no.” I think I had just some yoghurts or something and then it got to like eleven, and I was like “ah!” That was Tuesday and I had uni on Wednesday (.) and I was like, “ah I need to make something to bring into uni,” because I was worried about them not having something in that I could eat, so then I was like, “oh I’m gonna have to make something anyway.” So then I made some risotto and then I just ate it then ‘cos I’d cooked it. If I wasn’t in uni the

Annotations

Un-justifiable to pay

for food that you

don’t necessarily

want

“jealous”= emotive

term

Repeats “jealous”,

shows that this was

a key emotion

experienced

Self-motivation to

get through the trial

and an idea of

proving resilience

Insight into how it

can be difficulty

without an end

point

Emphasises “same”=

lack of variety

Skipping meals due

to motivation to

cook

Difficulty in coming

up with meal ideas

Forced to cook due

to routine

Themes

Feelings of

jealousy

Resilience

Lack of variety

Motivation

Difficulties

finding suitable

foods out and

about

149

next day, I probably wouldn’t have eaten dinner that day as well (.) but it was ‘cos I was forced to prepare for the next day, then I was like, “ok fine, I’ll make something.” But yeah, I just didn’t have the motivation to cook, whereas normally I get really excited about cooking. So I think (.) maybe I guess maybe if I was doing it for longer (.) I would, I don’t know, no I think I would have found it really hard.

I: Where you said about cooking for uni the next day, do you normally do that? Or is that something that was different for you?

P: Er, I normally prepare something, so I normally make a salad or a sandwich which takes two minutes. So I do that norm*, sometimes in the morning (.) if I’m not organised but sometimes the night before but it takes like two minutes to make a salad (.) whereas I had to cook something for um (.) on this thing ‘cos I couldn’t have a salad or a sandwich, so (.) that was different yeah.

I: Did the time, did it take longer then?

P: Yeah, longer to prepare, yeah. ‘Cos I made risotto one day, so yeah I had to cook that, whereas normally I’d just make something. So yeah, it did take longer.

I: We’ve talked a bit about lifestyle. Was there any impact on social life at all?

P: Um (.) I’m trying to think. Probably not this week (.) um just because nothing that was happening, nothing that happened was (..) involved with food, but I think that could have been an issue. So today, my house are having a thanksgiving dinner. Obviously it was thanksgiving yesterday, so we were going to do it yesterday (.) um but then obviously I wouldn’t have been able to eat much. But then (.) my housemate had work so we changed it to today, but that could have been, if it had been on Thursday, that would have been an issue. So (.) yeah. I think it was just luck that nothing happened. But yeah, a lot of the things I do with my friends revolve around food (laughs). So like we’ll have like, I don’t know, like every Wednesday normally some of the girls from the course come round to mine or I go to theirs and we make dinner together. But we didn’t do that this week because (.) I was on the mashed diet. I was on the diet so we just didn’t do it and I wasn’t feeling very well as well, but (.) I think we (.) yeah (.), we didn’t do it because (.) I don’t know, yeah we were just like, “oh we’ll just leave it until next week then.” So I didn’t do that this week. And yeah, I would have missed this thanksgiving thing if it hadn’t been today. So I think it does impact upon social life (.) because you feel like you’re being a bit of a (.) um (..), you feel like you’re being a bit annoying asking people to change stuff. So like say if we had done thanksgiving, like if I had been like, “oh can we have mashed potatoes instead of roasted?” I would have

Annotations

Emphasises

“forced”= implies

lack of choice

More time needed

to prepare food

Emphasises “could”

= insight into how

diet modification

could impact social

life

P believes that

modified food

would have

impacted

appreciation of

“Thanksgiving”

meal. Important

meal in socialising,

and for cultural

reasons

Stopped a normal

social event due to

diet

Social limitations

due to personal

feelings regarding

asking people to

adapt

Themes

Motivation

Increased

planning and

preparation

Food is central

to social life

Changes to

social routines

Feeling

“annoying to

others”

150

just felt annoying because I know that they would prefer roasted. They probably wouldn’t really mind to do it but (.) I don’t think I would have felt comfortable asking (.) people to change their routine as well. Like it would have been fine for the girls to have come round to mine for dinner but I just thought, they would probably prefer making their own dinner better, that’s not (.) fork-mashable. And we’ll just do it another week. So I think yeah you don’t want to ask people (..) to um (.) change what they’re doing. Yeah.

I: Yeah. So in terms of the whole trial then, what do you feel that you’ve learnt from doing it?

P: Um (…) I think I’ve learnt how hard it is. Yeah (.) ‘cos I think before I would have the perception that (.) this um (.), so texture E is the easiest because it’s the least modified and you can still eat a lot of foods that you don’t have to modify at all like porridge or banana or (.) you don’t have to prep everything. Um (.) but actually it’s a lot harder than I thought and there’s a lot of foods (.) that you kind of take for granted that you can eat um (.) when you’re not on this diet that you can’t (.) when you are. And yeah I think how much it affects the social side of things (.) like not being able to prepare food with other people and not being able to…You can eat with other people but sometimes it’s easier not to because you don’t get jealous of what they were eating. Um (.) and yeah (.), I think it did affect, I think it yeah, affected social life more than I thought and I think (.) it was harder than I thought it would be to think of things (.) to eat.

I: Ok. and do you think that you can apply this to future practice as an SLT if you were working in the dysphagia field?

P: Yeah. I think I would focus more on (…) um (.) kind of like clueing them up themselves to be able to judge themselves what the texture should be, rather than referring to a sheet (.) which can be useful to start off with, but obviously when you can’t include everything. So when I was like, “ah is courgette on there?” I think, and I looked and it wasn’t, and I was like, “ah is it, is it not?” ‘Cos I think if you did more descriptions of what the food should look like or what um (.), then kind of give them the tools to kind of do it themselves (.), I think that’s easier. And I think then it puts, gives more control to them. ‘Cos I hated, what I was saying earlier, looking at the sheet and being like, “ah it says I can’t have it.” Whereas if you were thinking, maybe if you were thinking more about it yourself, making the judgement yourself, then it might be easier. Um (.) yeah and I think I’d try and like give more practical tips about good ideas. I haven’t really come up with any good ideas myself these four days (laughs), but to try and pick some up and learn from other people and (.) give them on the form. ‘Cos that page that you gave me that had like (.) um, suggested meal ideas that was quite good to get your ideas. So I think um

Repeats

“annoying”= really

emphasises her

feelings regarding

asking people to

adapt to her needs

Putting the needs of

others first=

implications to her

social life

Repeats pre-

conceptions of fork

mashable foods=

shows how much P’s

opinions have

changed

Limited with food

choices

Repeats “jealous”

Emphasises

“harder”= shows

how understanding

has changed by

doing the trial

Giving people

independence

Helping patients to

be able to interpret

the guidelines

Emphasises

“control”= implies

this is important to

P

Talks about practical

advice

Implies that the trial

was a challenge

Themes

Asking others

to adapt

Prior

assumptions

Restriction

Changes to

social routines

Practical

solutions

Difficulties in

coming up with

meal ideas

151

yeah, ‘cos I wouldn’t have thought of jacket potato, ‘cos that’s something that I don’t normally eat. So I wouldn’t have thought to make that, so I think having an ideas page is useful because it gives you a good thing to start with. And maybe remind you of foods or meals that you don’t normally eat that you could do. Yeah, so I think more practical, rather than like a list of things (.) that you can’t eat.

I: Yeah, that’s good. Do you think it’s a useful task for other SLT students to do?

P: Yeah, I would say it’s really useful. Yeah. Because it just allows you to be (.) in their shoes (.), um even for a short period of time (.), just to realise how hard it actually is, and how hard it is to judge whether food is ok or not. Because I think it’s easy to say like, say if you go to a visit and you see them eating something that you know, you told them you can’t, I think it’s easy to be like, “oh they’re not following my instructions and they didn’t listen to me,” and like blame the carer or whatever. But if you think about it (.), it’s actually quite hard to think about. Like you would think beans were fork-mashable, but obviously they’re not ‘cos of the husks, so there’s lots of things like that which you would assume would be fine, when actually they aren’t. So I think it made me realise um (.) that I wasn’t actually aware of what was, what I could have and what I couldn’t have, so how am I gonna expect someone else (.) to be aware? So I think it is really useful. Yeah, yeah, I think it was useful, I would recommend it.

I: Yeah. And was there anything else that you wanted to add at all that I haven’t asked?

P: Um (…) I don’t think so. No, I don’t think so.

I: Ok, that’s brilliant, thank you very much for giving me your time there.

P: That’s alright.

Key

I= Interviewer P= Participant (.) = Pauses Underlined = Word emphasised in speech * = Word cut off


Themes

Appreciation of

difficulties

Understanding

of non-

compliance

Determining

the suitability

of foods

Annotations

Coming up with

ideas was a

difficulty for P

“in their shoes”=

interesting

description.

Understand the

patient perspective

P has more

understanding of

why people may

not comply

Assumptions not

always correct

Repeats “useful” to

emphasise point

152


I: Just before we start, are you happy to be recorded for the interview?

P: Yeah that’s fine.

I: Just to let you know that you’re known as participant five, so you’re anonymous in the study, all of your details are confidential as well, so it will be in the report but it will not be shared elsewhere.

P: That’s fine.

I: So, just before we start, could you tell me a little bit about what your feelings were about the trial before you actually started it?

P: Erm, well I was, I was quite worried about it really ‘cos I erm (..) ‘cos I’m an absolute chocoholic and I eat generally very unhealthily and I wasn’t sure how I’d (.) manage my normal eating on a softer diet. Yeah I thought I’d just be miserable for four days (.) really. Erm (.) but it wasn’t as bad as I thought, than actually, sorry I’m probably jumping ahead here.

I: No, go for it.

P: Erm but I did slip up a few times actually. Erm so I wonder if maybe that’s why it wasn’t so bad, just ‘cos actually I didn’t follow it that strictly. Erm but yeah, I did quite a lot of planning beforehand (.) like er meal plans and wrote out a proper shopping list. I did a proper shop for it all. So I think being prepared made me feel a bit better about it. Like I would have really struggled had I just (.) done it like willy-nilly.

I: Can you tell me a little bit more about your planning and preparation?

P: Yeah, so I erm (.) yeah I just thought about the foods I liked to eat, whether they’d be acceptable or not. A lot of them weren’t (.) but um I spoke to my mum about it as well and discussed what would be appropriate. I wrote out my food plan. Erm (.) so originally I ended up not having a lot of these meals actually ‘cos I think it was the effort involved with cooking them. So I was gonna have like jacket potatoes with the skin left behind and cauliflower cheese but erm (.) in the end, you know, you organise these meals but then life gets in the way and sometimes other things come up, don’t they? Erm (.) yeah (..) I planned quite a lot but I didn’t execute it that well.

I: Ok. How does this compare to your normal shopping and preparation for food?

Annotations

Emotive word: “worried”

Expectation of negative emotions- emotive word ‘miserable’

Planning meals and shopping ahead of diet

Organisation can relieve concerns

Favourite foods not part of diet

Effort involved in preparing fork-mashable foods

“life gets in the way”= hard to balance life and cooking different meals?

Themes

Prior

assumptions

Planning ahead

and being

prepared

Increased effort

153

P: Erm (.) I think I’m generally quite spontaneous with my shopping, so I’ll just go to Lidl and just pick anything off of the shelf that looks nice to me. Erm I’m not one for writing a shopping list. And I’m not one for doing one big weekly shop, I sort of tend to pop in the shop whenever I need something, erm ‘cos I live a five minute walk away (.) so erm (..) so it’s probably very dis-organised of me, but generally, it’s very convenient for me, so I don’t have to plan. I never really sort out meal plans or anything like that (.) I just (.) shop as I go along. Usually it’s like, I shop on the day for my dinner that night, so “what do I fancy?”

I: Just going back, sorry did you say that you did a big shop for this week?

P: I did for this, yeah. I went to Tesco after uni and did a big shop.

I: Ah ok, so it was different for you?

P: Yeah, and I went to Tesco as opposed to Lidl, as I thought it might have a bit more choice with softer foods.

I: Ah ok, brilliant. In terms of actually following the guidelines that I gave you, how did you find it?

P: Well, shall I get my food diary out?

I: Yeah go for it.

P: (Looks at food diary.) The first day I tried quite hard to stick to it (.) erm so I had, for lunch, I had roast chicken soup but then actually when I was eating it, I thought it was probably a bit thin for the diet ‘cos it was quite like a watery consistency. Even though I tried to stick to that, I thought it would probably need thickening up if I was actually on the diet. Erm (.) then for dinner I had a ready meal fish pie that was really soft. Snacks was banana and a packet of crisps. So that day was fine. I think that day I was particularly motivated to really (.) yeah. And then the second day (.) porridge, so that would be ok, Skips and this is where I slipped up, I had a McFlurry, which as I bought it I thought it would be ok, erm (.) but then actually talking to another one of the participants, they said that actually ice-cream was actually a difficult one ‘cos it melts. You’re not really meant to have ice-cream. So that was with the best of intentions, and also it has chocolate chips, which I hadn’t realised either, so erm, yeah (.) sometimes I would say the McFlurry and the soup, both times I thought they would have been ok, but actually they probably wouldn’t have been. And I wonder if maybe if I was actually on the diet for health reasons I wouldn’t have, I think I would have had to have just thrown them away because it would endanger things (.) which would be really irritating. Erm (.) and then for dinner, I had lentil bake (.) so (.) lentils and cheese and onion all cooked together, and angel delight for pudding and a chocolate mousse for a snack. So that was all, just my McFlurry

Chooses food based on appeal

No planning or preparation in normal routine

Choosing food according to what they feel like on the day

Thinking ahead about choice

Adjective “hard” implies effort

Using knowledge of texture to determine if consistency if suitable

Motivated at the start of trial

“slipped up”, implies accidental mistake

Participant hadn’t realised was non-complaint to begin with

“irritating” to throw food away

Annotations

Normally choses

food based on

appeal

Normally shops for

convenience=

change to routine

Had to change the

shop due to limited

choice in regular

shop

Learnt suitability of

some foods

“trying hard to stick

to it”, implies

challenge

“slipped up”-

implies it was an

accident,

participant un-

aware

Difficulty in

knowing what

is/isn’t compliant

“irritating” to

throw food away

Themes

Change in

lifestyle

Change in

lifestyle

Determining

the suitability

of foods

154

slip up. Erm (..) so day three again porridge, packet of Skips, lentil bake and chocolate mousse, but then I also had a chocolate chip cookie (laughs). That was because I went out with my boyfriend to watch ice-hockey, and he bought snacks and I (.) erm (.) there was part of me not wanting to refuse what he bought, and part of me that just couldn’t resist the chocolate chip cookie (laughs)! So erm (.) I slipped up then again, but that was intentional, I knew what I was doing but I just didn’t have the willpower to not have it when it was right in front of me. Then day four was just completely out the window (.) erm because we went out for Christmas dinner as a house. So I think that was like a social thing. Erm (.) so I had a banana for tea afterwards (.) but (.) erm (.) Christmas dinner (.) although a lot of it would be soft enough (.) as I had mash, parsnips, broccoli, cauliflower cheese, stuffing, gravy. Erm things like the meat, the ham, the turkey and the roast potatoes wouldn’t have been complaint with the diet. Erm (.) but again I just didn’t have the willpower to refuse them once I was there. Erm (..) yeah so I think ‘cos that was a social thing (.) yeah I really, I really struggled with the idea of maybe adapting my meals slightly, I just couldn’t do it, I think I would have found it too difficult. And also, I think a financial thing, I think ‘cos I knew I was paying ten pounds for this meal, and the meat is the most expensive bit, it would be a real shame (.) to not have that (.) but erm, yeah sorry I just couldn’t resist that bit!

(LAUGHTER)

I: That’s fine!

P: So actually, three of the four days I did slip up, well four of four days, if you count the soup as well. But some days were with the best intentions and some days were just lack of willpower!

(LAUGHTER)

P: But generally I found it not as difficult as I thought I would, but I don’t know if that is because I slipped up occasionally. So it’s not that I went four days without chocolate, because I did have my chocolate cookie and things like that.

I: Yeah, yeah. And were there any challenges when you were actually cooking and preparing the meals?

P: Erm I found that alright actually. I think it was because I do quite enjoy cooking and because I had it planned out in my head (.) erm like, “right today you’re gonna make your lentil bake,” like I didn’t mind doing that so much, and erm (..) I was (..) I felt quite comfortable that what I was making would be complaint with the diet. So I think cooking wasn’t particularly an issue, it was more out and about that I struggled with, when I didn’t have cooking facilities and I didn’t have a stash of food in my cupboard. Erm (.) so I’d always have a packet of Skips

Annotations

Difficult to refuse what others have bought you. Difficulty to resist temptation.

Compliance a challenge in social situations, particularly cultural occasions such as Christmas

Use of word “struggled” to indicate challenge. “even slightly”= hard to modify to some extent, even if it’s not the full extent

Cost implications when food refused

“lack of willpower”= difficulty resisting temptation

P’s insight that non-compliance may have made the experience easier

Felt confident in own cooking skills

Harder to comply when not at home

Themes

Resisting

temptation

Changes to

social life

Cost

implications

Willpower

Difficulties

preparing food

out and about

155

and a banana out with me but sometimes you want a bit more, hence the McFlurry (laughs)!

I: And how did you feel the food choices were like out and about, was it easy or difficult to get fork-mashable foods?

P: I thought it was really difficult actually. Erm (.) I mean it’s difficult enough to sort of think of snacks that you can get from Tesco (.) erm (.) but yeah when you’re out and about in town (.) yeah I couldn’t really find anything (.) that (.) I mean I probably, if I’d looked harder maybe I could have found something, but then yeah (.) the only thing I could find really was the McFlurry, which again, wasn’t really complaint. Erm (.) but I suppose it would have been better for me than I suppose a sandwich or something (.) which was generally what there was on offer.

I: Yeah. What were your feelings when you were actually eating the modified food?

P: Well (…) I didn’t mind eating so much the stuff that I’d cooked, because I chose stuff that I really liked, so I would have fish pie anyway. I did a ready meal just for convenience. And then the lentil bake I really love, so I’ll happily eat that. I did get a bit bored of having like Skips and bananas (.) all the time (.) erm (..) sorry what was your question again? Sorry!

I: Erm, how did it feel when you were eating modified foods?

P: Yeah (.) erm I think it was just a bit samey that was the problem. It was all just quite repetitive. I felt like every day I was having the same snacks, the same puddings. Erm (.) for dinner, the actual meals themselves were fine (.) I think that’s ‘cos I maybe thought outside the box a bit more. I hadn’t (..) when I was planning I just thought of three kinds of snacks, but I didn’t really think that actually I wouldn’t want the same snacks every day. Erm (.) if anything, I think maybe it was just a bit boring but (.) it wasn’t (.) it wasn’t too bad. Erm (..) but yeah it was hard sometimes like watching your housemates eat like chips, and you’re there with like your mush. Erm (.) but yeah generally the meals were ok, it was more the snacks that I struggled with.

I: Right ok. What was your appreciation of mealtimes like during the trial?

P: Sorry what do you mean by that?

I: So were you looking forward to dinnertime, lunchtime?

P: Erm (.) not really actually. Erm I think ‘cos I saw it as more like an obligation, so like normally I would just go down to the kitchen and think, “oh what do I fancy eating today?” or like go shopping and think, “what do I fancy eating?” whereas

Annotations

Adjective “difficult” and word stress implies challenge in finding fork-mashable foods out and about

Trying to weight up whether one non-complaint food is safer than another

“didn’t mind”-implies it is ok when you choose things that you enjoy

Bored of eating the same things

Repetition of “same”= emphasises the lack of variety

Harder to choose snacks than meals

Difficult to know what you’ll want when you plan ahead

“mush” to describe fork-mashable texture. Negative connotation?

“obligation”= emotive noun. Implies P is not eating for pleasure

Themes

Difficulties

finding suitable

food out and

about

Lack of variety

Lack of variety

Lack of variety

Lack of

enjoyment

from food

156

I think because I had it in my head that this time I have to cook this, it wasn’t as exciting. I think it was (..) erm (..) yeah became more an obligation, something that I had to do. And also as I had it planned days in advance, it wasn’t as exciting as well because I knew exactly what I was gonna eat that day, and usually I quite like just seeing what I fancy in the moment.

I: Ok, so do you feel that that was a change then?

P: Yeah I think it did actually. I wouldn’t spend all day looking forward to my fish pie and as nice as it was, I think because it wasn’t, in that moment I probably would have preferred something else (.) but (.) yeah it wasn’t difficult to eat, it just wasn’t as exciting.

I: Right ok. So you’ve talked to me a little bit about non-compliance during the diet. So could you just tell me a little bit more about your reasons behind the non-compliance? You said about going out with friends, was that one of the main reasons?

P: I think so, yeah. I think also because I knew that for me (.) it wouldn’t endanger my, I wouldn’t be at risk of aspiration (.) erm if I did not comply. Erm (.) it was very easy to think, “ah it will be alright, it’s just one meal.” Erm it would be interesting actually if I did have a swallowing problem to see if I would (.) react the same way. I don’t know if I would but erm (.) yeah I think social aspects is a really big one for me. I have a very big connection to food and a lot of the social things that we do (.) me and my friends, it’s all to do with food and I would have really struggled to just eat fork-mashable food with them. Then yeah, times like with the McFlurry when I thought I was complaint but wasn’t (.) erm I guess that was just a difficulty getting fork-mashable food when you’re out and about. And also the social aspect so (.) I’d gone with my friends to MacDonalds, they were getting Big Macs and I thought, “well, what’s the most soft thing on the menu? Probably a McFlurry.” Looking back it probably wasn’t really the right thing but erm (.) I think yeah, you want to feel like you’re part of it so they were having a MacDonalds, so I wanted to as well.

I: Right ok. And do you feel that your social life was impacted in any other way at all during the four days?

P: Erm (.) well normally I have a lot of meals with my boyfriend. Normally he’d cook for me a lot of the time. Erm (.) so but I didn’t want him to have to do the fork-mashable diet so I (.) tended to just cook for myself. So (.) yeah it sort of impacted that, like I didn’t really spend as much time with him in the evenings. Erm (..) but then apart from that I think I still saw my friends just as much. Erm (.) but then again that lead to non-compliance. I think if I’d been really strict on myself I

Annotations

Disadvantage of planning ahead- it makes mealtimes less exciting

“obligation” repeated

Wasn’t as exciting as having the freedom to choose on the day, in the moment

Perhaps it was challenging as no dysphagia present? P is rationalising non-complaince.

Emphasising adverbs “really” and “very”, implies how significant food and socialising is to them

Don’t want to feel separate from the group when eating out

Not eating with boyfriend, change in normal routine

Cooking alone

Less time with boyfriend

Themes

Lack of

enjoyment

from food

Limited

spontaneity

Limited

spontaneity

Food is central

to social life

Food is central

to social life

Changes to

social life

157

would have limited the social aspects of it (..) to allow for (.) fork-mashable food as opposed to (..) socialising.

I: Ok. So you said that you spent less time eating with your boyfriend, how did that make you feel, did it have any knock-on effects?

P: Yeah. I think that I find that spending time with him is a really good de-stresser from uni and erm (.) so I did spend less time with him and I think especially ‘cos we’ve got an exam coming up this week, I did find that I was getting quite stressed. Erm (.) yeah it’s interesting to think about that ‘cos the stress wasn’t directly from being on a soft diet but (.) it probably was indirectly from that. It sort of changed my routine and I think sometimes I need that routine to stay stable. I think I just got a bit stressed out sometimes.

I: Ok. And a similar sort of question really, do you feel that your overall lifestyle was affected?

P: Erm yeah, I think I just lost spontaneity of the lifestyle I normally lead (.) so erm (.) yeah it was quite debilitating really. You sort of erm (.) yeah (.) it’s erm (.) it’s just not as fun I think when you’re on a modified diet. Yeah and I think I would have to really, really structure my routine if I was on this diet constantly. Like I’d have to meal plan every week and I’d have to do one big shop (.) and I think (.) yeah, for four days it didn’t really impact my lifestyle that much, but I think if I was on this constantly, it would really change it.

I: And why do you think it would change that, is it because as you said there, your routine?

P: Yeah I think I’d have to change my routine and I think I’d have to just completely change my mind set about food. Erm (..) yeah I just have no willpower when it comes to eating bad foods and I think (.) that is something that if I was actually at a danger of aspiration, I would really have to change my core beliefs about foods, which just makes it sound so dramatic, but I think food is a really big part of my life! It would change my life quite dramatically actually.

I: Yeah, yeah. You told me about when you were eating with others and you said that you were eating ‘mush’, can you just tell me a little bit more about your feelings when you were eating with others?

P: Yeah, I sort of erm (..) yeah well one day I was eating my lentil bake and that was the second day in a row that I’d had that for tea, and my housemates I think were eating wedges or something, and I love wedges. And I think my meal did seem a lot less appetising, even though I do enjoy the meals that I planned. Erm (..) but (.) yeah maybe it was the sense of obligation as well. And I think yeah (.) it goes back to like it

Annotations

Participant believes that to be complaint, socialising needs to be restricted

Soft diets not the direct cause of stress, but can contribute.

Normal routine= stability

Strong use of adjective: “debilitating”

“would have to”= implies changes would need to be enforced

Soft diet would entail change in attitude towards food. Potentially disassociate pleasure from food?

Adverb “dramatically”, implies that a permanent soft diet would result in a substantial life change

Difficult to see something that you enjoy eating but can’t have

Repeats “obligation”

Themes

Limited

spontaneity

Change in

lifestyle

The need of

attitude change

Lack of

enjoyment

from food

158

wasn’t what I wanted in that moment. I couldn’t just be spontaneous and erm quite often if I see my housemate cook something, I think, “oh I like the look of that, I’ll cook it as well!” Erm so yeah, I think I, and yeah I probably did look at my food in a negative light. I did, and I called it the mush diet when I was on it, which was probably the negative connotations. Yeah (..) I think it often does seem less appetising compared to theirs.

I: Yeah. And did you have any reactions from anybody at all?

P: Erm, often they were quite complementary about my food. So erm (.) they took my recipe for my lentil bake ‘cos it was a bit different. But I think ‘cos I found it less exciting (..) I think, I thought they were more excited about my food than I was!

I: Oh ok. Did that help you?

P: Yeah I think so. Yeah I think especially with the lentils, especially day two ‘cos I was just getting really bored of it by then. Erm (.) so yeah I think to have them excited did make me feel a bit more excited (.) and a bit less like it was just boring mush on my plate.

I: Oh that’s good. And what do you feel that you’ve learnt from doing the four day trial?

P: I’ve learnt that (.) it doesn’t look like it, but I do have more willpower than I thought (.) ‘cos I was, I found it really hard when I went to MacDonalds not to take anyone’s chips or to get any of my own. But actually, I learnt that I can turn down food (.) which was something that I’ve never really done before. I’ve never really restricted myself when it comes to food. I sort of I learnt that it is possible. And yeah it was quite an interesting insight for me because obviously (.) as part of the speech therapist’s role you sort of, you can sometimes quite flippantly say to someone, “right go on this fork-mashable diet for this time,” and I think often we think of fork-mashable as not that bad at all, it’s at least not puree. Erm (.) but actually it can really change your lifestyle and like mine was only for four days and it changed it enough. I think it would be really difficult if you were on it constantly or permanently or even if it was for like, an indefinite amount of time until you get better, you wouldn’t really have like an end in sight. I think it just gave me a new appreciation for how difficult it must be for those people (.) especially when it’s often (.) accompanied by like (.) some sort of neurogenic problem or a stroke or something. I think it is sort of like an unnecessary evil to put on top of them erm when they’ve already got enough to worry about. So I thought it was really good for me as a speech therapy student to sort of understand what it’s like for them, having to sort of live that lifestyle. Erm (..) yeah and I learnt that it is possible but it’s really not as fun and exciting as a normal diet is.

Themes

Limited

spontaneity

Positive

reactions

Lack of

enjoyment of

food

Willpower

Change in

lifestyle

Increased

empathy

towards

patients

Annotations

Repeats about lack of spontaneity

P’s interpretation of why the term “mush diet” was used= because it was a negative experience

Positive reaction from others

Positive reactions of others can help

Repeats the term “mush”, emphasises dislike of diet

Able to stick to the diet. Repeats “willpower” again= indicates P feels this diet requires willpower

First experience of restriction

Implies recommendations are made without knowing the implications of following a soft diet

Views have changed since following the trial

Appreciation of what it’s like to be a patient

“unnecessary evil”= Powerful and emotive description of diet recommendations

159

I: Right ok. And how do you think that you could apply this learning to your future practice as an SLT, if you did go down the dysphagia route?

P: Yeah I think I would just be a lot more empathetic if people didn’t comply to the diet. I think often, you know you’d walk into your patient’s hospital room and they’d have chocolate wrappers on the side and you’d say to them, “this isn’t complaint with your diet,” but actually (.) it would just make me appreciate how difficult it is to stick by it. Especially if you’ve got people bringing you food in and you don’t want to be wasteful and you don’t want to be rude. I think yeah, it just gives me the ability to be more empathetic with (.) my patients I think and (..) maybe when I’m giving out these, I recommend this diet for this person, I’d maybe take the time a bit more to talk to them about it and explain that it can be quite a big lifestyle change and maybe outline the reasons why it’s necessary, you know like, aspiration and everything. I think that maybe ‘cos SLTs are in such a rush, they might be quick to say, “right they need this diet,” and leave it at that without really properly exploring the emotional side of that with the patient.

I: Ok, so do you feel that the emotional side is quite important then?

P: Yeah and I think sometimes we just stick to the medical side of things and it’s understandable ‘cos we’re in such a rush, we’ve got so many patients to see. But I think actually it’s really important, and I think it would actually help with compliance a lot if we actually sat down with them and explained exactly why they need it, and if we sort of said that we really understand that it’s difficult to stick to, but this is for your health, and it’s the best thing for you (.) rather than (.) just leaving them with this complete lifestyle change and not really explain why, or (..) sort of recognising that it’s gonna be difficult for them.

I: Ok. And do you feel that your understanding of Texture E, what Texture E is, do you feel that that has changed in any way at all?

P: Erm (.) yeah well things like (.) ice-cream I thought was acceptable and I learnt that it wasn’t! Erm I think (.) yeah and actually things like Skips, I think I previously wouldn’t have thought that was ok but because it’s bite and melt, like it requires basically no chewing (.) erm I think yeah. In a way I think there was more than I thought there was, but in a way there was also less than I thought there was. And also not having bread, I thought was quite difficult (.) erm (.) yeah. Yeah I think I have learnt a bit more about what’s involved and I think it’s given me an idea of like (.) how lifestyle, how you can actually adapt fork-mashable into your lifestyle (.)

Themes

Appreciation of

difficulties

Understanding

of non-

compliance

Explaining to

patients

Explaining to

patients

Determining

the suitability

of foods

Annotations

Understanding of patient perspective has increased

Describes a change in how compliance is viewed- i.e. views it as challenging

Repeats “empathetic”= emphasises how empathy has increased

Will use new insight on ‘change of lifestyle’ to discuss with patients

Maybe P is making a point that SLTs need to take more time with patients exploring emotional effects of diet modification?

Word stress on “really”= shows significance

P feels that compliance will improve if SLTs show their understanding of the challenges

Learning of acceptable and un-acceptable foods

Word stress on both “more” and “less”= emphasises that P’s knowledge of complaint & non-complaint foods have changed

160

rather than just saying to people, “ yeah it’s food that you can mash with a fork.” Erm like the reality is, that they’ve got to try and make that into meals and snacks, and I think yeah it’s just educated me a bit about how to do that.

I: Ok, that’s really good. And finally do you feel that it’s a useful task for future SLT students to do?

P: Yeah I would definitely recommend it. I think erm (.) it just (.) there’s no way really to understand the emotional side of being on a modified diet and I think unless you actually do it. And I think four days is actually quite a good amount of time as well, because if you said to someone one day, they’d only have to think of three different meals and one snack maybe. But with four days, you’ve got to think of twelve meals and I don’t know, four, five, six different snacks. It’s quite a lot of different things to have to think of. Yeah I think it’s just (.) it’s taught me a lot about what it’s like to be on this diet in reality, and I think (.) erm (.) yeah I think it would be a really useful thing (.) to maybe build up empathy and education of SLT students.

I: Ok, ah brilliant. So that’s the end of all my questions. Is there anything that you wanted to add at all that I haven’t specifically asked you, that you felt was important?

P: No I don’t think so. I think that’s everything.

I: Ok brilliant. Thank-you so much for taking part in the trial!

P: That’s alright!

I: Thank-you!



Themes

Practical

solutions

Appreciation of

difficulties

Appreciation of

difficulties

Annotations

Implies that patients need to be equipped to know how to make fork-mashable foods into meals

“no way”= implies that it is difficult to teach the patient experience without experiencing it for yourself

Word stress on “a lot”= P has gained from this experience

Repeats “empathy”

161

Appendix 7.18 Participant 1: Master table of themes with verbatim quotations

Superordinate theme 1) Factors that influence the experience of diet modification Planning and preparation Lines 66-67: “So practically it was easy because…you

already had a system” Personality Lines 113-114: “I’m quite a compliant person in

general.” Regular diet Line 166: “I only eat crunchy food” Accepting difference Lines 747-748: “one of the things that might help

people, is to feel they are different” Prior assumptions Line 147: “I thought it was going to be easier in a way” Cooking knowledge and ability Lines 675-676: “maybe I’m just not a very good cook.” Determining the suitability of foods

Lines 406-408: “So I felt very insecure, many times during the trial, that I was actually making the right food or eating the right thing.”

Superordinate theme 2) Impact of change Intense reactions Line 831: “there are almost like gut feelings” Lack of enjoyment Lines 366-367: “I kind of just felt sad just looking at the

plate” Lack of control Line 467: “It’s almost like losing your free will” Emotional connection with food Lines 451-452: “food is really emotional isn’t it?” Physical effects of modified food Line 439: “It always felt heavy and loaded” Going hungry Lines 280-281: “I went hungry (..) some of the times.”

Lines 107-108: “you have to choose between eating something that’s not within the diet (.) or be hungry”

Impact to lifestyle Lines 323-324: “in that way it did impact my work.” Sensory appeal of textures Lines 371-372: “just the thought of having to eat

everything the same texture.” Restriction Line 153: “oh my god, I can’t eat anything!””

Lines 382-383: “There’s a whole world of foods that were out of my reach”

Superordinate theme 3) Challenges in applying diet modifications Increased planning and preparation Line 181: “there was a lot more planning” Increased effort Line 416: “It’s also sort of physically tiresome” Confliction with lifestyle Lines 297-298: “I was thinking of placement, preparing

things, moving back” Difficulties with finding convenience foods

Lines 263-264: “There were not many things that were convenient foods”

Difficulties in coming up with meal ideas

Lines 307-308: “How am I going to cook this or not? (…) I don’t really like gravy (..) what can I do instead of gravy?”

Absent-mindedness Lines 799-800: “I caught myself nearly putting something in my mouth without even thinking”

Changes to healthy eating

Lines 231-233: “I just went to the ready-made section. That for me is a big thing ‘cos I never eat ready-made.” Line 638: “I felt that I was eating unhealthily”

Superordinate theme 4) Challenges out and about

162

Having to “explain” Lines 525-526: “I ended up explaining” Lack of reaction Lines 570-571: “more often (.), nobody commented” Refusing food Lines 772-773: “I didn’t want to refuse the food he was

offering.” Difficulties finding suitable food out and about

Lines 508-509: “There’s choosing the food in a public place and then once you get the food, whether it’s appropriate”

Superordinate theme 5) Learning from the trial Appreciation of difficulties Lines 403-404: “my appreciation of people who have to

do it day in day out” Line 862: “I think I’ll be more empathic”

Altered perceptions Lines 58-59: “it’s very different (laughs) to live through it”

Diet modification as a last resort Lines 848-849: “I do not want to put someone on a modified diet unless it’s …completely unavoidable”

Practical solutions Lines 222-223: “You need to, not just to be shown recipes (.) but to …be (.) shown how to modify your diet

163


Superordinate Theme 1) Factors that can influence the experience of diet modification Planning and preparing ahead Lines 109-110: “I already knew what I was gonna

cook and how I was gonna cook it” Regular routine Line 285: “It was all home cooked, but that’s kind of

normal for me” Regular diet Lines 142-143: “I think it’s because all of these things

are already in my diet.” Cooking knowledge and ability Lines 89-90: “I knew how to cook all these things” Knowledge of guidelines Lines 113-114: “I kind of already knew what was

fork-mashable and what wasn’t fork-mashable” Adaptability Line 202: “Yeah, I was happy to change it” Enjoyment of food Line 231: “I always appreciate my meals” Superordinate Theme 2) Challenges with diet modification Absent-mindedness Line 257: “it was just absent mindedness” Restriction Line 162: “oh I just want to have a packet of biscuits

right now!” Lines 180-181: “it was literally just cutting out biscuits that were really crumbly”

Superordinate Theme 3) Change Feeling healthier Line 335: “it was probably a little bit healthier” New mealtime routine Line 336-338: “I was, Superordinately actually

sticking to mealtimes… so it was probably actually forcing me into slightly better habits”

Superordinate Theme 4) Awareness of others Negative reactions Line 291: “Just the look of it kind of disgusted her” Having to “explain” Lines 310-311: “I quickly explained, “oh you know

I’m doing this fork mashable thing” Positive reactions Lines 331-332: “they were actually really jealous of

what I was eating” Implications for eating in restaurants Lines 346-347: “If I was eating out (.) then I would

have to be really careful” Superordinate Theme 5) Learning from the trial Appreciation of difficulties Lines 357-358: “I think you don’t get that

appreciation on a piece of paper.” Relating to patients through the experience

Line 438-439: “I know what it’s like”

Understanding of non-compliance

Lines 446-447: “, you can sort of gauge why there might be some non-compliance”

Explaining to patients Lines 119-120: “just kind of explain, you know, these things are fork-mashable”

164


Superordinate Theme 1) Impact of change Feeling infantile Line 545: “you do feel like a child” Emotional connection with food Lines 474-476: “I’ve worked with a lot of people

who’ve really, really struggled emotionally, psychologically to detach themselves from food

Cost implications Lines 49-50: “I spent way more money than I normally spend”

Going hungry Lines 193-194: “I’d rather not eat, than eat something I didn’t enjoy”

Compensation Line 344: “it needs to compensate I guess” Changes to healthy eating Lines 55-56: “I spent a lot of money on junk food”

Lines 591-592: “I ate less healthy food, I felt like I ate hardly any vegetables”

Sensory appeal of textures Lines 197-198: “what makes food satisfying, is a mix of textures really”

Restriction Line 603: “I could murder a stir fry” Superordinate Theme 2) What can help Importance of planning and preparing

Line 43: “Monday I didn’t plan and it was much harder”

Enthusiasm to experience Lines 11-12: “I really wanted to try it” Personality Lines 163-166: “I probably have a bit of a cavalier

attitude towards…making decisions about my lifestyle, like valuing fun more than…”

Focus on the positive Line 330: “focus on the things that you do have” What others think Line 497: “I don’t care what people think” Regular diet Line 528-529: “I principally ate things that were

basically fork-mashable anyway” Adaptability Lines 670-671: “I personally got more value out of

eating things that lent themselves to being mashable” Superordinate Theme 3) Challenges in applying diet modifications Determining the suitability of foods

Line 135: “Although if it was soaked in gravy? I don’t know”

Rejecting food Lines 118-119: “it’s really hard to reject it.” Wasting food Lines 161-162: “I found it really hard to throw them

away” Control Line 282: “there wasn’t a reason why I needed to do it” Increased preparation Lines 614-615: “it required a bit more prep” Difficulties buying food out and about

Lines 187-188: “It was practically impossible out and about”

Challenges with take-away Lines 246-248: “there’s not somewhere I can get a vegan takeaway which is fork mashable right now”

Absent-mindedness Line 358: “the chocolate, it was just totally accidental” Un-anticipated texture Lines 571-572: “if you’re not anticipating the lump then

it’s more problematic” Superordinate Theme 6) Learning from the trial Practical solutions Lines 739-740: “I might like do exercises around like

brainstorming”

165

Emphasising safety Line 709-710: “really, really stress the safety element” Helping students Lines 732-733: “And for them to, I don’t know, spend

fifteen minutes thinking or thinking about fifteen dinners” Understanding non-compliance Lines 568-569: “how frequently it would be the best

attempt, wouldn’t quite be there” Line 633: “when you have special food, harder to resist”

166


Superordinate Theme 1) Factors that influence the experience of diet modifications Regular diet Lines 16-17 “there’s not much I can eat, compared to

what I normally do eat” Prior assumptions Lines 13-14: “I thought that’s the least modified,

it can’t be that hard” Resilience Lines 261-262: “I wanted to stick to it to kind of

prove to myself that I could.” Determining the suitability of foods

Lines 131-132: “we probably have more of an idea than somebody that didn’t”

Superordinate Theme 2) Changes to lifestyle and social life Lifestyle changes Lines 36-37: “I normally go shopping every

week, but I didn’t” Lines 305-307: “So I (.) yeah normally come in, but I didn’t this week because I couldn’t think of something to bring in to uni with me”

Changes to healthy eating Line 160: “it was quite hard to eat healthily” Changes to social routines Lines 430-432: “we didn’t do that this week because

(.) I was on the mashed diet.” Lines 225-227: “well normally two or three of us make a meal together…but they weren’t eating the same as me.”

Superordinate Theme 2) Challenges in applying diet modifications Increased planning and preparation Lines45-46: “I think it takes a lot more planning.” Difficulties in coming up with meal ideas

Line 61: “I kept having like, ideas for part of a meal”

Motivation Lines 210-211: “so I didn’t have the motivation to prepare it and make it.” Lines 382-383: “I couldn’t be bothered to make something”

Resisting temptation Lines 77-78: “I was like, (gasps) I really want them!”

Superordinate Theme 3) Impact of change Lack of enjoyment from food Lines 143-144: “I didn’t enjoy the food that

much.” Lack of variety Lines 147-148: “I had porridge most days I think” Sensory appeal of textures Lines 192-193: “Everything’s the same texture,

isn’t it really? Which was quite hard” Food is central to social life Lines 201-202: I really like food so I always think

about what I’m going to have for dinner! Restriction Line 25: “I can’t have like salads for lunch” Perceptions of being “fussy” Lines 234-235: “I felt like I was being a really

fussy eater.” Feelings of jealousy Line 347: “I just felt a bit jealous” Lack of control Lines 282-283: “when someone’s telling you you

can’t, it makes you want it more” Superordinate Theme 4) Challenges out and about

Positive reactions Line 248: “they were always really interested”

167

Asking others to adapt Lines 250-251: “you don’t want to ask people (..) to um (.) change what they’re doing”

Difficulties finding suitable foods out and about

Lines 320-321: “You can’t rely on stuff being available to you if you want to buy stuff”

Having to “explain” Line 270: “All the time I had to explain” Difficulties preparing food out and about

Lines 309-310: “you can’t prepare that in uni”

Superordinate Theme 5) Learning from the trial Practical solutions Lines 474-475: “I think I would focus more on

…clueing them up themselves” Appreciation of difficulties Lines 505-506: “it just allows you to be (.) in their

shoes” Understanding of non-compliance Line 507: “just to realise how hard it actually is”

168


Superordinate Theme 1) Changes to lifestyle

Changes in lifestyle Line 58: “I went to Tesco as opposed to Lidl” Lines 248-249: “I would have to really, really structure my routine if I was on this diet constantly”

Changes to social life Line 224: “I didn’t really spend as much time with him” Lines 227-228: “I think if I’d been really strict on myself I would have limited the social aspects of it”

Superordinate Theme 2) Challenges in applying diet modifications Determining the suitability of foods

Lines 357-358: “ice-cream I thought was acceptable and I learnt that it wasn’t”

Increased effort Lines 34-35: “the effort involved with cooking them”

Resisting temptation Lines 94-95: “couldn’t resist the chocolate chip cookie (laughs)!”

Prior assumptions Line 12: “I was quite worried about it” Superordinate Theme 3) Impact of change

Lack of enjoyment of food Lines 290-1: “it was just boring mush on my plate.” Lines 177-178: “I saw it as more like an obligation”

Lack of variety Lines 161-162: “I felt like every day I was having the same snacks” Line 156: “I did get a bit bored of having like Skips and bananas”

Limited spontaneity Lines 273-274: “it wasn’t what I wanted in that moment”

Cost implications Lines 111-112: “the meat is the most expensive bit”

The need of attitude change Lines 259-260: “I would really have to change my core beliefs about foods”

Food is central to social life Lines 205-206: “a lot of the social things that we do (.) me and my friends, it’s all to do with food”

Superordinate Theme 4) What can help Positive reactions Line 282: “often they were quite

complementary about my food” Planning ahead and being prepared Lines 22-23: “I did quite a lot of planning

beforehand” Willpower Lines 294-295: “I do have more willpower than I

thought” Superordinate Theme 5) Challenges out and about

169

Difficulties finding suitable food out and about

Lines 142-143: “when you’re out and about in town (.) yeah I couldn’t really find anything”

Difficulties preparing food out and about

Lines 133-134: “out and about that I struggled with, when I didn’t have cooking facilities”

Superordinate Theme 6) Learning from the trial Appreciation of difficulties Lines 323-324: “I think I would just be a lot more

empathetic if people didn’t comply to the diet.” Understanding of non-compliance Lines 327-328: “it would just make me appreciate

how difficult it is to stick by it.” Explaining to patients Lines 333-334: “, I’d maybe take the time a bit

more to talk to them about it and explain” Practical solutions Lines 366-367: “how you can actually adapt fork-

mashable into your lifestyle”

170

Appendix 7.23 Table showing the merging of participant themes

Superordinate Theme

Subordinate Themes Themes identified in individual interviews merged

with subordinate theme 1. Factors that

influence the experience of diet modification

1.1 Prior assumptions Enthusiasm to experience 1.2 Proximity to regular diet Regular routine, Regular diet

1.3 Planning ahead and being

prepared

1.4 Cooking experience 1.5 Perspective Accepting difference,

Adaptability, Focus on the positive, Resilience, Willpower


2.1 Determining the suitability of foods/prepared textures

Determining the suitability of foods, Knowledge of guidelines

2.2 Increased planning, preparation and effort

Increased planning and preparation, Increased effort, Difficulties in coming up with meal ideas, Motivation,

2.3 Routine Absent-mindedness, Confliction with lifestyle,

2.4 Rejecting food Wasting food

3. Challenges out and about

3.1 Preparation of food in public 3.2 Availability of suitable food in public

Difficulties with finding convenience foods, Implications for eating in restaurants, Challenges with take-away

3.3 Reactions of others Lack of reaction, Negative reactions, Positive reactions

3.4 Having to “explain” Asking others to adapt Refusing food,

4. Changes as a result of the diet modifications

4.1 Changes to lifestyle Feeling healthier, New mealtime routine, Limited spontaneity, Impact to lifestyle

4.2 Changes to social life Food is central to social life 4.3 Changes to food choices Changes to healthy eating,

Cost implications, 5. Impact of change 5.1 Restriction

5.2 Sensory appeal of textures Physical effects of modified food

171

5.3 Lack of enjoyment from food

Enjoyment of food, Going hungry, Compensation, Lack of variety,

5.4 Lack of control Feeling infantile, Control 5.5 Emotional reactions Intense reactions, Emotional

connection with food, Perceptions of being “fussy”, Feelings of jealousy, Resisting temptation

6. Learning from the trial

6.1 Increased understanding and appreciation

Appreciation of difficulties, Altered perceptions, Understanding of non-compliance

6.2 Future Practice Practical solutions, Diet modification as a last resort, Explaining to patients, Helping students, Emphasising safety

172

Appendix 7.24 CONFIDENTIALITY CHECKLIST

Speech and Language Therapy

Student number: ST20041074

Module number: SLP6080

Assignment: Project

Evaluate your submission and any supporting documentation, appendices etc. by answering the

following questions:

Yes No

1 Have you identified any person by their real name? ✔

2 Has any organisation been identified by its real name? ✔

3 Has any place been identified by its real name? ✔

4 Have any exact dates of birth been stated? ✔

5 Have any addresses and / or postcodes been included? ✔

6 Have any identifiable logos or letterheads been included which

might identify any individuals, places or organisations?

✔

7 Has any other documentation been included with this

submission that might enable any individuals, places or

organisations to be identified?

✔

If you have answered ‘yes’ to any questions, please explain why you feel this does not constitute a

breach of confidentiality in the space below:

The university name and logo was included in the documentation in the appendices. This was to

display that ethical approval was obtained via the university. All contact names, addresses, telephone

numbers and emails were removed.

173

8.0 - Word count Introduction & Literature review – 2,950

Methodology – 1,466

Results – 3,319

Discussion – 2,161

TOTAL – 9,896

in the patient’s shoes: the experience of diet ......b.sc.(hons) speech and language therapy in...

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