A qualitative study exploring staff attitudes to maintaining hydration in neurosurgery patients

Abstract Aims To explore staff perceptions of the processes and influences on maintaining patients’ hydration on a busy neurosurgery ward. Background Dehydration continues to be a major concern in the NHS where its avoidance is hindered by complications arising from clinical conditions, poor assessment and documentation of hydration and a lack of staff time to monitor fluid intake. Recent work has explored patient perceptions of hydration care but there has been little conducted recently that has explored those of staff. Methods Semi‐structured interviews were conducted with staff working on a neurosurgery ward during 2016. We used open‐ended questions to elicit experiences of hydration care and explore factors that influenced the maintenance of hydration in patients. Results We found that staff were aware of the importance of hydration and saw it as a central aspect of the care they provided. A range of staff are involved in the assessment of patients’ hydration requirements and their ability to meet them. Similarly all staff were expected to provide oral fluids for patients able to drink independently. Competing priorities inhibited the time staff could spend providing hydration care which had an impact on the timely and accurate completion of fluid balance charts and meant that relatives were relied on to support patients requiring assistance in drinking.


| BACKG ROU N D
Patients rely on the support of healthcare providers to remain hydrated yet staff are spending less time with patients than ever (Westbrook, Duffield, Li, & Creswick, 2011), leaving those with limited movement or impaired cognitive ability particularly vulnerable.
In response to enduring concerns, a series of initiatives have been introduced in the UK designed to raise awareness and improve hydration care for secondary care patients (Lecko, 2014;Lewington & Kanagasundaram, 2011). However, despite the best efforts of policy-makers and providers, reports of harm, occurring due to dehydration in our hospitals, continue to emerge (Lecko & Best, 2013).
Recent work has explored patient perspectives of hydration (Johnstone, Alexander, & Hickey, 2015) yet there is little which has investigated staff experiences of the realities of maintaining hydration on the modern ward. To meet this gap our qualitative study engaged staff on a busy neurosurgery ward, to help understand the issues around the maintenance of hydration for patients with a range of physical and cognitive capabilities. We explored staff attitudes and awareness, how they assessed and maintained hydration and the barriers and facilitators they encountered.

| Aim
The aim of the study was to explore the experiences of staff attempting to maintain hydration on a busy neurosurgery ward for a diverse range of patients. The objectives were to explore the processes and systems used, the particular staff involved and when and any facilitators or barriers encountered.

| Design
This qualitative study was conducted in one ward in a busy UK hospital. Data were collected over 12 months using semi-structured interviews. Semi-structured interviews were chosen as the topic guide helped us define the areas to be explored, but also allowed us to pursue any emerging ideas in more detail (Britten, 1999). The ten interviews were conducted by a single researcher and the study was facilitated and analysed with the help of a Practice Development Nurse.

| Setting/participants
The research was carried out on a neurosurgery ward in a large, modern acute hospital in Central England. The ward consists of 36 beds, 16 in single rooms and 20 occupy five rooms containing four beds. The neurosurgery ward was chosen because its patients typically exhibit a wide range of physical and cognitive capacities, age and elective and non-elective admissions. Elective admissions are those scheduled in advance and in neurosurgery include spinal, craniotomy, or shunt operations whereas non-elective admissions can be defined as unplanned or urgent due to clinical need often as a result of traumatic injury. Taken together this means the patients on the ward are broadly representative of the wider patient group. Representatives of each staff group involved in the process of maintaining patient hydration were purposively selected to participate, including registered nurses, nursing assistants, a housekeeper and two ward sisters. They were provided with an information sheet in advance of the study, by a member of the study team, before then being consented and interviewed the next day.

| Data collection
Semi-structured interviews were held with staff and patients at a mutually agreed time in a private room on the ward. The interviews were conducted by Author1, a Research Fellow with 10 years experience of qualitative research conducted in a variety of healthcare settings. One ward sister was consulted prior to commencement to explain the background of the study. None of the other participants were known to the interviewer. Open-ended questions were used, to elicit experiences of hydration care and to explore the range of factors that encourage or discourage fluid intake. The topic guide can be found in Box 1.

| Analysis
The interviews were digitally recorded and transcribed verbatim.
They lasted between 12 and 25 min and the data they produced managed using nVivo Software v10 (QSR International, 2012).
Thematic analysis of the data was employed which involved reading and re-reading transcripts to become familiar with the data and to permit the identification of themes and categories (Morse & Field, 1995). The key themes and concepts were identified by Author1 and cross-checked by Author2, the Practice Development Nurse with several years experience in service improvement. During the analysis these themes were regularly reviewed and refined as new data were accumulated using the constant comparison method (Strauss & Corbin, 1990). Writing and re-writing of the thematic analysis was an integral part of interpreting the data (Richardson, 1994). The interviews continued until data saturation was reached and no new themes or insights obtained (Bowen, 2008).

| Rigour
Data collection and analysis followed best practice in qualitative research strategies (Krefting, 1991), including maintenance of records of the interviews and subsequent rounds of analysis, further enhanced by the input of an experienced nurse and a senior neurosurgery consultant.

| RE SULTS
A total of 10 interviews were conducted with staff holding a variety of job titles, including nursing assistants, staff nurses and ward sisters. The years in post of staff on this ward varied from less than 1 year to over 12 years. This data is summarized in Table 1.
The analysis produced four key themes and associated subthemes. The four key themes were: 1) Assessment of Hydration describing the influences of clinical characteristics of patients and the staff responsible; 2) The Maintenance of Hydration, describing the provision of fluids and the monitoring of hydration levels; 3) Facilitators of hydration, describing third party support and staff awareness; 4) The Barriers experienced in relation to patient characteristics, finite resources and unreliable fluid balance charts.
This describes the influences on determining the hydration needs of patients on admission and the job title of the staff responsible.

Non-elective admissions
Two pathways emerged depending on whether they were nonelective or elective admissions.
Many non-elective admissions are nil-by-mouth until they have been diagnosed and a care plan determined: 3. How is Hydration maintained?

Prompts
• Do you provide assistance? What is its nature?
• How do you decide on the appropriate level of support?
• Who is responsible?
• Are fluid balance charts used/respected? 4. What do you feel are the key barriers to patients' hydration?

Prompts
• What/when are the opportunities to drink • Is accessibility of fluid an issue?
• Are you able to meet patient preferences? The constant monitoring and re-appraisal of the patients' needs and capabilities by those attending them was described: "It's not assessed formally, it's more of an informal assessment that you're sort of… so as you get to know the patient sort of limitation wise" SN1

| Maintenance of hydration
Here we describe how hydration is maintained; firstly the means by which fluids are provided for patients and secondly the way ensuing levels of hydration are monitored.

| Facilitators to hydration
Two key facilitators were described 1) the use of carers and relatives in supporting assisted hydration and 2) the benefits of raising awareness, amongst staff, of the importance of maintaining adequate patient hydration.

Use of relatives
Staff described a degree of dependence on third party support and named relatives as one group they relied on:

Importance of hydration
The awareness of how important the role of hydration is, in maintaining health and promoting recovery, was described:

"I think most people understand that fluid's important for your health and it's just like…'You get the jugs, push the fluids and document the output' Everyone knows how to do that." NA3
It was acknowledged that, although awareness was increasing, and hydration care was improving, it was not yet optimal: "We used to just slam down a jug and hope for the best, but I think we were quite… we're getting better, good is probably the wrong word, but we're getting better."

Training and experience
Staff would be reminded to make sure drinks were readily accessible by patients, taking into account any restriction in their movement: "We encourage the staff to make sure that when they

| Barriers
There were several barriers described that might inhibit successful maintenance of hydration on the ward relating to patient characteristics, finite resources and unreliable fluid charts.

Borderline independent patients
Patients who were borderline dependent, or whose condition might change, presented a challenge, particularly when attention was focussed on those considered more vulnerable: "…it's easy to put up a bag of fluid and then they're hydrated for the day…but when you think they're looking after their own fluids and then suddenly you Not everybody involved in hydration had access to the software system that hosted the charts. A code was required, which agency staff did not possess, so they relied on others to enter the data: "The majority of our staff have access like it's more if you've got external agency staff they don't have access, if they write it down our own staff will put it in."

Inaccurate input
The Fluid Balance Charts were sometimes populated using an estimation of the fluid consumed, based on what was remaining in the jugs, yet without knowing when the jugs were last filled: "So a lot of the time you're guess working. You're, like, 'Well, 250 mls has gone out of that jug.' but is it their first jug of the day? Is it the second?" NA1

| Summary of findings
There is a lack of literature exploring staff perspectives on the barriers and facilitators of maintaining hydration in busy secondary care environments. Our study found that a range of staff were involved in the assessment of patients' capabilities to maintain their hydration and those we spoke to were not only aware of the importance of this maintenance but contributed, at some stage, to hydrating patients. However, many described how pressures on their time meant that maintaining adequate patient hydration was just one of several competing priorities and restricted them to issuing simple verbal prompts to patients instead of being able to invest time in socializing the process. These same pressures meant they lacked opportunity to regularly complete fluid balance charts, often entering estimated data after the event and frequently relied on relatives to support those patients who needed assistance with hydration. Particularly for patients deemed capable of independent or assisted hydration. For it emerged that it was this group considered most at risk in comparison to more clinically dependent patients who were hydrated intravenously or via naso-gastric tube.  Lecko, 2014;NICE, 2016), may have contributed to this recognition, alongside reminders of best practice issued by senior hospital managers. A range of staff would be involved in assessing hydration needs, including speech and language therapists though there was a lack of awareness of existing protocols this has been seen before in the healthcare environment (Cabana et al., 1999;Powell et al., 2011;Pronovost, 2013). The potential adverse effects on the study ward of nonadherence were mitigated by the understanding amongst staff that the process of assessing hydration requirements is a continual one, offering protection to patients whose capabilities and needs alter.

| Specific findings
Perhaps counter-intuitively non-elective admissions and those patients who were most seriously ill were considered less vulnerable to dehydration because they were more likely to be receiving fluids intravenously or through a naso-gastric tube. It was the patients considered capable of independently maintaining their hydration who were deemed most vulnerable as not all patients are equally vocal in requesting fluids. There is existing evidence that amongst more passive patients the fear of being considered difficult inhibits the willingness to speak-up (Doherty & Stavropoulou, 2012).
Staff acknowledged that the regular verbal reminders they provided patients, might not ensure that individuals consumed an adequate volume of fluid. Previous evidence has supported the notion that this type of repeated prompting can actually be counterproductive as it precludes the richer, social experiences of drinking and reinforces the feeling of dependency in patients (Mentes, 2006;Phelan, 2011). The removal of the social aspects of drinking experienced by many patients in the ward environment can have a negative impact on their hydration, medicalizing drinking and removing the social cues they might otherwise draw on (Archibald, 2006;Godfrey et al., 2012;Simmons et al., 2001). This offers another reason as why staff felt family members were so important in maintaining hydration, not only providing physical assistance with drinking but also social context. Several previous studies have also described the importance of involving family members in the care of their relatives in hospitals (Collier & Schirm, 1992;Greenwood, 1998;Higgins & Cadd, 1999;Li, 2005;Li, Stewart, Imle, Archbold, & Felver, 2000) and how they can fulfil a valuable role as vigilant members of a patient's healthcare team (Carr & Fogarty, 1999;Cioffi, 2006).
Though willing, the possibility of staff interacting with patients while they drink in the way that relatives might, was inhibited by the increasing pressure on staff time which reflects previous research (Mentes, Chang, & Morris, 2006;Simmons et al., 2001). There is also evidence that nurses only spend approximately a third of their time with patients (Westbrook et al., 2011) despite it being central to their job satisfaction (Westbrook et al., 2011), reducing the number of errors (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002;Duffield et al., 2011;Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002) and leading to better patient outcomes (Staniszewska & Ahmed, 1998). Instead the demands placed on nursing staff mean that multi-tasking is increasingly common and one of our participants described the difficulties experienced in supporting patient hydration whilst also conducting a medication round. Yet there is a growing expectation of nurses, to manage such competing priorities which is a concern considering evidence that multi-tasking can lead to lengthier time to task completion, memory lapses, errors and accidents (Appelbaum, Marchionni, & Fernandez, 2008).
These constraints on staff time also limit their capacity to complete charts every time they provided fluid instead entering estimations at a later point. It also emerged that not everyone providing fluid had access to the software system that hosted the fluid charts.
Issues, around the validity of fluid balance charts, have been observed previously (Care Quality Commission (CQC), 2013; Francis, 2013;Pinnington, Atterton, & Ingleby, 2016;Reid et al., 2004) and these shortfalls perhaps contributed to the fact that staff continued to follow recommendations to use physiological cues in determining hydration (Francis, 2013).

| Strengths and limitations
Our work provides a much needed staff perspective on the experience of maintaining hydration on a busy, acute ward where gaps in hydration care remain, despite growing awareness of its importance.
The work we have conducted here might usefully be extended to other wards and secondary care facilities. That saturation was reached after comparatively few interviews can be explained by consensus theory, which describes how those of similar experience provide similar answers, when asked about a focussed topic area (Romney, Batchelder, & Weller, 1986). Nevertheless, the evidence we present adds a compelling and current perspective to the existing evidence base.

| CON CLUS IONS
Ward staff were clearly aware of the importance of hydration, but acknowledged that time constraints, particularly for busy nurses, meant that they could not be more directly involved in supporting hydration. This left independent, yet passive patients at particular risk from dehydration. This risk might be eased by increasing the variety of drinking devices offered to patients to better support independent consumption. Physiological clues continue to be used by nursing staff that could not always rely on of the accuracy of fluid balance charts, particularly as more staff were involved in providing fluids than had access to the hosting software. It is unlikely that the time pressures experienced by staff will ease in the near future so the support of relatives, carers and auxiliary staff is likely to remain essential, as is a more reliable way of capturing data on fluid balance.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest.