Essay: Explore effective hydration care for elderly in clinical settings

Abstract
Purpose: To explore effective hydration care for elderly in clinical settings and what (if any) implications this has on nursing practice for improvement.
Method: A literature study of primary research was conduct with the use of online databases such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Medical Literature Analysis and Retrieval System online (MEDLINE) of research published within the last ten years.
Findings: From the literature review, it was found that significant issues exist in nursing management of hydration care. These issues are associated with an increased recognition of hydration, increased compliance with the dehydration guidelines and multiple strategies for effective hydration care. Despite observational and clinical research a lack of empirical evidence makes raising hydration as a key health area problematic with regard to patient safety and self-management linked with nursing practice. There is also a need to develop a universal system in hydrations care studies to facilitate meta-analysis.
Conclusions: The multi-strategy based approach can enhance effective hydration care and promote self-management in elderly inpatients with dehydration risk. Findings highlight hydration care and education must become and remain a priority as a part of dignity in care and form the basis on which quality care for older people to establish.
Key words: hydration, elderly, inpatient, nurse, effective
1.0 Introduction
Dehydration is a potentially dangerous state of a reduction of the amount of water in the body, which is associated with increased mortality, morbidity and disability (Hooper et al., 2014; WHO, 2011). While severe dehydration (fluid loss≥10% of body weight) is life- threatening, even a fluid loss equivalent to 1-2% of body weight can have an adverse effect on physical and mental performance, particularly in older people in hospitals (Jéquier and Constant, 2010). However, there are no exact figures on the dehydration status of the UK population. This is relatively due to a lack of dehydration focus or information as a public health issue for the development of sustainable strategies in hydration policy
Despite dehydration is a preventable state, elderly patient dying of thirst raises many questions about the standards of care received by elderly inpatients. This issue has been highlighted repeated by independent organisations (CQC, 2012, the patients Association, 2010). Moreover, it has long been associated with failing standards of care due to a lack of awareness, monitoring and populated training. Borland (2011) reports dehydration contributes to around 800 deaths in hospital annually. According to the Care Quality Commission (CQC) report (2012), many patients are not being given enough to drink and water is being left out of reach or no fluids are given for long periods of time. Subsequently, the Francis report (2013) shows older patients are particularly at risk of dehydration because of inadequate or no nursing assistance. Thus, due to a lack of effective support for elderly patients that are particularly vulnerable, dehydration can lead to significant patient safety concerns.
Adequate hydration is recognised as a fundamental aspect of essential clinical care within the UK (DH, 2010). It is necessary for nurses to explore effective hydration care for elderly inpatients to ensure services meet the personal needs. Despite Wilson (2014) classifies a clear idea of what good hydration practice should involve, he claims that good hydrating is not just about providing drinks for older people, the challenges take account of screening, research, raising awareness, workforce training, and effective practice.
The aim of this review is to identify nursing practice in improving hydration care and consequent patient outcomes within the clinical settings. Report by Dr Wilson on behalf of the parliamentary hydration forum (2014) found that nurses are uncertain about aspects of their role and accountability. The report also raises the main challenge for nursing staff as well as patients of poor recognition of dehydration and working on urgent dehydration profile reform particularly in older people. Cook (2005) has argued the complexities of managing hydration in patients and pointed out the role of the nurse in hydration management has been ill-defined in the literature. Soon after, Mentes (2006) highlighted greater awareness should be raised for holistic, individualised hydration care, particularly for elderly in clinical settings. Hence, Nurse-driven multi- strategy based approach is found to improve regulated and inspected care issues through the recognition and compliance with guidelines.
2.0 Methods
2.1 Search strategy
To find the most appropriate, relevant, and useful literature for this review, an online search of articles published until July 2016 was performed in databases including the Cumulative Index to the Medical Literature Analysis and Retrieval System online (MEDLINE) and Nursing and Allied Health Literature (CINAHL). A systematic search was conducted using key search terms such as hydration, elderly, inpatient, nurse and so on (See Appendix A).
These searches were initially restricted in academic databases for relevant generalisable data and literatures published between 2006 and 2016 for up to date evidence (Aveyard, 2014). The search found many articles (n = 363), in spite of this, few seemed to be of specific relevance to the topic question. Using Boolean operators of ‘OR’ and ‘AND’ to further refine the search, it provided a more useful result (Cronin, Ryan and Coughlan, 2008). Despite hydration abstracts, relevant literature was sparse. In response, ‘snowballing and backward snowballing’ was used as the second strategy for preliminary evidence gathering of literature to find relevant studies within the literature (Sayers, 2007). These strategies were also adopted in Google Scholar, which provides literature research with an advanced facility known as ‘citation tracking’ (Shultz, 2007). As a result, the search process had a wide catch of peer-reviewed literature and presented up-to-date selection. Appendix B details the strategy flow diagram to demonstrate how the search produced five papers.
2.2 Critiquing framework
The Critical Appraisal Skills Programme (CASP) cohort study checklist appraisal tool was used to critically appraise five pieces of evidence identified in this review as it provided a relevant but international critiquing of evidence (Parahoo, 2014).This facilitated the ability to systematically examine research evidence to assess its relevance , results and validity for clinical implementation (Burls, 2009). Using critiquing frameworks provides a systematic basis to identify if research is well designed and constructed; if there are any limitations and if the research can be applied to local practice (Glasper and Rees, 2013; Steen and Roberts, 2011). While the chosen studies were of different designs, a comprehensive, structured checklist from CASP with appropriate modifications was used to examine the quality and critique the integrity of the chosen papers (Appendix C). Unfortunately, it cannot overcome the problem of publication bias and the ‘grey literature’ (Bowling and Ebrahim, 2005).
2.3 Limitation
There are potential limitations of this search which include using only few academic databases, adopting literatures from only the last decade and exploiting Google Scholar to index ‘most relevant’ result. This search strategy may potentially omit relevant and valuable evidence; yet, it would have been more difficult to search through a greater body of literature to find relevant research. Even though various study designs of the literatures supply more aspects of view, it may well imply a weakening in the power of the review. Moreover, the selection with only two researches from outside UK may hinder the international contribution to health service innovation in the UK (Lobiondo-Wood and Haber, 2014). However, with the goal of generalisability and transferability, it was necessary.
3.0 Critical review
This chapter will critically appraise the literature surrounding hydration care for elderly inpatients (≥65 years old) (See the eligibility in Appendix C: the summary table of the key evidence).
A total of five papers have been reviewed (Appendix C). Those chosen were: Johnstone, Alexander and Hickey (2015), El-Sharkawy et al. (2015), Godfrey et al. (2012), Wakefield et al. (2009) and Ullrich and Mccutcheon (2008). Three papers used multiple methods while the study design in all papers includes an observational method. One of the studies took place in the United States of America (USA) and one took place in Australia, whereas three studies took place in the United Kingdom. It could be argued that despite differences in overall health structure, hydration is a global concern and the care in both dewestern countries are broadly similar to that of the UK (Robertson, Gregory and Jabbal, 2014; Roe and Liberman, 2007). For those reasons, the choice of studies maximizes the possibility of data generalisation.
The themes identified were, hydration Identification and assessment, culture and attitude in hydration care, health-promotion strategies. It has been identified that five studies with various design, none involving randomised comparisons. Results were mixed: all studies involved hydration factors; three favoured nursing care strategies based on social, functional, environmental, culture and attitude with slightly different focus; two studies conducted on technique Identification and assessment to explore risk factors and indicators. The data was combined to verify if multi-strategy approach model based on Godfrey et al. (2012) was applicable. However, the data was insufficient as more research was needed, particularly randomised trials.
It is worth to specifically mention that the study by Godfrey et al. (2012) in the University of the West of England shapes this literature review. This study has been internationally cited 21 with 8 versions and it presents a rich and in-depth understanding of the complexity of hydration care. The study provides solid local evidence of strategy-based approach model to promote social interaction has been proved by the other studies in significantly improving hydration status and meeting complex hydration needs in the elderly. More importantly, the study has recommended effective hydration care should include education targets, hydration principles, attitude and various strategies. The proposition forms the context of approach model, which has valuable implications to encourage extended participants in the complexity of hydration care and promote patient self-care and self-management for health change.
3.1 Hydration identification and assessment
The five studies had analysed hydration factors for nursing identification and assessment from perspective of individual variables, physiological, psychosocial, and environmental and technique methods. However, with various study designs, each has different focus aspects that together give more comprehensive evidence in hydration care (See Appendix C).
Research has suggested that nurses’ recognition of patient dehydration status is poor (Wilson, 2014; Bryant, 2007; Ferry, 2005). El-Sharkawy et al. (2015) and Wakefield et al. (2009) measured their findings accurately and objectively to minimise bias .Johnstone, Alexander and Hickey (2015) found that 42% of patients could not reach the jug of water, which indicated the nurses did not recognise patients’ hydration complex needs that not just a cup of tea. Correspondingly, El-Sharkawy et al. (2015) found 62% were still dehydrated at 48 hours after admission. These findings are consistent with those from the other three studies. Thus, this may have implications for allowing for patients’ condition to deteriorate without efficient recognizing and assessing for appropriate hydration care (NCEPOD and Stewart, 2009; Wakefield et al., 2009).
The study by Godfrey et al. (2012) presents results of qualitative semi – structured interviews with people (size of 49) to their perception of fluid balance, hydration care and determinants of hydration strategies. Interestingly, it described in the literature that the environment as one of factors that where it is consumed beverage, variety (according to preferences) (Godfrey et al., 2012). Despite other four studies more or less had discussed the factors, Godfrey et al., (2012) had the more practical discussion that is easy to recognise (See Appendix D). For example, these factors increase the risk dehydration due to the inability to control the sphincters and move to the bathroom. This situation for the elderly is potentially embarrassing, which consequently leads to loss of desire to drink and the risk of dehydration due to low fluid intake is upsurge (Godfrey et al., 2011). Additionally, the importance of drinks available while they are required and desired is a factor highlighted by service users (Godfrey et al., 2012).
As for psychosocial factors, Johnstone, Alexander and Hickey (2015) agree the factors that list in Appendix D. In the meantime, Godfrey et al. (2012) only referred to the fear of suffering from incontinence, which takes the elderly to ingest lesser amounts of liquid that are lack of further evidence to support (Ferry, 2005; Hooper et al., 2014). The literatures agree that ageing decreased sensation of thirst experienced the logo aging (Godfrey et al., 2012; Kenney and Chiu, 2001).
The results in El-Sharkawy et al. (2015) are credible as there appear to be stringent inclusion criteria, bias elimination, data collection and analysis. Selection bias was minimised, as the non-avoidable factor affecting cohort allocation were factors related to consistent ethical argument, removing the possibility of selection based on demographics or illness severity (Gerstman, 2013). While cohort studies do not sit as highly on the Hierarchy of Evidence (Evans, 2003) as RCTs and systematic reviews, the ethical implications of using the latter two should be considered. But then again, to obtain consent, appropriateness and the use of randomisation present problems for patients and clinicians with regards to non-maleficence (Bellavance and Alexander, 2011).
Further to say, El-Sharkawy et al. (2015) from more technique data collection through assessment tools such as CCI, NEWS, and NRS, to supply the insight of identifying hydration status for care change. Moreover, the descriptive statistics of patients with p values from 0.93 to 0.001 (the probability that the results obtained are due to chance. The smaller the value, the more reliable the data is (O’Brien, Osmond and Yi, 2015). This is a form of convenience bias; on the other hand, this is an appropriate consideration of the study design and should not greatly affect the reliability of the data. The data show precise results, improving the reliability of the study by showing to be replicable. Nevertheless, this study with large size of sampling of 200 produces more convincing results; it can be one important component of multiple strategies as monitoring to identify. But then, it is a single-centre study while interpreting the results which doesn’t necessarily represent the overall hydration complex situations.
El-Sharkawy et al. (2015) objectively measured the outcomes (hydration status and mortality rate with model adjustment for age, gender, illness severity) to give a statistically significant result. The objectivity in this regard strengthens the validity of the data. If outcomes were measured subjectively (i.e. what the researchers thought they had observed) there is a greater risk for confirmation bias (Pines, 2008). Having alternate data collection methods could affect the internal validity (Wilcox et al., 2012). Indeed, the authors state that this is to allow for evaluation of the implementation of the multiple strategies, which is a fair consideration. The study identified potential confounding variables (age, disease and ability) and accounted for these through multiple linear regression analyses (statistical tests that model relationships between variables).
3.2 Culture and attitude in hydration care
Researches has suggested not just health professional but also patients are sometimes confused about hydration matter and wonder about issues such as, how best to determine hydration status , how much individuals should drink and the need to drink fluid regularly(Wilson, 2014, Holdsworth, 2012). Five papers addressed staff and older people demonstrated the understanding the importance of hydration in the brief of background, study process or conclusions. However, insufficient knowledge of principles of hydration, insufficient theoretical interpretations has been a major concern (Wilson, 2014, EFSA, 2010 and NPSA, 2007).
On the basis of the results of this study, hydration should be a primary staffing priority. Hydration is fundamental to health and the well-being for elderly that has been recognized globally (WHO, 2011).Wilson (2014) emphasises that good hydration practice must become a part of regulated and inspected care issue. In line with it, Johnstone, Alexander and Hickey (2015) states that despite majority of nurses are under pressure at work, hydration must remain the duty of every health professional. Conversely, the report of El-Sharkawy et al. (2015) found that the dehydration rate was reduced from 79% at admission only to 68% after two days and 7% death among the participants. This also has been cited in the study of Johnstone, Alexander and Hickey (2015). The finding has an indication on nursing attitude and culture environments, suggesting the transformation of culture and attitude in leadership and professional practice into positive and proactive hydration support to meet personalised needs.
Another worth to mention is the study by Ullrich and Mccutcheon (2008). This descriptive study explored nursing practise of caring for older people with communication issues in the residents care setting. Notwithstanding the small size of 17, the study found that behavioural interaction based on reflective practices in promoting hydration care. Armed with this knowledge, nurses will be well equipped to assess the individual needs and to make clinical decisions about the most appropriate evidence-based nursing interventions to be used.
3.3 Health –promotion strategies
The relationship between the risk of dehydration and functional status is also complex. In this regard, Godfrey et al., (2012) emphasized that dehydration links with falls, constipation, rehabilitation outcomes, and risk of bladder cancer. Accordingly, El-Sharkawy et al. (2015) explained the impact of dehydration upon the well-being and patient outcomes. Consequently, this study highlights dehydration in elderly inpatients as a major concern for patient safety with poor outcome.
Equal importance is an insight into the use of criteria such as clinical /outcome indicators and benchmarking, what to do with what occasions, how to use such tools to nurses’ best advantage (Bullock, Clark and Rycroft-Malone, 2012). Patients with fluid imbalances that are fluid deficits or fluid overload can experience a variety of signs and symptoms. Nurses are in a position to be the first to recognize and respond to signs of fluid imbalance. In point of fact, Godfrey et al. (2012) is emerging that there are inadequacies in the skills and ability of nurses to do this well. Consequently, Bullock, Clark and Rycroft-Malone (2012) highlight the basic foundation of knowledge should embrace an understanding of the relationship between fluid imbalance and patient outcome.
Family/career involvement
The study of Godfrey et al., (2012) suggests older people in hospital appear to benefit when a family member or carer participate in aspects of their care. Beneficial family/career participation includes sharing information with staff. This information may establish the elderly’ usual behaviour patterns and will help to individualise a hydration care plan in order to provide a relatively consistent routine and encourage the desire of their hydration need. Family involvement in hydration care is discussed. More importantly, this kind involvement in patient care should not replace the nurses’ responsibility of providing this aspect of service. Therefore, developing knowledge and associated skills around this topic should be facilitated by reflecting upon nurses’ clinical experience and the ability to link theory and practice.
Develop comprehensive hydration strategies to implementation
Water intake recently there has been greater interest in dehydration in the elderly (Bryon et al., 2008; Abdallah et al., 2009) particularly among those living in residential care facilities (Bryon et al., 2010). Meanwhile, Godfrey et al. (2012) argues that despite hydration need in older people is complex; a positive environment and the socialising are helpful factors in increasing water intake in older individuals. They found in their study that patients thought it was bad that there were specific serving occasions when they were served drinks and they not adapted to their individual needs.
Godfrey et al. (2012), a qualitative study using multiple methods to collect and analyse the initial set of data, emphasise the importance of recognising the influence of health-promotion strategies. The multiple methods of collecting data in the study, improve the validity of the results as it is the process of triangulation. It has minimised the general limitation in qualitative research that researcher’s cultural viewpoint and beliefs affect their interpretation of the thing they observed. In this study, there is a clear correlation between the implementation of health-promotion strategies for improving hydration status. While correlation does not imply causality (Beebe, Hithcock and Menzies, 2009), it can be assumed that taking into account confounding factors, this research strengthens the body of evidence supporting the use of multiple strategies in hydration care. The sampling is not done randomly (See exclusion criteria in Appendix C), but it covers a broad range of possible perspective or situations related to the topic of multiple strategies with suggestion.