Recognising and Preventing Dehydration

Introduction and Background
Dehydration is a fluid imbalance in the body caused by too quickly a loss of fluid or by too little fluid going into the body. As the body ages, it becomes increasingly difficult to maintain an optimum fluid balance as the body’s ability to recognise its need for fluid becomes dulled (Ainslie et al., 2002; Rolls and Phillips, 2009). Dehydration can occur particularly quickly in the elderly, with potentially harmful effects (see for example Weinberg et al., 1995; Davidhizar, Dunn and Hart, 2004) including increased risk of hospitalisation (Gordon et al., 1998; Xiao, Barber and Campbell, 2004) and increased risk of fatality (Warren et al., 1994). Recent figures (Press Association, 2011) show that high numbers of nursing home residents are dying in the UK as a result of dehydration and research from America shows that this could be due to low staffing numbers (Harrington et al., 2000; Schnelle et al., 2004; Bostick et al., 2006; Shipman and Hooten, 2007).
Study Rationale

Low staff numbers and staff morale could lead to a higher risk of dehydration in nursing home residents for a number of reasons including low motivation to carry out duties. This may create a vicious circle in which low staff morale leads to more staff absences and short staffing as a result. Identifying low staff numbers and low staff morale as a predictor of risk of dehydration could help nursing home providers tackle the problem more effectively and reduce resident risk of dehydration.
Research Question
Can under-staffing and low staff morale predict a higher risk of resident dehydration in UK nursing homes
Literature Review
A literature review was carried out to identify the gap in knowledge relating to dehydration in UK nursing homes. The key words and terms used to carry out this search were: “dehydration”, “nursing homes”, “UK”, “understaffing”, “risk” and “staff low morale”. The literature review revealed some relevant studies, most of which had been carried out primarily in America.
Although there are causes of dehydration that arguably cannot be caused by poor nursing home conditions or under-staffing, there are many that can. Excessive sweating, too little fluid intake or fluid accumulation could be caused by patient neglect, such as failure to escort a patient to the toilet or something as simple as failing to notice an elderly patient is having trouble pouring from a water pitcher (Kayser-Jones et al., 1999; Mentes, 2006). Understaffing has been associated with a decrease in patient care quality in general. For example, Harrington et al. (2000) found that fewer registered nurse hours in nursing homes had a significant, negative relationship with quality of care. Schnelle et al. (2004) used three different data collection methods to compare nursing homes that had reported differing statistics about staff numbers and quality of care. It was also found that higher staffed homes performed significantly better on processes of care than lower staffed nursing homes. However, Harrington et al. (2000) found that facility characteristics and state were stronger predictors of care quality within nursing homes and by their own admission state that much more work is needed in the area.
The Royal College of Nursing’s (2010) guidelines on safe nurse staffing levels in the UK state that avoidable complications can only be avoidable if effective nursing care is delivered effectively and consistently. They report that nurses with no more than six patients under their care rarely feel that patient care is compromised, whereas a ratio of one to eight leaves nurses feeling that patient care is being regularly compromised. In nursing home settings, there is an average of 18 patients per registered nurse during the day, and 26 patients per registered nurse at night (Royal College of Nursing, 2010). These numbers suggest that nursing homes are continuously under staffed.
Morgan et al. (2003) have suggested that dehydration may not simply be a result of the aging process, but also a result of dependent living. This sentiment has been echoed by later research. Bossingham, Carnell and Campbell (2005) found that elderly adults who lived out in the community were matched to young adults in terms of hydration balance. In contrast, Mentes et al. (2006) found that 31% of 35 nursing home residents they observed over a six month period were suffering from dehydration. Kayser-Jones et al. (1999) found that nursing home residents were more at risk of dehydration when staffing was inadequate and supervision of residents was poor. It was also found that mean fluid intake of the residents was inadequate. In the UK, recent figures from the Health Service Journal (Press Association, 2011) online obtained from the Office for National statistics show that between 2005 and 2009, 667 elderly residents of care homes died as a result of dehydration. These figures suggest that understaffing in nursing homes has a role to play in high levels of dehydration in UK nursing homes. They also suggest that elderly individuals in the care of nursing homes may be at more risk of dehydration than if they were to be cared for in the community.
Dyck (2007) has commented that despite the importance of both numbers and type of staffing in nursing homes on residents health, the research behind the relationship has been minimal and there are currently a number of key gaps in the literature. Firstly, the majority of research has been carried out in America. Therefore, research into the issue in the UK is lacking. Secondly, the literature fails to take into account the potential role of staff morale in the relationship between staff numbers and care quality. The decrease in quality of care thought to be associated with low staff numbers could be also partly due to low staff morale. Registered nurses with high morale in the workplace may be able to cope better in situations where staff numbers are low and reduce the impact these low numbers have on resident care. Finally, there are few studies that have focussed on the impact that low staff numbers and morale have on dehydration in particular.
Purpose of the Study
The purpose of this study is to investigate the degree to which under-staffing and low staff morale has an impact of resident risk of dehydration in UK nursing homes.
Research Design and Methodology
This study will use a quantitative method in the form of closed statement questionnaires.
Data Protection Procedures
See ethical considerations.
Setting
The interviews will be carried out within each nursing home. Resident’s will be interviewed either within their own rooms or in communal areas. Staff will be interviewed independently, within a suitable, quiet room within the nursing home premises.
Sample
Local nursing homes will be invited to take part by letter. Invitation letters will be followed up by a telephone to call to confirm whether the nursing home is interested.
Data Collection
Residents will be asked the following statements to assess risk of dehydration:
I often feel thirsty during the day.
I don’t have adequate access to water during the day.
I am not given a choice of what liquid I can drink during the day.
I am offered plenty of water throughout the day.
I find it hard to help myself to water.
I am able to go to the toilet whenever I need to.
I often feel uncomfortably warm during the day.
My water needs are always met promptly.
Nursing home staff will be administered a separate questionnaire with the following statements:
I enjoy my job.
I look forward to coming to work every morning.
If I was offered a new job elsewhere I would take it immediately.
I feel that I am supported adequately during my duties at work.
I have low morale when it comes to my job.
I feel that the nursing home is adequately staffed on a daily basis.
I struggle to attend to all my residents.
I feel that my level of pay is good.
Residents and staff will be asked to state whether they strongly disagree, disagree, don’t know, agree or strongly agree to the statements. Each answer will be scored from one to five with one corresponding to a ‘strongly disagree’ answer and five corresponding to a ‘strongly agree’ answer. In addition to the interviews, the nursing home manager will be asked to provide the average ratio of staff to residents on day and night shifts.
Controls
Residents taking medicines that affect renal function should be excluded from the questionnaire as this will increase their risk of dehydration. Additionally, the questionnaires include statements that will be negatively scored. These are designed to identify participants who have not fully understood the questions or who are guessing the answers. In the residents’ questionnaire these are question numbers four, six and eight. In the staff questionnaire these are question numbers three, five and seven.
Ethical Considerations
Residents’ or staff personal details will be completely anonymised and each participant will be assigned a unique identifying number. Personal details of participants and of the participating nursing homes will also be anonymised and kept on a secure, password protected database.
Data Analysis
The questionnaires will be scored, categorised and entered into a SPSS (2010) database. Residents’ questionnaires will be scored into three categories: a score between 8 and 20 will be categorised as a low risk of dehydration, a score between 20 and 28 will be categorised as a medium risk and a score of between 28 and 40 will be categorised as a high risk of dehydration. The staff questionnaire will be scored in a similar way: a score between 8 and 20 will be categorised as low morale, a score of 20 to 28 will be categorised as normal morale and 28 to 40 will be categorised as high morale. Average staff to resident rations obtained from the nursing homes will also be categorised in to high, medium and low for both day and night shifts. Once all the data is entered into the database, a logistic regression will be performed to predict the outcome of resident risk of dehydration based on the predictor variables of staff morale and staff to resident ration.
Findings
Discussion
Study Limitations
This research proposal has a number of limitations. The use of a questionnaire can result in social desirability bias, particularly in the case of the staff. Nursing home staff may feel worried about revealing their true feelings surrounding their job. Anonomysing results may go some way to reducing this limitation as will enabling staff to carry out the interview without the presence of an interviewer.
Another limitation is failure to obtain a direct measure of dehydration. However, nursing home managers are unlikely to disclose cases of dehydration or deaths related to dehydration unless required by law. However, use of a urine colour chart could have been useful in assessing whether a resident was suffering from dehydration at the time of completing the questionnaire.
Another limitation of the study is the use of a visual questionnaire. This format may mean that residents or staff with visual difficulties are unable to partake in the study. To tackle this limitation, questionnaires could be administered in interview format so that participants are able to answer orally.
Produce a time table, explore potential problem and includean estimation of resources.
Conclusion
References
Ainslie, P.N., Campbell, I.T., Frayn, K.N., Humphreys, S.M., MacLaren, D.P.M., Reilly, T. and Westerterp, K.R. (2002) Energy balance, metabolism, hydration, and performance during strenuous hill walking: the effect of age. Journal of Applied Physiology, 93(2), pp. 714-723.
Bossingham, M.J., Carnell, N.S. and Campbell, W.W. (2005) Water balance, hydration status, and fat-free mass hydration in younger and older adults. American Journal of Clinical Nutrition, 81(6), pp. 1342-1350.
Bostick, J.E., Rantz, M.J., Flesner, M.K. and Riggs, C.J. (2006) Systematic review of staffing and quality in nursing homes. Journal of the American Medical Directors Association, 7(6), pp. 366-376.
Davidhizar, R., Dunn, C.L. and Hart, A.N. (2004) A review of the literature on how important water is to the world’s elderly population. International Nursing Review, 51(3), pp. 159-166.
Dyck, M. J. (2007) Nursing staffing and resident outcomes in nursing homes: Weight loss and dehydration. Journal of Nursing Care Quality, 22(1), pp. 59-65.
Gordon, J.A., Lawrence, C.A., Hayward, R.A. and Williams, B.C. (1998) Initial emergency department diagnosis and return visits: Risk versus perception. Annals of Emergency Medicine, 32(5), pp. 569-573.
Harrington, C., Zimmerman, D., Karon, S.L., Robinson, J. and Beutel, P. (2000) Nursing home staffing and its relationship to deficiencies. The Journals of Gerontology, 55(5), pp. S278-S287.
Kayser-Jones, J., Schell, E.S., Porter, C., Barbaccia, J.C. and Shaw, H. (1999) Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision. Journal of the American Geriatrics Society, 47(10), pp. 1187-1194.
Mentes, J. (2006) Oral hydration in older adults: Greater awareness is needed in preventing, recognising, and treating dehydration. The American Journal of Nursing, 106(6), pp. 40-49.
Mentes, J.C., Wakefield, B. and Culp, K. (2006) Use of a urine color chart to monitor hydration status in nursing home residents. Biological Research for Nursing, 7(3), pp. 197-203.
Morgan, A.L., Masterson, M.M., Fahlman, M.M., Topp, R.V. and Boardley, D. (2003) Hydration status of community-dwelling seniors. Aging Clinical and Experimental Research, 15(4), pp. 301-304.
Press Association, 2011. Hundreds of care home deaths caused by dehydration. Health Service Journal, [online] 31 January. Available at: http://www.hsj.co.uk/hundreds-of-care-home-deaths-caused-by-dehydration/5024860.article [Accessed on 27 January 2012].
Rolls, B.J. and Phillips, P.A. (2009) Aging and disturbances of thirst and fluid balance. Nutrition Reviews, 48(3), pp. 137-144.
Royal College of Nursing (2011) Guidance on safe nurse staffing levels in the UK. London: Royal College of Nursing.
Schnelle, J.F., Simmons, S.F., Harrington, C., Cadogan, M., Garcia, E. and Bates-Jensen, B.M. (2004) Relationship of Nursing Home staffing to Quality of Care. Health Services Research, 39(2), pp. 225-250.
Shipman, D. and Hooten, J. (2007) Are nursing homes adequately staffedThe silent epidemic of malnutrition and dehydration in nursing home residents. Until mandatory staffing standards are created and enforced, residents are at risk. Journal of Gerontological Nursing, 33(7), pp. 15-18.
Warren, J., Bacon, E., Harris, T., McBean, A.M., Foley, D.J. and Phillips, C. (1994) The burden and outcomes associated with dehydration among US elderly, 1991. American Journal of Public Health, 84(8) pp. 1265-1269.
Weinberg, A.D., Minaker, K.L., Coble, Y.D. et al. (1995) Dehydration evaluation and management in older adults. The Journal of the American Medical Association, 274(19), pp. 1552-1556.
Xiao, H., Barber, J. and Campbell, E.S. (2004) Economic burden of dehydration among hospitalized elderly patients. American Journal of Health-System Pharmacy, 61(23), pp. 2534-2540.