What are the perceived factors that influence accurate fluid balance chart completion in acutely unwell medical inpatients?
It has been long recognised that the maintenance of fluid balance was important for patient care, with Florence Nightingale highlighting the importance of food and drink to patients and noting that many patients are starved in the midst of plenty (Skretkowicz 1992). However little appears to have changed in over 100 years and it is evident these issues are still relevant to contemporary nursing practice.
Fluid balance charts (FBC) are non invasive tools (Tang & Lee 2010) that are used to document the type and amount of fluid administered to, and lost by the patient (Eastwood 2006). Collins et al (2013) suggests that nurses are able to detect and document subtle changes in the patients’ physiological state before trends become apparent by using their experience and documentation. The aim of a FBC is to keep an accurate daily record of fluid intake and output in order to identify deficits in intake or output and action accordingly (Scales & Pilsworth 2008). Although there are other ways to record fluid balance including daily weights or measurement of central venous pressure, FBCs remain the most frequently used as they are non invasive and can be completed contemporaneously. These charts are used to influence patient treatments and interventions, including the implementation or cessation of intravenous fluids, and the removal or insertion of urinary catheters.
Bolylan & Brown (1985) stated that FBCs are poorly and inaccurately maintained with Armstrong- Esther (1996) believing that FBCs were the least accurate of all observation charts with FBC being notoriously inaccurate in the deteriorating patient group (Sheppard 2000). Jonsson et al (2011) highlighted that prior to admission to intensive care nursing documentation is poor, although this may not be representative of poor patient care. There have been several national publications recently recognise that despite the awareness of poor FBC completion little has been achieved to improve this.
Aims/ Objectives
The aim of this study was to develop an understanding of factors which influence accurate completion of fluid balance charts. The specific objective was to identify perceived factors which influence accurate fluid balance chart completion in acutely unwell medical inpatients.
Methods
A qualitative approach using one to one semi structured interviews was used. A purposive convenience sample was undertaken. Registered Nurses (RNs) employed on seven acute medical wards in a large acute hospital Trust, working a range of shifts, who reported to complete FBC were invited to take part. Interviews were transcribed and anonymised. Transcripts were coded and themes arose identified. Initial codes were assigned for salient constructs and expanded as necessary and codes then compared across transcripts to identify convergence and divergence. Codes were refined by grouping and themes developed. Ethics and governance approvals to undertake the study were gained.
Results
Seventeen RNs participated in the study. Five key themes were identified: individual insight, making time to do it, knowledge and training, making it easier to be accurate and competing ward activities. In keeping with previous research all participants identified FBC completion as an integral part of patient care, and that for FBCs to be effective they needed to be completed accurately and in full. All but one of the participants identified that FBC completion was currently inaccurate. Participants identified there needs to be change in current practice to facilitate an improvement in FBC completion.
Conclusions.
This small qualitative study contributes to the current local understanding of factors that influence FBC completion. As this was a relatively small, single centre study it is not possible to generalize these findings in a wider context without carrying out further research. In the local context the findings suggests that practice could be improved by standardising practice by the development of a formal education programme and guidelines on FBC completion.