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An investigation into the use of fluid balance charts by qualified nurses Aileen Hemmisley Abstract: despite considerable changes to nursing practice in the last 10-15 years, certain procedures remain unchallenged. Nursing is gaining increasing autonomy, but evidence suggests that many widely accepted and practised routines and procedures have little clinical value due to the unreliability of the measurements. This study explores the use of fluid balance charts to assess a patient's fluid status. The use of such charts is widespread, but they are often inaccurate and commenced for no underlying clinical reason. The aim was to investigate the use of these charts by qualified nurses. The sample was selected from the qualified members of nursing staff working within the renal directorate of the Royal Hospitals NHS Trust, and the data was collected using questionnaires. The results of this small scale study indicated that the use of fluid balance charts by qualified nurses is often not rational and is of little worth in the clinical management of patients. The charts are often inaccurate and unreliable. This has implications in terms of practice and resources. Contents. Back to Nursing Progress contents. Introduction and the research problem As has been stated a common tool used by nurses to assess fluid status is the fluid balance chart or intake/output monitoring. However, there has been considerable debate over the continuing use of these charts. A review of the use of fluid balance charts on the nephrology wards demonstrated that the charts were inaccurate and commenced unnecessarily, for example clinically stable patients continued to be monitored. A large proportion of a nurse's daily workload is spent completing charts. (1), (2) Fluid balance charts are widely used in the expectation that the medical staff will use the information to prescribe the appropriate fluid management. However, there is evidence to suggest that this does not occur. (3), (4) Various reasons have been suggested to explain why this should happen. Several research studies indicate that a considerable amount of nursing practice is based on ritual and routine rather than scientific evidence. (5), (6) Indeed, some estimates claim that as little as 15-20% of nursing interventions are empirically effective. (7) This situation has several important implications. Implications for nursing practice Nurses are now expected to be increasingly proactive in their approach to patient care. Nursing interventions should be based on scientific evidence rather than ritual and routine. Rituals imply a service delivery based on intuition and assumption. This could be costly in terms of wasting valuable nursing time. The public service sector is expected to be accountable for its practices. Recent changes in the NHS and the introduction of the internal market have led to an increase in the emphasis on audit and quality assurance. Routines and rituals have been placed under intense scrutiny in a bid to reduce costs and improve efficiency. Therefore, it was felt to be appropriate to investigate the use of intake/output monitoring as a means of assessing fluid balance status, in particular when and why this method was used. The objectives of the study were to
The working hypothesis for the study was that the use of fluid balance charts by qualified nurses is an inaccurate, unreliable and non-rational means of assessing fluid balance. Fluid balance charts Past research into the use of intake/output monitoring has focused on their accuracy in comparison with other methods of assessment such as daily weight measurements. Pflaum investigated the use of fluid balance charts and discovered that there was a mean daily error in calculations of 8OOmls.(3) The study suggested that fluid balance charts only be used when done so in conjunction with daily weight measurements. Daffurn et al approached the problem in a different manner by observing nurses assessing fluid balance in a practical exercise and also by gathering data from a questionnaire.(8) The results of this study revealed from that sample felt that charts were inaccurate and commenced unnecessarily. The nurses also felt that the medical staff did not use the charts. However, it is impossible to generalise these findings to nursing practice in the UK, as there are no comparable British studies. In the UK work has tended to concentrate on BP recordings. For example, Kilgour and Speedie , found that a significant number of patients had their blood pressure recorded beyond the point when this was clinically necessary.(9) The reason given by ward staff was "to establish a ward routine". The charts were inaccurate and errors in recording were found to increase with the number of charts being used, especially when the reasons for the recordings were unclear. Such findings are certainly applicable to the use of fluid balance charts. Nursing rituals Nursing is often deemed to have its own sub-culture, having many characteristics of such, including a common language, uniform and routines and rituals. Ritual practices are common in nursing, yet the term implies "carrying out a task without thinking it through in a problem-solving, logical way. The nurse does something because that is the way it has always been done". (6) Many researchers have observed ritual and non-rational procedures in practice. The best known work is that of Chapman, who suggested that routines and rituals were not meaningless actions, rather they convey meaning and concern, demonstrating to the family and patient the "caring commitment" of the nurse.(5) She also suggested that such ritual behaviours are learnt in the socialisation process of nursing students and are extremely resistant to change. The reasons why nurses continue with non-rational procedures and routines were further explored by Burroughs and Hoffbrand. (10) The rationale for continuing with unnecessary charting, for example, could include,
However, it can be argued that the routine use of any chart is the antithesis of the problem solving, holistic, evidence based approach to modern nursing practice. Ritual actions "convey a reliance upon routines, procedures and out-moded practices that have little relevance for the contemporary practitioner". Research design In order to test the hypothesis, a quantitative methodology was used to give an objective and systematic approach to the data collection and analysis. A questionnaire format was chosen as this method of data collection allowed for data to be collected from a large sample, but was relatively simple to perform. A self completion format was chosen as this was quick and easy. The questionnaire was designed to contain a mixture of factual and attitudinal questions to allow for the exploration of current nursing practice. A small pilot study was undertaken to test the questionnaire for bias and to minimise any misunderstandings in the text. The questionnaire was divided into two parts: a structured response format using a five-point Likert scale and an unstructured response format consisting of open ended questions which allowed the sample to answer in greater depth regarding their experiences. The results were analysed using simple descriptive statistical methods. This approach was chosen due to the small sample size and the fact that a meaningful result could not be obtained from more sophisticated statistical methods. The sample was drawn from the qualified nursing staff employed on the nephrology wards. The nursing staff regularly use fluid balance charts in the care of renal patients. The sample consisted of qualified nursing staff only and was chosen from convenience for the researcher. The decision was made to exclude student nurses and health care support workers as they are not directly responsible for completing the charts. Thirty questionnaires were completed and returned, a response rate of 74%, from a total sample population of 42 nurses. All respondents were anonymous and consent was gained via a letter accompanying the questionnaire. Discussion of results The aim of this study was to investigate the use of fluid balance charts, particularly why and when they were used. The results clearly demonstrated that intake/output charts were inaccurate and unreliable, and that the use of such charts was in many cases a non-rational procedure and appeared to have no underlying clinical rationale. The sample indicated a strong support for the use of fluid balance charts. The charts are widely used, and their completion is regarded as a nursing responsibility. (2) Despite the importance attributed to these charts, comments from the sample revealed that they were used mainly as a guide or an estimate of fluid intake/output, rather than as the main method of assessment. So, why were the charts still being used? One reason that was highlighted by the study was that the charts were used as a teaching aid for patients to help them to manage their fluid intake. Renal patients require a great deal of education and support in adapting to a chronic illness. This may be one reason for the continuing use of these charts on the nephrology wards in some circumstances. It would not be possible to apply these findings to another clinical area. The sample also indicated that despite the importance attributed to the charts by the nursing staff, the medical staff also tended to use other means of fluid assessment e.g. jugular venous pressure, daily weight measurements. It would appear that the medical staff regard the charts as unimportant - although they may look at them - and use other more reliable means of assessment. According to previous research, one of the main reasons that these charts are used is to enable the medical staff to reach a decision regarding fluid management. However, this does not appear to be the case. This may be because in the majority of cases the charts were commenced for no underlying clinical reason, and were therefore worthless. Previous research has also highlighted the fact that nurses often state that their charts are ignored. (12) But there would appear to be little benefit in studying charts that are of no clinical value. Accuracy and reliability were areas highlighted by the sample, all of the respondents felt that fluid balance charts were subject to errors. Replication of information was another common finding. Approximately 75% of the sample agreed with the statement that fluid balance charts were commenced unnecessarily. The reasons for this are complex, but routines and rituals are well established in nursing, as has already been discussed. In these times of stress and change within the health service, it may be easier to adopt a task orientated approach rather than challenge existing practice. This leads to perpetuation of the use of fluid balance charts when they are nor clinically required. Limitations of study The research design can be criticised in several areas. Caution is advised when reviewing these results due to the limitations in sample size and selection, bias (the sample all knew the researcher) and the validity of the research method chosen. Future extension or replication of the study is recommended, and it may prove necessary to adopt a different methodological approach to investigate the reasons why nurses continue to use fluid balance charts. Despite the above limitations, several recommendations for practice, education and research can be made. Practice recommendations Documentation standards are poor and charts are inaccurately completed. It is recommended that other means of fluid assessment are more accurate and appropriate in all but the most unstable patients i.e. immediately post renal transplantation or acute renal failure. Most renal patients are weighed daily and it has been known for clinical areas to discard fluid charts completely in favour of this method. Patients should take responsibility, if possible for maintaining their own charts, as this increases reliability and accuracy. This would release valuable nursing time and hopefully increase patient compliance with their restricted fluid intake. This is particularly important in renal patients who have a chronic condition which will require adaptive changes in their lifestyle. Educational recommendations The study revealed that despite being a highly qualified and experienced sample, the nurses varied in their knowledge of when to use intake/output charts. A need for change in clinical practice has been identified, but this requires educate support, to ensure that nurses fell knowledgeable and empowered enough to make decisions regarding fluid balance assessments. Education is required to allow nurses to make clinical decisions based on a sound understanding of the principles of fluid balance. Education is also required to address the poor standards of documentation. Fluid balance charts in particular are subject to errors such as omissions and "guesstimates". Charts are legal documents, and such errors may have legal implications. Research recommendations This study highlights several areas where further research could be undertaken. For example, the attitudes of medical staff to the use of fluid balance charts could be investigated. A different methodological approach is also recommended to investigate the meanings ascribed to the use of charts. Any forthcoming data could then be utilised to challenge existing practice. Conclusion To conclude, the hypothesis that fluid balance charts were inaccurate and unreliable and that their use was non-rational was demonstrated by this study. Implications for future clinical practice and research are reflected by the changing role of the nurse in modern health care. Increased professional accountability and greater clinical responsibilities have focused attention on the suspicion that many activities and procedures have little or no evidence linked basis. A system is required that allows greater reflection on the continued use of fluid balance charts as a means of fluid assessment. Increased education and further research into this area may stimulate the recommended move towards the use of daily weight measurements and blood pressure recordings as being a more accurate and clinically sound method of assessment. Common errors in measuring fluid intake and output Errors in recording
Errors related to intake
Errors related to output
1. lyer R. New trends in charting. Nursing1991: 28; 48-50. 2. Holmes SB. Development of a nurse automated documentation system. Orthopaedic Nurse 1992: 11.1; 55-70. 3. Pflaum S. Investigation of input/output charts as a means of assessing body fluid balance. Heart and Lung 1979: 8; 495-502. 4. Kilfoy-Perez L. Comparison of acute fluid gains and losses to body weight changes. Unpublished Masters Thesis, Saint Louis University School of Nursing. 1994 5. Chapman CE. Ritual and rational actions in hospitals. Journal of Advanced Nursing 1983: 8; 13-20. 6. Walsh M, Ford P. Nursing rituals: Research and rational actions. Oxford, Butterworth Heinemann 1992, 7. Kings Fund Audit. Strengthening the knowledge base of clinical practice. London King Edward's Hospital Fund for London 1993. 8. Daffurn K et al. Fluid balance charts: Do they measure up? British Journal of Nursing 1994: 3.16; 816-20. 9. Kilgour D, Speedie 0. Taking the pressure off, Nursing Mirror 1985: 160. 9; 39-40. 10. Burroughs J, Hoffbrand B. A critical look at nursing observations. Postgraduate Medical Journal 1990: 66;370-2. 11. 0'Brien D, Davison M. Blood pressure measurements: Rational and ritual actions. British Journal of Nursing 1994: 3. 8; 393-6. 12. Locher CL. How to make the most of charting. Journal of Practice Nursing 1992: 42. 2; 35-43. This study was undertaken for submission as part of a Bsc (Hons) degree in Health Studies. Nursing Progress: Issue 5: January 1999. Copyright: Nursing Progress, Royal Hospitals NHS Trust. Back to Nursing Progress contents. Back to Issue 5 contents list. Last updated by DEB on 6/6/02 |
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