3.2 Themes
Three categories were identified after analyzing the content of the transcriptions based on TPB: attitude, subjective norms and perceptual behavioral control, including 6 main themes: positive attitude, negative attitude, supportive beliefs, unsupportive beliefs, facilitators and barriers.
3.2.1 Themes related to attitude
Attitudes in this study were identified as the feelings and enthusiasm towards providing thirst care for HF patients. Most nurses mentioned that in clinical work, symptoms of thirst in HF patients are easily ignored compared to other symptoms such as dyspnea and edema, but most of the interviewees considered it necessary to manage thirst symptoms for HF patients. There are also nurses who will take the initiative to look up relevant information and learn methods to relieve thirst symptoms, which helps relieve patients' thirst distress, anxiety and irritability, promote patient comfort, improve patient compliance, improve the quality of care, increase patient satisfaction and thus improve the nurse-patient relationship. On the other hand, the management of thirst symptoms in HF patients also increases the workload of nurses, which may abate their enthusiasm.
Positive attitude
For HF patients, thirst care can relieve thirst symptoms, reduce irritability and promote patient comfort. It was beneficial for patients’ recovery. Meanwhile, the psychological burden of patients’ family members was also reduced.
N3: “If you can manage the patient's thirst, it definitely helps with patient comfort. It must be good.”
N5: “The most prominent benefit is definitely for the patient, because the patient actually suffers a lot from thirst. Thirst makes the patient irritable and it is a vicious cycle, which would aggravate the disease. Heart failure patient needs to be kept emotionally stable. Therefore, if thirst can be well controlled, by whatever means, it would be very relieving for patient comfort and the disease.”
Some interviewees said that appropriate and timely thirst care by nurses could increase patients’ knowledge about the disease, improve their treatment compliance and promote recovery.
N7: “At least you can let the patient know how much water he should probably drink, or how much water is in his diet, and he would know what to expect. Then he would probably have better understanding of his condition. I think it would be better to have something like this, and the patient would be more compliant with the treatment.”
When the thirst symptoms in patients were alleviated, it was also beneficial for patients’ family by reducing their psychological burden. Eventually, the image of nurses could be enhanced.
N9: “And then to the patient's family, in fact, I think some family members really care about the patient. And if we can do a good job on thirst care, help the patient relieve thirst and other discomforts, the family will feel that the nurses are really attentive and they are trying to do everything possible to be nice to the patient besides providing nursing care, which will reduce the psychological burden of the family.”
Most interviewees mentioned the implementation of thirst care for HF patients could improve quality of care and patients’ satisfaction. It helps establish mutual trust and good patient-nurse relationship.
N9: “Therefore, it improves patient satisfaction, and quality of care.”
N6: “For us it can reduce misunderstandings between nurses and patients and build a good relationship between nurses and patients.”
Negative attitude
Some potential disadvantages were unfavorable for nurses to manage thirst symptoms among HF patients. The implementation of thirst care for HF patients might increase the nursing workload, affect the work schedule and cause problems for other coworkers.
N6: “There are certainly disadvantages. It increases the workload of nurses, that's for sure. For the nurses, this is definitely an extra piece of work, right?”
N7: “I am afraid of delaying my own work or dragging down my coworkers when giving patient education, which I think is the biggest impediment.”
Clinical work is so complicated and busy that nurses are exhausted by their routine work and they don’t pay enough attention to thirst symptom among HF patients.
N1: “Yes, I didn't pay attention to the cause of his thirst because of the busy work in the ward. The work is also mechanized, so there is little time to study this.”
N5: “And if you let the front-line nurses do this, time would be an issue and too much work could not be done.”
Considerable interviewees noted that the symptom of thirst is so mild compared to other common symptoms, which makes it easy to be ignored. Therefore, there is no awareness of the need to pay attention to thirst symptoms in HF patients.
N1: “We pay less attention to thirst as a symptom than other symptoms of heart failure.”
N4: “Thirst is just a small case among many and currently we don’t focus on thirst care unless we are told to do so.”
N5: “Maybe everyone is concerned about chest tightness, shortness of breath, lying down problem, and maintaining open airway. Thirst is a very small problem compared to those respiratory symptoms and so on.”
Due to insufficient related professional knowledge and skills, there are few interventions available.
N2: “Patients are given really small amounts of water, but there is nothing that can be done, as no other measures for symptom relief are known. There is still relatively little training on this aspect.”
N3: “Health education and psychological support is useless. Because the patient can't control himself, which is also a challenging problem.”
3.2.2 Themes related to subjective norms
Subjective norms refer to the supportive or unsupportive perceptions felt by nurses, which may influence whether or not they perform thirst care for HF patients. The support of leaders plays a key role in the implementation of thirst symptom management by nurses. However, there are currently no leaders and administrators to develop specific and actionable procedures, and the inability to reach a consensus among staff members has greatly limited the management of thirst symptoms in heart failure patients. In addition, the lack of patient knowledge related to the disease leads to a lack of understanding of nurses' operations and a poor attitude toward nurses, which also makes nurses lack motivation and sense of accomplishment when implementing thirst symptom management.
Supportive beliefs
The management of patient thirst symptoms is beginning to gain attention from leaders. In a recent seminar about fluid management in HF patients, it was mentioned that the management of thirst in HF patients should be of concern to medical staff.
N2: “I just happened to mentioned this in recent seminar that I was in charge of. This concept was brought up by a graduate student at that time, and this issue deserves our attention and efforts in our clinical work.”
Unsupportive beliefs
Stress from coworkers
Almost all interviewees indicated that the lack of specific and actionable standardized procedures developed by leaders and administrators is the most prominent factor, which did not support the development of thirst symptom care for heart failure patients. Participants cited inconsistent collaboration from coworkers (including between nurses and between nurses and physicians) and patients prioritizing other treatments over thirst care as unsupportive factors. The management of thirst symptoms in HF patients is greatly limited by the lack of standardized procedures in place, resulting in nurses' inability to assess thirst and take appropriate and timely measures.
N1: “It is difficult to know whether thirst is related to the patient's drinking habits. There is no objective assessment tool. It is as difficult to assess as dizziness.”
N5: “Sometimes you really want to do it, but there are no operational guidelines, which makes you very helpless. If there is a guideline for you to follow, which is an expert consensus, you’ll feel more reliable to practice.”
Due to the lack of consistent operational procedures, collaboration and consensus between physicians and nurses and among nurses could not be achieved, which might affect the management of thirst symptoms.
N9: “Sometimes the doctor just told the patient to limit water consumption to a certain degree and then he left. It's us nurses who are directly in front of the patient. He would strongly agree with the doctor and he would say that “the doctor said I can drink a certain amount of water, but you nurses do not give me any water, are you abusing me?”
N4: “This is my own personal approach, and I cannot represent other coworkers.”
Stress from patients
Most of the interviewees mentioned that HF patients do not understand why nurses restrict them from drinking water to relieve thirst symptoms due to the lack of associated knowledge. The interviewees said that health education and psychological care for patients is ineffective at this time, and patients may even mistakenly believe that nurses are mistreating them by not giving them water, and then treat nurses poorly, which lower nurses’ motivation and sense of identity when implementing thirst symptom management.
N9: “Many patients said, you don’t even give me water, so inhumane.”
N10: “We would say it is beneficial for your health, and when the patient kept asking for water, we would hide his bottle. The patient would feel like the nurses were abusing him.”
3.2.3 Themes related to perceptional behavioral control
Perceptual behavioral control refers to the nurses’ perception of barriers and facilitators in carrying out thirst care for HF patients.
Facilitators
Participants considered that professional and systematic training in thirst symptom knowledge and skills would contribute to the implementation of thirst symptom management. Several interviewees indicated that they had only come into contact with the knowledge of thirst symptoms in only one seminar, but it prompted them to consider patients' thirst distress in their clinical work and to think about how to address their thirst distress.
N1: “If professionals are invited to provide training related to the management of thirst symptoms, we can learn more about effective measures that will help us implement thirst management in our clinical work.”
Some interviewees said that strong literature search skills can help nurses consciously collect relevant information and better apply evidence-based interventions in their clinical work to solve patients' problems.
N1: “If nurses have better access to the literature, we will be able to access the knowledge that will help relieve the patient's thirst.”
Other interviewees mentioned the importance of adequate staffing, support of the leaders, and the development of a systematic daily work pattern in the management of thirst symptoms in HF patients.
N9: “It's the support of the leadership, (laughs), and I usually talk to the leadership first, so that I can feel more confident doing this aspect of care for the patients.”
N10: “You can do this more comprehensively if you have enough staff, but if you don't have enough staff, you may not do it comprehensively or carefully enough.”
N8: “When there forms a work pattern, that is, when the care of heart failure patients with thirst becomes part of the daily care, then we will not neglect to do it.”
Some patients with more severe thirst, especially patients with diabetes, may exhibit negative emotional states or behaviors, such as irritability and anxiety, which prompt health care providers to pay more attention to the patient's thirst symptoms.
N10: “Yes, the patient may be more obviously thirsty and keep telling you he's thirsty and then you can't give him water, it's actually very painful. It's understandable that the patients have negative emotions. This will grab our attention on the issue and make us wonder what is the best way to solve it.”
N3: “In heart failure patients with diabetes, this problem is particularly serious. They are constantly thirsty and keep asking you to give him water, no matter how you explain. It is beyond his control. This is a tricky problem.”
A high level of patient cooperation and positive feedback will encourage and facilitate the nurse to implement management of thirst symptoms.
N9: “It probably depends on whether the patient cooperates with me. Patient’s cooperation is beneficial for me to perform this aspect of care.”
N10: “Patients who have good feedback on our care and stuff like that will make me feel more motivated to help them with their thirst symptoms.”
Barriers
Patients' distrust and low cooperation with nurses affects nurses' implementation of management of thirst symptoms.
N2: “One major obstacle is patient cooperation.”
N8: “But sometimes it can be affected by the patient's attitude. The patient may be uncooperative or keep asking for attention and wanting to drink water. The more attention you pay to him, the more he drinks, the more often he asks for it.”
The heavy clinical workload and lack of human resources greatly limit the continuous and detailed care of thirst symptoms in HF patients. Nurses may not have enough time or energy to care for thirst symptoms besides ensuring the completion of their daily work.
N5: “I think it may be the problem of human resources and workload, which really makes us unable to cover everything.”
Most interviewees suggested that training courses related to the management of thirst symptoms in HF patients through school education or academic conferences were scarce, making it difficult for nurses to acquire knowledge related to thirst symptom care and apply it in clinical practice.
N3: “And I don't know what other interventions are available. There is also very little training in this area.”
N9: “It seems like none of the training is detailed. We all kind of follow what we learned from school, but the textbook doesn't mention the care of thirst symptoms.”