Results

Meeting participants included 18 academics/researchers (10 from the research team) and 9 providers, with the majority from Canada (78%); over half were from nutrition or food service disciplines. Participant details are provided in table 1. Participant comments on changes due to COVID-19 that impacted hydration were categorised as resident, staff or home related (table 2). Participants’ suggestions for overcoming these challenges are also provided. Resident-related issues resulted from the confinement of residents to rooms during the first wave of the pandemic. Residents were interacting with staff only during care routines in their room and these touch points were minimised (at least initially) to prevent the potential spread of infection. This meant that access to beverages was limited as well as lack of social stimulation to drink. Isolated residents were reported to be bored and depressed, resulting in apathy and decreased appetite. One provider highlighted that as a result of the COVID-19 restrictions there were ‘no volunteers, no exercise groups, no social activities… [this] would definitely make a downswing on the amount of liquid.’ Solutions included using a trolley to delivery drinks between meals and providing socially distanced opportunities for residents to share fluids with others.

Participants reported that COVID-19 precautions and procedures exacerbated longstanding issues of staff not prioritising hydration: ‘If staff are already not thinking about hydration during normal operations, then they are certainly not thinking about hydration during pandemic times’ (dietitian provider). Specific to COVID-19, limited staff, limited entries into residents’ rooms and new staff resulted in decreased fluid offerings, lack of time to support drinking assistance and lack of understanding of residents’ specific needs. Due to the many new tasks and activities required as infection control procedures, staff time was reported to be even more limited than usual for the routine tasks such as monitoring fluid intake. To promote hydration, participants suggested offering or encouraging fluid at every touch point. It was noted that systemic communication challenges among staff, such as lack of time to review documentation, impacted resident-centred practices, such as knowing individual drink preferences and how to support intake. New roles for staff were also a concern. In some homes, food service staff who usually provided between meal fluids through a snack service were removed from this activity, to minimise the number of staff entering a resident’s room. Educating or communicating preferences and extending meals to allow for greater fluid consumption and including other staff at meals to meet eating assistance needs were key strategies offered. Finally, documentation on intake was deprioritised with the new required infection control procedures taking priority. One provider attendee described that the ‘biggest challenge is sometimes [staff are] documenting everybody in the last fifteen minutes of their shift… we really question accuracy.’ Considering that all residents are at risk for dehydration, it was deemed crucial to encourage the implementation of home-level efforts to promote hydration. For example, one participant reported that ‘a lot of the processes and systems in long-term care [during the pandemic] is for residents to receive in-room service, rather than gather in dining rooms. Having that social aspect will encourage them to sit longer and have a few more sips, and improve their hydration.’

It was noted that, based on the suddenness of the COVID-19 pandemic in Canada, ‘Decisions [are] made fast and the larger picture, which is [the] resident and their quality of life, is lost’ (food service manager provider). There were several home-related effects due to pandemic procedures described by participants, but these varied across Canada and internationally, often because these decisions were left to the management of the home. For example, in some regions and homes, residents were not confined to their rooms, but grouped into smaller cohorts to increase physical distance during dining, while in others, residents were confined to their rooms and used disposable dishware and cups.

Several challenges were noted at the home level. High touch point areas such as self-serve beverages or water coolers were removed to reduce contamination. Similarly, a provider attendee noted that, with COVID-19, ‘tuck shops are closed—they [residents] can’t go out to get a drink like they used to.’ The use of personal protective equipment resulted in challenges recognising and communicating with residents, while family/volunteer visits were abruptly stopped and physical distancing occurred in dining rooms. To overcome these challenges, staff were redeployed to provide support at meals, and recreation staff specifically launched hydration events using trolleys to deliver special drinks to residents’ rooms. Strategies at the home level included education on the ability of industrial dishwashers to sufficiently sterilise dishware and on having staff wearing masks to introduce themselves to residents or have other identifying information readily visible for residents. Families were encouraged to bring in specialty items that could be quarantined.

The capacity to physically distance based on home configuration was reported to impact decisions about when and where food and beverages should be consumed. Offering water at every meal automatically provided an opportunity to support hydration. It was also noted that ‘COVID-19 has rewound the clock with respect to factors that lead to malnutrition and dehydration’ (dietitian provider). However, participants reported that crises such as the pandemic clarified for policy makers, homes, staff, residents and their families, what was important for residential care. They commented on the importance of working together with all staff being involved in promoting hydration and addressing challenges, the recognition that meals provide an important social opportunity for residents, and the understanding that families have a vital role in encouraging fluid intake and providing preferred beverages from outside the home. For instance, an attendee described that ‘families have a beautiful way of getting their family members to eat and drink,’ and another provider emphasised that ‘families have been limited in bringing products into a facility or into a centre, and sometimes families are providing those special foods or treats that can’t be accessed anywhere else, and that certainly is creating some issues in maintaining hydration overall.’ The group felt that lessons could be learnt from the experience of COVID-19, and these should be incorporated into routines beyond the pandemic. For example, the rigid time frames for meals result in rushed care; during the pandemic, some homes extended the meal serving times out of necessity due to delivery of trays to resident rooms or having two seatings for meals to reduce numbers. This was seen as a positive practice that could be sustained postpandemic. Participants also noted that successful strategies targeted more than one challenge at time, for example: ‘the key thing is that there has to be beverages available… so it’s not adding too much work to their [staff members’] day, and it’s part of their routine.’

The oral hydration typology16 was new to many participants, especially the providers. Ideas and strategies for supporting hydration using the typology for five resident subcategories of sippers, forgets to drink, fears incontinence, dysphagia and physically dependent are outlined in table 3 and categorised as: supplies, timing, facility context, socialisation and education. Examples for sippers include, identifying times when the resident drinks more as well as preferred beverages; offering beverages on a mobile cart at activities and promoting socialisation by having staff model drinking behaviours; or allowing residents to stay in the dining room to linger over their beverages. Making beverages accessible for those who forget to drink and providing between meal reminders and prompts, but also pairing these residents with tablemates who drink well were strategies provided by the group. Eating and drinking were noted to be social events and a key strategy offered was incorporating beverages into every communal activity in the home as ‘[residents] can’t drink what is not offered’ (nutrition researcher not from the research team). Educating staff on hydration needs and strategies to support these residents were other ideas. For those who fear incontinence, educating the resident on the importance of fluid intake and Kegel exercises while training staff (including non-nursing) to support them to the washroom when they are out of their personal room, were noted ways of helping these residents. For those with dysphagia, sufficient variety of thickened fluids, normalising a thickened texture to support hydration in all residents and educating the family and resident on the need for thickened fluids were ideas offered by participants for this group. For residents who are physically dependent on others, finding cups or using adaptive equipment that they could potentially use and drink from on their own were provided strategies. However, it was noted that sufficient trained staff or volunteers who can individualise support at meals, recreation activities and routine care (eg, brushing teeth, medication times) was needed.

Participants described that some form of assessment process would be needed to make the most of using the typology to identify strategies for individual residents. Trial and error were discussed as important for employing strategies at the individual level. A philosophy of care that promotes a social model was discussed as a means of promoting fluid intake across the typology subgroups. The continuous, mindful creation of new routines to offer beverages and assistance, as residents change in their capacity, was a key learning from the experience of the pandemic.

Understaffing was an overarching issue for addressing hydration that impacted all of the hydration typology. The pandemic has highlighted, especially for those who do not work in this sector, that residential homes are understaffed. Many of the strategies identified in tables 2 and 3 require staff for encouraging, creating opportunities, or aiding drinking. It is evident that hydration requires sufficient staffing and the concentration of all care tasks to the nursing staff during the first wave of COVID-19 likely exacerbated risk for dehydration. As one provider participant put it, ‘in some sites, food service staff did have the responsibility of providing fluids, and with COVID-19, decisions had been made that there were risks associated with food service staff moving from one unit to another unit providing those fluids. That task was then removed for those individuals and put back to healthcare aides.’ Education is a final overarching requirement to ensure adequate hydration, as reasons for not drinking vary. During the pandemic the continual replacement of staff, exacerbated by illness and policies of having only one home for employment, means that new and current staff need to be adequately and continuously trained.