‘Nursing Times stands with the people of Ukraine’

10 August, 2018 By Tom de Castella

The object in question resembles a toddler’s drinking cup. It’s plastic and there’s a lid from which protrudes a wide, circular spout. But you won’t find a Thomas the Tank Engine logo on it, as this receptacle – the plastic spouted beaker – is what many older patients in care homes and some NHS wards are given to drink from.

No one seems to know exactly how long plastic spouted beakers have been in circulation for. Nurses working in the 1990s say they remember them being introduced, but they may have been around for much longer.

“If you’re still using plastic spouted beakers, then have a proper think about it”

The beakers were probably brought in to minimise spillages, though they may also have been viewed as a way of helping patients with certain conditions that impair their ability to hold a cup or to swallow normally.

However, despite concerns being raised for many years about their negative impact, the beakers can still be found on the wards and in care homes. Change may be in the air though.

In June, a group of nurses, speech therapists and care home workers started a campaign to replace them. Using the social media hashtag #endplasticspoutedbeakers they called on healthcare settings to consider alternatives.

The campaign on Twitter has brought different professionals together and shown how passionate people are about the issue. Those behind it argue that spouted beakers can both be dangerous and have the effect of undermining a patient’s dignity.

Elizabeth Meatyard is among those who has spoken out on social media against the use of the beakers. She said she wanted people to start a conversation about what was appropriate for an older person to drink out of.

“Although she can hold a glass or a teacup, nine times out of 10, I’m handed one of these awful spouted beakers”

A former nurse, she has an aunt in a care home in Birmingham. She said: “Although she can hold a glass or a teacup, nine times out of 10, and in spite of innumerable conversations with staff, I’m handed one of these awful spouted beakers.”

Care home residents like her aunt “instinctively” know how to hold a cup or glass and argues that too give her a spouted beaker is “taking away the tiny bit of independence she has left”.

Ms Meatyard highlighted that the staff at the care home were “all lovely”, but claimed there was something wrong with the culture if it was considered acceptable to “infantilise” older people.

What was needed would not take much time, she said, arguing that to help her aunt to drink out of a glass or tea cup would give a completely different level of care. “I want her and other people I see in her situation to have a dignified last year or so,” she told Nursing Times.

She noted that her aunt’s care home was currently rated as “outstanding” by the Care Quality Commission and questioned why it seemed to be turning a blind eye to beakers.

She called for CQC inspectors to be routinely asking staff why plastic spouted beakers were the norm rather than the exception in the settings they visited. “It is part of nursing care. I wouldn’t give an outstanding rating,” said Ms Meatyard.

“They should only be used when a patient has been formally assessed and it is part of their care plan”

Dr Joanne Fillingham, clinical director of allied health professions at NHS Improvement, said that in a few cases, such as Parkinson’s or Huntington’s disease, spouted beakers may be necessary. However, for others, they have the potential to cause harm, warned Dr Fillingham, who is a speech and language therapist by training.

Fluid enters the mouth further back – mid tongue where the spout ends – rather than at the front of the mouth, as would happen with a normal cup, she told Nursing Times. It allowed less time to process the fluid and swallow and there was a risk of aspiration pneumonia – when food/fluid enters the larynx and has the potential to track down to the lungs instead of going down the oesophagus to the stomach.

“For patients who are frail or older that’s not a good thing,” she said. “So, clinically, for these people it doesn’t make sense.” In addition, she highlighted the beakers could have a negative impact on dignity.

“Throughout our lives we drink using a glass or mug,” she said. “The only time we use a spout is when we’re babies, because you’ve got that suck reflex – drinking from a teat or bottle.”

She emphasised that adults did not need to suck in that way – and to assume someone could only drink this way was “infantilising”. Dr Fillingham added that, “for years and years”, therapists had fought against inappropriate use of plastic spouted beakers and that she wanted greater awareness so they were not used just a default choice.

“Are we promoting a person’s dignity by giving them a beaker to drink out of?”

Dawne Garret, the Royal College of Nursing’s professional lead for care of older people, said they could also be confusing for patients.

“People living with dementia may not recognise what they are used for, preventing them from staying hydrated,” she said. “Lids on the beakers also make it difficult for patients to assess what they are drinking, particularly if they need to ingest thicken liquids.”

In spite of the new campaign and the previous concerns, researchers acknowledged there was a lack of evidence on how widespread the use of spouted beakers actually was.

Dr Iain Lang, senior lecturer in public health at the University of Exeter, who has been following the campaign on Twitter, said he suspected no one really knew for sure. “There’s probably been research done on hydration in care homes but whether any of that is about [spouted beakers], I don’t know,” he said.

The question of a drinking cup may seem a “tiny thing” but it touched on wider issues, he said. Dr Lang suggested it may come down to a clash between what was convenient for staff versus the dignity of patients.

Despite the lack of hard evidence, anecdotally plastic spouted beakers seem to be most commonly found in care homes.

George Coxon, director of the Pottles Court care home in Devon, which is rated “outstanding” by the CQC, said during the 1990s spouted beakers were “standard issue” in care homes and that they remained so in some places.

“No residents in my care home use them,” he stated. Instead, they used a “whole bunch of mongrel cups”, which he believed was more homely. A resident can say “that’s my mug”, rather than everyone having an identical product, he said.

Mr Coxon noted that one resident used a double handed vessel, as it was easier for her to pick up, but there was no lid or spout. While he would not rule out ever using them if deemed necessary in a certain situation, he emphasised it was about giving residents personal choice.

“If they want a plastic spouted beaker that’s fine but don’t assume they do, always ask,” he told Nursing Times. If a beaker was required, he advised people to make a record so that in the event of a CQC inspection they could demonstrate it was a deliberate decision and not something done thoughtlessly.

Tracey Chapman is an Admiral nurse working in the community and used to work in an acute trust with dementia patients. Far too often, spouted beakers were given routinely to all older patients, she said.

“You shouldn’t assume that because someone is elderly, frail or confused or has a dementia diagnosis that giving them a plastic spouted beaker is acceptable,” she said. “Are we promoting a person’s dignity by giving them a beaker to drink out of?”

She said she remembered one older woman who did not understand the spout. She would turn the beaker around, tip it up and try and drink, she said, with the result that the liquid spilled down her front.

Ms Chapman, who described the experience of drinking from a spouted beaker as “awful”, said that all nursing students should be made to try it. “Unless you have that experience it’s hard to empathise,” she told Nursing Times.

Dr Fillingham agreed that the beakers were unpleasant to drink from and added that, as they were often used for tea and coffee, they soon become stained too. “Plastic spouted beakers aren’t nice for anyone,” she said. “I wouldn’t want to drink out of one and I wouldn’t want my mother to drink out of one.”

But she said that, where a patient could not make a choice, nursing staff would need to make a decision in their best interests. In such cases, there were often better alternatives than plastic spouted beakers, such as using adult gym bottles, she highlighted.

Nursing Times asked NHS England for a national view on the use of spouted beakers ni the health service, but a spokeswoman said it was for individual trusts to decide what patients drank from.

Evidence from several acute trusts contacted by Nursing Times indicated that the beakers were not used routinely but were not outlawed either.

Manchester University NHS Foundation Trust, which has nine main sites, including three acute hospitals, said it only used spouted beakers in “exceptional” circumstances.

“It has been widely accepted for a number of years across all our hospitals that wide spouted beakers should not be used,” said a trust spokesman. “In exceptional cases, for a small number of patients after clinical assessment, the use of wide spouted beakers may be considered to be beneficial to maintain the individual’s independence and hydration.”

In addition, a spokesman for Guy’s and St Thomas’ NHS Foundation Trust in London said it only used them “where there is a clear clinical need as assessed by the speech and language therapist”.

The Royal College of Speech and Language Therapists acknowledged that there were times when spouted beakers may be necessary.

“We believe usage should be based on individual patient need and choice,” a spokeswoman said. “For example, we are aware that people with Parkinson’s disease who have tremors may prefer to use plastic spouted beakers.”

But the RCN’s Ms Garret was forthright in her opposition, stating that plastic spouted beakers “pose multiple problems” if their use was not closely monitored. “They should only be used when a patient has been formally assessed and it is part of their care plan,” she said.

Mr Coxon stated: “If you’re still using plastic spouted beakers, then have a proper think about it and make sure you’re doing it for the right reasons.”

The plastic beakers have been for at least 50 years, despite a wide range of specialist beakers/ cups/ mugs now being available, with ones suitable for Parkinson’s, or people with tremors. Many hospitals have heavy cups with small handles, making them difficult to use by disabled and older people with dexterity or poor grip. Investment is needed in more user friendly designs. Patients need choice. Some problems can be overcome by a plastic bendy straw, that Mr Gove wants to ban. Special straws are avaliable with one way valves to make sucking easier. Too often as your article suggests assumptions are made about the patient, with the choice being cup or plastic beaker for hot drinks. Fruit juice in individual containers makes drinking them impossible, or much spilling. Hydration is important as is dignity.

I can ‘t thank you enough for bringing this issue to the fore. As with most things to do with ‘hydration care’ it opens up so many wider issues related to older care, dignity and time to care… being repeated concerns. I completely agree with key points in the article. As Chair of the National Hydration Network – this is something we can ensure stays on the agenda and lobby for specific research into this area. I’m not a very active tweeter – but I will make a point of going to your # and spreading the word. Very best wishes to everyone involved in this article.

I don’t know how many words made up this piece but it could have been summed up in three words: assess your patient/client/resident. You should no more offer a spouted beaker to someone automatically any more than you should use baby language to an adult or vice versa. However to condemn these beakers out of hand as “undignified” is ridiculous. It is “undignified” to be dehydrated or be wearing your drink down your front because your hands shake. Has anyone been in a gym recently? How many able bodied people are more than happy to use a beaker with a spout without it impinging on their dignity?

I think that all the above have all made some valid comments. We need to get away, once and for all,from ritualistic practices that plague so many areas of our practice however it is not just nurses that need to be proactive in giving patients/residents a choice and what best meets their actual needs; managers, carers and families also need to take this on board. Managers because they hold the purse strings, carers, especially in NH’s, are often the primary staff who provide the majority of front line care such as assisting with eating & drinking & families as they sometime overrule or think they know best for their ‘doting’ relative.

I have often thought plastic beakers were undignified. China would be nice but do not bear up to commercial dishwashers. I work with dementia clients . Drinking vessels often get mixed up , dropped , thrown etc . The spout could be shortened to enhance proper swallowing, perhaps weighting the base to avoid tipping. But a ‘nice’ decorated outer casing may be a cheaper alternative, looking like a normal cup With a lid ?

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