Analysis of barriers to thirst intervention in critically ill patients by ICU nurses: A qualitative study based on the Theoretical Domain Framework

Analysis of barriers to thirst intervention in critically ill patients by ICU nurses: A qualitative study based on the Theoretical Domain Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of barriers to thirst intervention in critically ill patients by ICU nurses: A qualitative study based on the Theoretical Domain Framework Ruixuan Wang, Xiaolan Chen, Jiannan Luo, Lisha Huang, Huiman Lian, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7893573/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Thirst is a common and highly distressing core symptom in critically ill patients, ranking as the second most significant source of distress after death. However, healthcare providers often underestimate its severity. Nurses play a crucial role in identifying and alleviating thirst, making it essential to understand the barriers affecting their ability to manage this symptom. Objective To explore the barriers to thirst management behaviors among intensive care unit nurses for critically ill patients, providing a reference basis for developing thirst management strategies for critically ill patients. Methods Purposeful sampling was used to develop an interview guide based on a theoretical domain framework. 13 intensive care unit nursing staff members were interviewed using a face-to-face semi-structured interview method, and the interview content was analyzed and coded using directed content analysis. Results Analysis of the interview results identified six theoretical domains influencing thirst management behaviors in critically ill patients: knowledge, skills, social/professional roles and identity, environment and resources, social influence, and behavioral norms. Key issues included healthcare providers' incomplete understanding of thirst management, weak awareness of thirst management, unfamiliarity with thirst assessment procedures, heavy daily workloads and equipment shortages, unfavorable organizational culture, and unclear processes and specific measures. Conclusion The implementation of thirst management for critically ill patients is influenced by multiple factors. The six areas identified in this study can serve as targets for improvement. Managers should explore strategies, and implementation plans for thirst management in critically ill patients to enhance the quality of thirst management for this population. Intensive Care Unit Nurse Critically ill patients Thirst Theoretical Domain Framework Qualitative Research 1. Introduction Thirst is a subjective sensation regulated by multiple factors that drive fluid intake behavior( 1 ). Due to various factors such as illness, treatment, and medications, severe patients commonly experience thirst symptoms( 2 , 3 , 4 ). Multiple studies have indicated that thirst is one of the five symptoms that should be assessed daily in severe patients( 5 ), and it is the most common and intense discomfort symptom( 6 , 7 ). Studies show that 70% of critically ill patients experience thirst symptoms, with a prevalence of moderate to severe thirst at 55.8%( 8 , 9 , 10 ). Thirst induces intense anxiety and despair in critically ill patients, significantly impacting their psychological and mental well-being( 7 ), and increases the risk of delirium ( 11 )and post-ICU syndrome, thereby prolonging the treatment process and severely affecting patient outcomes. Thirst is considered by critically ill patients to be the second most stressful factor after death( 12 , 13 ). However, ICU healthcare providers do not place sufficient emphasis on thirst in critically ill patients, and most ICU nurses lack experience in managing thirst symptoms in critically ill patients. Their perception of patients' thirst often differs from the patients' own experiences, leading to a situation where patients' thirst is frequently underestimated, under-assessed, and under-managed in clinical nursing practice( 14 , 15 ). Currently, thirst in critically ill patients has not been systematically assessed or adequately addressed. Failure to promptly alleviate thirst not only severely impacts patient comfort and reduces nursing satisfaction but also increases the incidence of adverse events such as unplanned extubating( 16 , 17 ), posing higher demands and challenges for nursing work. The Theoretical Domain Framework is a theoretical framework that integrates various psychological theories and their underlying structures to study factors related to human behavioral change. Researchers can use the TDF to explore the factors influencing behavioral change from individual, organizational, and societal perspectives. Existing studies have confirmed( 18 , 19 , 20 ) that by using the TDF to develop interview guidelines and conduct coding analysis for qualitative research, one can systematically and comprehensively identify and categorize the barriers involved. This study, based on the Theoretical Domain Framework and employing qualitative research methods, explores the barriers to thirst management in critically ill patients by ICU nurses, identifies the theoretical domains influencing ICU nurses' thirst management behaviors, and aims to guide the development of thirst management protocols for clinical healthcare providers, thereby improving thirst management practices for critically ill patients. 2. Methods 2.1 Research subjects From July to August 2025, nurses from the intensive care unit of a tertiary-level hospital in Puning City were selected as interview subjects using purposive sampling. Inclusion criteria: nurses must have professional qualifications; ICU work experience ≥ 3 years; clear verbal communication skills; awareness of and consent to participate in this study. Exclusion criteria: Nurses not directly involved in patient care, such as administrative nurses or pharmacy nurses; nurses absent due to sick leave, maternity leave, or further education; rotating or further education nurses. The sample size was determined based on information saturation. Basic information is presented in Table 1 . All participants signed informed consent forms. Table 1 Participant demographic characteristics Participant Gender Age Job Title Years of experience in the ICU (years) N1 Female 45 Deputy Chief Nurse 26 N2 Female 34 Senior Nurse 15 N3 Female 33 Senior Nurse 15 N4 Female 32 Senior Nurse 13 N5 Female 33 Senior Nurse 13 N6 Female 30 Senior Nurse 7 N7 Female 33 Junior Nurse 13 N8 Female 29 Junior Nurse 6 N9 Male 27 Nurse 5 N10 Male 34 Senior Nurse 13 N11 Male 30 Nurse 5 N12 Female 32 Senior Nurse 12 N13 Female 30 Junior Nurse 10 2.2 Developing interview guidelines Based on a literature review, the research team preliminarily drafted an interview outline according to the research objectives and theoretical domain framework. They then conducted preliminary interviews with two nurses, adjusted the outline based on the results, and finalized the interview outline, which included 12 theoretical domains( 21 ). The interview outline is shown in Table 2. 2.3 Data Collection and Analysis This study used face-to-face semi-structured interviews. Before the interviews, the interviewees were informed of the purpose of the study and obtained informed consent before recording. A quiet duty room was selected as the interview location, and the interview duration was about 30 to 40 minutes. The interview process requires detailed records of the interviewee's expressions and nonverbal reactions. It is also necessary to pay attention to flexibly adjusting the order of questions in the outline, avoid leading questions, and encourage interviewees to actively express themselves. The interviewer should transcribe the audio and notes into a document within 24 hours after the interview. Two researchers independently coded the same material using the framework content analysis method( 22 ) and analyzed the interview data using TDF as the coding framework. In case of disagreement, the research team would discuss and determine the final decision. Throughout the data collection process, self-reflection( 23 ) was conducted to prevent the researcher's personal characteristics, qualifications/experience, and biases from affecting the research results and causing deviations in the results. 2.4 Quality Control The interviewer was a postgraduate student who had received systematic training in qualitative research courses and had ICU nursing experience. This study followed the principle of maximum difference and selected people of different ages, titles, working years, etc. for interviews to ensure the representativeness of the data. The data collection process flexibly used techniques such as follow-up questions and empathy. In the data analysis stage, two researchers analyzed and verified according to the theoretical domain framework, focusing on the text data from an objective perspective, reading and thinking deeply many times. At the same time, it was reported regularly at the research group meeting and discussed with the members to reach a consensus. After the researchers sorted out the materials, they returned them to the interviewees for verification and supplemented or modified them according to the feedback from the interviewees. 3. Results When the number of respondents in this study reached 11, no new information emerged, 2 additional nurses were interviewed and no new themes emerged, so the interviews were stopped, numbered N1-N13, and the general information of the interviewees is shown in Table 1 . Thru the coding and comparison of the transcribed text, six (knowledge, skills, social/professional roles and identity, environment and resources, social influence, and behavioral norms) barrier factors for medical staff to implement thirst management for critically ill patients were analyzed and extracted. 3.1 Lack of knowledge and skills related to thirst management Due to the rapid changes in the condition of critically ill patients and the constant risk of life-threatening situations, healthcare professionals must promptly assess the patient's condition and initiate emergency interventions. Therefore, nurses tend to focus more on observing and assessing objective indicators such as vital signs, often neglecting patients' thirst issues. This leads to an inability to promptly identify and address patients' thirst problems. Additionally, most nurses have limited proficiency in assessing and intervening for thirst, resulting in a narrow range of nursing interventions that fail to effectively alleviate patients' thirst. “Our understanding of knowledge related to thirst management for critically ill patients is fragmented, and we are unclear about how to accurately assess the severity of a patient's thirst. Most of us rely on our own experience.” (N4) “I observe the patient's lips for dryness or peeling and the condition of their mouth during shift handover, but I do not further assess whether there are symptoms of thirst, the severity of such symptoms, or whether intervention is needed.” (N5) “During work, we do encounter patients who constantly say they are thirsty and want to drink water. However, sometimes patients are on a no-food, no-water regimen. If consulting the doctor confirms the need to maintain this regimen, we can only comfort them by using a cotton swab dipped in warm water or petroleum jelly to moisten their lips. I am unsure of other possible interventions.” (N7, N11) “For intubated patients, if I notice they are thirsty, I report it to the doctor and ask whether fluid replacement is needed or if I should moisten their mouth. Personally, I don't have much experience handling such patients. For sedated or minimally conscious patients, I am currently unaware of other specific management methods.” (N3, N10) “I don’t know how to obtain relevant guidelines and expert consensus, nor how to implement the recommended practices.” (N2) “Thirst is not easily observable, especially in comatose patients. Sometimes when busy, it may not be considered, or if the patient does not express it, one may not proactively monitor whether the patient is thirsty or wants to drink water.” (N9, N12) “Compared to other symptoms the patient presents; thirst is not given as much priority. Pain and other symptoms are easier to assess, so thirst is often overlooked.” (N8) 3.2 Weak awareness of thirst management The social/occupational role identity domain corresponding to this theme is manifested in this study as role ambiguity in thirst management among ICU nursing staff. This is primarily reflected in insufficient collaboration within the medical team. “Our primary responsibility should be patient treatment and care; thirst assessment and management should be handled by the attending physician.” (N8) “The assigned nurses change daily, making it difficult to coordinate effectively with the attending physician.” (N3) “Some doctors primarily focus on patients' vital signs and do not prioritize thirst-related issues. We also have numerous daily tasks and cannot follow up on these matters, so we can only adhere to medical orders.” (N4, N13) 3.3 Human resource constraints and lack of equipment ICU patients have a high turnover rate and severe conditions. Respondents indicated that daily nursing procedures are numerous, and all aspects of patient care are handled by nurses, who primarily focus on monitoring vital signs and completing core tasks. The lack of thirst assessment equipment impacts the accuracy of thirst assessment in critically ill patients. “Our daily work is quite diverse and time-consuming, leaving little time to focus on patients' thirst-related issues. Additionally, many patients are comatose, making assessments challenging, and there are no specialized assessment devices available. For conscious patients who do not express their needs, we would not proactively intervene.” (N1) “Currently, the nurse-to-patient ratio is difficult to maintain at 1:1, often being 1: many, making it challenging to allocate time to monitor patients' thirst levels.” (N2) “If we could assign someone specifically to assess thirst and communicate with the attending physician to resolve the issue, the situation would improve significantly.” (N3) “Sometimes, if the patients we manage are conscious, they will actively say they are thirsty and want to drink water. However, in many cases, we are busy resuscitating patients or performing other treatments and cannot leave, so we can only let them wait and are unable to observe and intervene in a timely manner.” (N6, N11) “Our work is already very busy, and sometimes we must work overtime to complete tasks. Therefore, actively offering water to patients feels like something beyond our regular nursing duties. We focus more on tasks like ventilator care and monitoring vital signs, so we often overlook observing patients' fluid intake.” (N9, N10) 3.4 Lack of organizational climate and social support In this study, the lack of organizational atmosphere and social support was evident in the process of managing thirst in critically ill patients. Interviews revealed that the department had not established an atmosphere conducive to thirst management and that interactions among department members led to suboptimal implementation outcomes. Unclear division of labor among healthcare providers, poor communication, and unclear management responsibilities, coupled with the absence of specific implementation plans and management systems tailored to the department's actual circumstances, also hindered nurses' ability to implement thirst interventions. The department does not require staff to specifically address patients' thirst issues. Typically, if a patient's lips appear dry, staff will use a cotton swab or petroleum jelly to moisturize them. Everyone follows this practice, so there is little focus on addressing patients' thirst issues (N7). Everyone just wants to finish their shift quickly and go home early. So even if they know patients may have thirst issues, there's simply no time to address it. Even if they want to, when they ask senior nurses, they're told to just moisten the lips or ask family members to buy a spray bottle for intermittent use. No other suggestions are given, so over time, they stop paying attention to the issue (N8, N10). “Sometimes when reporting to doctors that patients have thirst issues, they just tell us to handle it the old-fashioned way and observe, without any additional measures. It feels like doctors don’t take it seriously either, so I didn’t think much of it either.” (N5) “Thirst management should be a nursing priority. While monitoring vital signs, we may overlook the patient's comfort. Thirst can also affect other vital signs. The discomfort from thirst can make patients restless, increasing the risk of delirium and post-ICU syndrome, thereby prolonging the treatment process and severely affecting the patient's prognosis. This should be given attention” (N1). 3.5 Lack of implementation plans and regulatory measures The behavioral norms theory domain corresponding to this theme refers to changes in objective, observable self-regulation processes. In this study, this manifests as the absence of standardized procedures and regulatory measures for thirst management in critically ill patients. Interviews revealed that there are currently no unified operational standards in clinical practice, with most healthcare providers relying on work experience to form specific operational habits. Thirst assessment is not standardized, and there is incomplete knowledge of assessment processes (tools) and intervention measures. Unclear intervention protocols hinder the clinical practice of thirst management in critically ill patients. Interviews suggest that effective regulatory measures would enhance the standardization of thirst management. “Generally, when we see a patient with dry, peeling lips, we use a cotton swab to wipe them or use a moist cotton ball to wipe the mouth. Sometimes we also use petroleum jelly, but we don’t know how to assess the severity of thirst, how long the effect of wiping lasts, or how often we need to reassess and intervene—there are no unified requirements for this.” (N6, N13) “The department currently lacks standardized guidelines for thirst assessment. When busy, staff often neglect to assess patients' thirst levels or determine the need for timely intervention, instead relying on personal experience.” (N4) “During departmental training sessions, the importance of thirst management is mentioned, but there are no detailed operational guidelines to reference, and the effectiveness of thirst management is difficult to evaluate.” (N2) 4. Discussion This study found that healthcare professionals lack knowledge and skills in managing thirst in critically ill patients, leading to insufficient awareness among some healthcare professionals regarding thirst management in critically ill patients. In the current nursing education system, cultural competence training has been proven to significantly enhance nurses' cross-cultural sensitivity and clinical decision-making abilities( 24 , 25 ). However, specialized teaching content on thirst management in critically ill patients remains significantly lacking in nursing curricula in China. Theoretical instruction primarily focuses on oral disease prevention (e.g., saline wipe techniques) rather than proactive intervention for thirst symptoms, resulting in nurses' insufficient understanding of the pathophysiological mechanisms of thirst and individualized relief strategies ( 8 , 26 ), which poses challenges for clinical implementation. Enhancing healthcare professionals' awareness of thirst management is a crucial foundation for conducting thirst management initiatives. ICU nurses primarily acquire knowledge about thirst through clinical practice, professional lectures, academic conferences, and peer exchanges. Among the desired supplementary channels, specialized training, expert lectures, and practical experience enhancement rank among the top three. This indicates that nurses seek to deepen their understanding through systematic training and theoretical learning and integrate this knowledge with clinical practice. Therefore, it is recommended to systematically advance specialized training on thirst management for ICU patients while consolidating practical exchanges and academic activities to comprehensively enhance nursing staff knowledge. From a social influence perspective, a poor organizational atmosphere is one of the primary barriers to thirst management. Interference among team members, herd mentality, and inefficient collaboration patterns hinder the standardized implementation of thirst intervention measures. Related studies confirm that healthcare personnel are easily influenced by organizational environments when implementing thirst management, such as colleagues' negative attitudes or differences in process execution forming implicit constraints that weaken nursing compliance( 26 , 27 ). The interview results of this study further indicate that phenomena such as new members being assimilated and neglecting thirst assessment, as well as gaps in multidisciplinary collaboration, are prevalent in ICU nursing teams. The fundamental cause lies in the lack of emphasis on thirst management by management. It is recommended that department leaders incorporate thirst management into the new employee training system, strengthen team consensus through regular case discussions and standardized process drills, thereby enhancing intervention confidence and quality. Optimizing human and material resource allocation and regulatory processes for thirst management in critically ill patients requires evidence-based practice to integrate multi-dimensional resources and establish a standardized system. In terms of human resource allocation, the results of this study also confirm that excessive workloads are the primary reason ICU nurses neglect thirst issues. Under China's closed management model for ICUs, nurses are responsible for all daily care tasks, which are complex and physically and mentally exhausting, directly leading to a decrease in the implementation rate of thirst interventions( 27 ). In response, Shaanxi Province in China issued the “Implementation Plan for Strengthening the Construction of Critical Care Medical Service Capabilities,” explicitly requiring medical institutions to “equip critical care specialists according to standards” and “prioritize critical care medical staff,” while establishing performance evaluation and incentive mechanisms for critical care nursing positions. This aims to alleviate workload pressure through flexible human resource allocation and the establishment of dedicated positions. A multicenter trial( 28 )further validated the feasibility of the “human-machine collaboration” model, where smart devices monitor physiological indicators (such as heart rate and oxygen consumption) in real time, freeing nurses from basic monitoring tasks and allowing them to focus on personalized interventions. This model increased patient compliance by 40% and reduced readmission rates by 32%. Resource allocation must combine technological innovation with spatial optimization. The Department of Critical Care Medicine at Shanxi Cancer Hospital in China adopted the “oral spray method” to alleviate thirst. The 50-100ml sprayer is inexpensive but highly effective, with mist droplets evenly covering the oral mucosa to reduce the risk of lip cracking and infection. The Chegu Campus of Peking Union Medical College Hospital has established a “thirst-free ward” pilot program, integrating non-pharmacological measures such as ice stimulation therapy and warm water misting( 29 )for thirst management, effectively improving patients' thirst conditions. Regulatory processes and institutional frameworks must be based on standardization. Therefore, managers should address the negative effects of excessive workloads on nurses, regularly organizing psychological support activities to alleviate occupational stress and thereby enhance work enthusiasm. Additionally, hospital management should focus on improving the nursing support system, scientifically allocating nursing staff, and creating a healthy and orderly professional environment to ensure the sustainability of high-quality nursing services. 5. Limitations The respondents in this study were only from one hospital, so the results may have certain limitations. Further multicenter clinical studies are needed to validate the findings. In the future, multi-center investigative studies combining quantitative and qualitative methods could be conducted based on this study to validate the results and provide reference and inspiration for managers. 6. Conclusion This study, based on a theoretical domain framework, identified six theoretical domain components related to barriers to thirst management behaviors among ICU nurses caring for critically ill patients. These findings provide a reference for setting goals for future clinical improvements, further standardizing ICU nurses' thirst management behaviors for critically ill patients, optimizing the thirst management process for critically ill patients’ post-surgery, and narrowing the gap between evidence-based thirst management practices and clinical practice for critically ill patients. Declarations Acknowledgements The authors would like to thank all nurses who participated in this study Author contributions All authors made significant contributions to the conception of the article, the design and execution of the study, and the acquisition, analysis, and interpretation of the data. n the end, the version of the article for publication was unanimously endorsed and approved for submission to the journal. It was also agreed to assume responsibility for the content of the text. Funding The authors did not receive any funding for this study. Data availability Data cannot be obtained from a third party and are not publicly available. The full dataset and data analysis code following receipt of ethics approval may be available from the corresponding author JYC. Ethics approval The study was conducted in accordance with the Declaration of Helsinki. Ethical clearances and approvals were secured from the Ethics Committee of Puning People's Hospital (Puning People's Hospital Ethics Review [2025] No. 28). Informed consent was obtained from all study participants. Principles of voluntary participation, privacy, and confidentiality were observed. Only anonymous data were collected and analyzed. Consent for publication Not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests Supplementary Information Additional file 1: Appendix 1. Interview Guide. References Halm MA. Managing Thirst in the Critically Ill. Am J Crit Care. 2022;31(2):161–5. Arai S, Stotts N, Puntillo K. Thirst in critically ill patients: from physiology to sensation. Am J Crit Care. 2013;22(4):328–35. Stotts NA, Arai SR, Cooper BA, Nelson JE, Puntillo KA. Predictors of thirst in intensive care unit patients. J Pain Symptom Manage. 2015;49(3):530–8. Flim M, Rustoen T, Blackwood B, Spronk PE. Thirst in adult patients in the intensive care unit: A scoping review. Intensive Crit Care Nurs. 2025;86:103787. Chanques G, Nelson J, Puntillo K. Five patient symptoms that you should evaluate every day. Intensive Care Med. 2015;41(7):1347–50. Puntillo KA, Arai S, Cohen NH, Gropper MA, Neuhaus J, Paul SM, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38(11):2155–60. Kjeldsen CL, Hansen MS, Jensen K, Holm A, Haahr A, Dreyer P. Patients' experience of thirst while being conscious and mechanically ventilated in the intensive care unit. Nurs Crit Care. 2018;23(2):75–81. Lin R, Li H, Chen L, He J. Prevalence of and risk factors for thirst in the intensive care unit: An observational study. J Clin Nurs. 2023;32(3–4):465–76. Lee CW, Liu ST, Cheng YJ, Chiu CT, Hsu YF, Chao A. Prevalence, risk factors, and optimized management of moderate-to-severe thirst in the post-anesthesia care unit. Sci Rep. 2020;10(1):16183. Fukunaga T, Ouchi A, Aikawa G, Okamoto S, Uno S, Sakuramoto H. Prevalence, risk factors, and treatment methods of thirst in critically ill patients: A systematic review and meta-analysis. PLoS ONE. 2025;20(3):e0315500. Sato K, Okajima M, Taniguchi T. Association of Persistent Intense Thirst With Delirium Among Critically Ill Patients: A Cross-sectional Study. J Pain Symptom Manage. 2019;57(6):1114–20. Yava A, Tosun N, Ünver V, Çiçek H. Patient and nurse perceptions of stressors in the intensive care unit. Stress Health. 2011;27(2):e36–47. Zengin N, Ören B, Üstündag H. The relationship between stressors and intensive care unit experiences. Nurs Crit Care. 2020;25(2):109–16. Liao C, Guan Q, Ma X, He X, Su Y, Fan D, et al. Construction of an assessment scale for thirst severity in critically ill patients and its reliability and validity. J Clin Nurs. 2025;34(3):795–804. Pattison N. Symptom management of thirst for seriously ill and dying patients in critical care. Intensive Crit Care Nurs. 2025;86:103869. Boet S, Patey AM, Baron JS, Mohamed K, Pigford AE, Bryson GL, et al. Factors that influence effective perioperative temperature management by anesthesiologists: a qualitative study using the Theoretical Domains Framework. Can J Anaesth. 2017;64(6):581–96. Oyama Y, Yamase H, Fujita K, Tashita H, Honda T, Yoshida K, et al. Critically ill patients' experiences of discomfort and comfort in the intensive care unit: A qualitative descriptive study. Aust Crit Care. 2025;38(2):101115. Cane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37. Yang Y, Gao Y, An R, Wan Q. Barriers and facilitators to exercise adherence in community-dwelling older adults: A mixed-methods systematic review using the COM-B model and Theoretical Domains Framework. Int J Nurs Stud. 2024;157:104808. Wright L, Bennett S, Meredith P. Using the Theoretical Domain Framework to understand what helps and hinders the use of different sensory approaches in Australian psychiatric units: A survey of mental health clinicians. Aust Occup Ther J. 2023;70(5):599–616. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26–33. POPE C, ZIEBLAND S, MAYS N. Analysing qualitative data[J/OL].[2024-03- 12].https://www.bmj.com/content/320/7227/114.DO1 : 10.1136/bmj.320.7227.114 Dodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220–2. Park HS, Jang HJ, Jeong GH. Effects of a cultural nursing course to enhance the cultural competence of nursing students in Korea. J Educ Eval Health Prof. 2019;16:39. Chang L-C, Lin H-L, Lin T-Y, Liao L-L. Evaluation of a Hybrid Learning Module on Cultural Competence for the Postgraduate Year of Nursing Programs in Taiwan: A Quasi-Experimental Study. SAGE Open. 2024;14. Fang CHEN, Zhixia J, Mingjing YANG, Qian LUO, Xia Z. A study on the perceptions and behaviors of ICU nursing staff on thirst in mechanically ventilated patients in Guizhou Province. Chin J Nurs. 2023;58(09):1104–11. Li S, Mi J, Tang Y. A qualitative study of nurses' perception on patients' thirst in intensive care units. Intensive Crit Care Nurs. 2022;69:103184. Yamaoka K, Katsumata Y, Kohsaka S, Shiraishi Y, Kondo M, Nagashima K, et al. Patient-centered medical tools for sustained motivation in cardiac rehabilitation of patients with heart failure: protocol of a multicenter randomized controlled trial (EXERCISE-HF trial). Contemp Clin Trials Commun. 2025;47:101522. Zhao Peng X, Lijun L, Lin Y, Mingyu L, Linyan Z, Zhihui, et al. Network meta-analysis of non-pharmacological interventions to improve thirst in ICU patients. Evid Based Nurs. 2025;11(06):1015–24. Additional Declarations No competing interests reported. Supplementary Files Appendix1..docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviewers invited by journal 23 Nov, 2025 Editor assigned by journal 17 Nov, 2025 Editor invited by journal 27 Oct, 2025 Submission checks completed at journal 25 Oct, 2025 First submitted to journal 25 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jiayin","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2025-10-18 12:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7893573/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7893573/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96981275,"identity":"491e8fef-3f20-4dae-b42f-aaddeb9288a0","added_by":"auto","created_at":"2025-11-28 09:17:13","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76747,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscriptnoidentifyinginformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-7893573/v1/e5385cad1519230d59fc7c1d.docx"},{"id":96981273,"identity":"2f7cd1e8-56b2-4d50-9f48-4002e2b71f9b","added_by":"auto","created_at":"2025-11-28 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09:17:13","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":87791,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7893573/v1/6a570f210b0d93be5edf70c1.html"},{"id":96981277,"identity":"acf0674f-055d-4af3-85c9-4696a40fd9a6","added_by":"auto","created_at":"2025-11-28 09:17:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":684258,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7893573/v1/f6872909-d889-46df-9200-e1c435e2dce6.pdf"},{"id":96981272,"identity":"d805088a-c7bd-4626-bde9-545350d4d60d","added_by":"auto","created_at":"2025-11-28 09:17:09","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16449,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1..docx","url":"https://assets-eu.researchsquare.com/files/rs-7893573/v1/8f36ed84c44c6eab3725bd64.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of barriers to thirst intervention in critically ill patients by ICU nurses: A qualitative study based on the Theoretical Domain Framework","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThirst is a subjective sensation regulated by multiple factors that drive fluid intake behavior(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Due to various factors such as illness, treatment, and medications, severe patients commonly experience thirst symptoms(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Multiple studies have indicated that thirst is one of the five symptoms that should be assessed daily in severe patients(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and it is the most common and intense discomfort symptom(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Studies show that 70% of critically ill patients experience thirst symptoms, with a prevalence of moderate to severe thirst at 55.8%(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Thirst induces intense anxiety and despair in critically ill patients, significantly impacting their psychological and mental well-being(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), and increases the risk of delirium (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)and post-ICU syndrome, thereby prolonging the treatment process and severely affecting patient outcomes. Thirst is considered by critically ill patients to be the second most stressful factor after death(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, ICU healthcare providers do not place sufficient emphasis on thirst in critically ill patients, and most ICU nurses lack experience in managing thirst symptoms in critically ill patients. Their perception of patients' thirst often differs from the patients' own experiences, leading to a situation where patients' thirst is frequently underestimated, under-assessed, and under-managed in clinical nursing practice(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Currently, thirst in critically ill patients has not been systematically assessed or adequately addressed. Failure to promptly alleviate thirst not only severely impacts patient comfort and reduces nursing satisfaction but also increases the incidence of adverse events such as unplanned extubating(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), posing higher demands and challenges for nursing work. The Theoretical Domain Framework is a theoretical framework that integrates various psychological theories and their underlying structures to study factors related to human behavioral change. Researchers can use the TDF to explore the factors influencing behavioral change from individual, organizational, and societal perspectives. Existing studies have confirmed(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) that by using the TDF to develop interview guidelines and conduct coding analysis for qualitative research, one can systematically and comprehensively identify and categorize the barriers involved. This study, based on the Theoretical Domain Framework and employing qualitative research methods, explores the barriers to thirst management in critically ill patients by ICU nurses, identifies the theoretical domains influencing ICU nurses' thirst management behaviors, and aims to guide the development of thirst management protocols for clinical healthcare providers, thereby improving thirst management practices for critically ill patients.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Research subjects\u003c/h2\u003e\u003cp\u003eFrom July to August 2025, nurses from the intensive care unit of a tertiary-level hospital in Puning City were selected as interview subjects using purposive sampling. Inclusion criteria: nurses must have professional qualifications; ICU work experience\u0026thinsp;\u0026ge;\u0026thinsp;3 years; clear verbal communication skills; awareness of and consent to participate in this study. Exclusion criteria: Nurses not directly involved in patient care, such as administrative nurses or pharmacy nurses; nurses absent due to sick leave, maternity leave, or further education; rotating or further education nurses. The sample size was determined based on information saturation. Basic information is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All participants signed informed consent forms.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant demographic characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eJob Title\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYears of experience in the ICU (years)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDeputy Chief Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eJunior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eJunior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eJunior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Developing interview guidelines\u003c/h2\u003e\u003cp\u003eBased on a literature review, the research team preliminarily drafted an interview outline according to the research objectives and theoretical domain framework. They then conducted preliminary interviews with two nurses, adjusted the outline based on the results, and finalized the interview outline, which included 12 theoretical domains(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The interview outline is shown in Table\u0026nbsp;2.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Collection and Analysis\u003c/h2\u003e\u003cp\u003eThis study used face-to-face semi-structured interviews. Before the interviews, the interviewees were informed of the purpose of the study and obtained informed consent before recording. A quiet duty room was selected as the interview location, and the interview duration was about 30 to 40 minutes. The interview process requires detailed records of the interviewee's expressions and nonverbal reactions. It is also necessary to pay attention to flexibly adjusting the order of questions in the outline, avoid leading questions, and encourage interviewees to actively express themselves. The interviewer should transcribe the audio and notes into a document within 24 hours after the interview. Two researchers independently coded the same material using the framework content analysis method(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and analyzed the interview data using TDF as the coding framework. In case of disagreement, the research team would discuss and determine the final decision. Throughout the data collection process, self-reflection(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) was conducted to prevent the researcher's personal characteristics, qualifications/experience, and biases from affecting the research results and causing deviations in the results.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Quality Control\u003c/h2\u003e\u003cp\u003eThe interviewer was a postgraduate student who had received systematic training in qualitative research courses and had ICU nursing experience. This study followed the principle of maximum difference and selected people of different ages, titles, working years, etc. for interviews to ensure the representativeness of the data. The data collection process flexibly used techniques such as follow-up questions and empathy. In the data analysis stage, two researchers analyzed and verified according to the theoretical domain framework, focusing on the text data from an objective perspective, reading and thinking deeply many times. At the same time, it was reported regularly at the research group meeting and discussed with the members to reach a consensus. After the researchers sorted out the materials, they returned them to the interviewees for verification and supplemented or modified them according to the feedback from the interviewees.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eWhen the number of respondents in this study reached 11, no new information emerged, 2 additional nurses were interviewed and no new themes emerged, so the interviews were stopped, numbered N1-N13, and the general information of the interviewees is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Thru the coding and comparison of the transcribed text, six (knowledge, skills, social/professional roles and identity, environment and resources, social influence, and behavioral norms) barrier factors for medical staff to implement thirst management for critically ill patients were analyzed and extracted.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Lack of knowledge and skills related to thirst management\u003c/h2\u003e\u003cp\u003eDue to the rapid changes in the condition of critically ill patients and the constant risk of life-threatening situations, healthcare professionals must promptly assess the patient's condition and initiate emergency interventions. Therefore, nurses tend to focus more on observing and assessing objective indicators such as vital signs, often neglecting patients' thirst issues. This leads to an inability to promptly identify and address patients' thirst problems. Additionally, most nurses have limited proficiency in assessing and intervening for thirst, resulting in a narrow range of nursing interventions that fail to effectively alleviate patients' thirst.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our understanding of knowledge related to thirst management for critically ill patients is fragmented, and we are unclear about how to accurately assess the severity of a patient's thirst. Most of us rely on our own experience.\u0026rdquo; (N4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I observe the patient's lips for dryness or peeling and the condition of their mouth during shift handover, but I do not further assess whether there are symptoms of thirst, the severity of such symptoms, or whether intervention is needed.\u0026rdquo; (N5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;During work, we do encounter patients who constantly say they are thirsty and want to drink water. However, sometimes patients are on a no-food, no-water regimen. If consulting the doctor confirms the need to maintain this regimen, we can only comfort them by using a cotton swab dipped in warm water or petroleum jelly to moisten their lips. I am unsure of other possible interventions.\u0026rdquo; (N7, N11)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For intubated patients, if I notice they are thirsty, I report it to the doctor and ask whether fluid replacement is needed or if I should moisten their mouth. Personally, I don't have much experience handling such patients. For sedated or minimally conscious patients, I am currently unaware of other specific management methods.\u0026rdquo; (N3, N10)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know how to obtain relevant guidelines and expert consensus, nor how to implement the recommended practices.\u0026rdquo; (N2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Thirst is not easily observable, especially in comatose patients. Sometimes when busy, it may not be considered, or if the patient does not express it, one may not proactively monitor whether the patient is thirsty or wants to drink water.\u0026rdquo; (N9, N12)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Compared to other symptoms the patient presents; thirst is not given as much priority. Pain and other symptoms are easier to assess, so thirst is often overlooked.\u0026rdquo; (N8)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Weak awareness of thirst management\u003c/h2\u003e\u003cp\u003eThe social/occupational role identity domain corresponding to this theme is manifested in this study as role ambiguity in thirst management among ICU nursing staff. This is primarily reflected in insufficient collaboration within the medical team.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our primary responsibility should be patient treatment and care; thirst assessment and management should be handled by the attending physician.\u0026rdquo; (N8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The assigned nurses change daily, making it difficult to coordinate effectively with the attending physician.\u0026rdquo; (N3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some doctors primarily focus on patients' vital signs and do not prioritize thirst-related issues. We also have numerous daily tasks and cannot follow up on these matters, so we can only adhere to medical orders.\u0026rdquo; (N4, N13)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Human resource constraints and lack of equipment\u003c/h2\u003e\u003cp\u003eICU patients have a high turnover rate and severe conditions. Respondents indicated that daily nursing procedures are numerous, and all aspects of patient care are handled by nurses, who primarily focus on monitoring vital signs and completing core tasks. The lack of thirst assessment equipment impacts the accuracy of thirst assessment in critically ill patients.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our daily work is quite diverse and time-consuming, leaving little time to focus on patients' thirst-related issues. Additionally, many patients are comatose, making assessments challenging, and there are no specialized assessment devices available. For conscious patients who do not express their needs, we would not proactively intervene.\u0026rdquo; (N1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Currently, the nurse-to-patient ratio is difficult to maintain at 1:1, often being 1: many, making it challenging to allocate time to monitor patients' thirst levels.\u0026rdquo; (N2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If we could assign someone specifically to assess thirst and communicate with the attending physician to resolve the issue, the situation would improve significantly.\u0026rdquo; (N3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes, if the patients we manage are conscious, they will actively say they are thirsty and want to drink water. However, in many cases, we are busy resuscitating patients or performing other treatments and cannot leave, so we can only let them wait and are unable to observe and intervene in a timely manner.\u0026rdquo; (N6, N11)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our work is already very busy, and sometimes we must work overtime to complete tasks. Therefore, actively offering water to patients feels like something beyond our regular nursing duties. We focus more on tasks like ventilator care and monitoring vital signs, so we often overlook observing patients' fluid intake.\u0026rdquo; (N9, N10)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Lack of organizational climate and social support\u003c/h2\u003e\u003cp\u003eIn this study, the lack of organizational atmosphere and social support was evident in the process of managing thirst in critically ill patients. Interviews revealed that the department had not established an atmosphere conducive to thirst management and that interactions among department members led to suboptimal implementation outcomes. Unclear division of labor among healthcare providers, poor communication, and unclear management responsibilities, coupled with the absence of specific implementation plans and management systems tailored to the department's actual circumstances, also hindered nurses' ability to implement thirst interventions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe department does not require staff to specifically address patients' thirst issues. Typically, if a patient's lips appear dry, staff will use a cotton swab or petroleum jelly to moisturize them. Everyone follows this practice, so there is little focus on addressing patients' thirst issues (N7).\u003c/p\u003e\u003cp\u003eEveryone just wants to finish their shift quickly and go home early. So even if they know patients may have thirst issues, there's simply no time to address it. Even if they want to, when they ask senior nurses, they're told to just moisten the lips or ask family members to buy a spray bottle for intermittent use. No other suggestions are given, so over time, they stop paying attention to the issue (N8, N10).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes when reporting to doctors that patients have thirst issues, they just tell us to handle it the old-fashioned way and observe, without any additional measures. It feels like doctors don\u0026rsquo;t take it seriously either, so I didn\u0026rsquo;t think much of it either.\u0026rdquo; (N5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Thirst management should be a nursing priority. While monitoring vital signs, we may overlook the patient's comfort. Thirst can also affect other vital signs. The discomfort from thirst can make patients restless, increasing the risk of delirium and post-ICU syndrome, thereby prolonging the treatment process and severely affecting the patient's prognosis. This should be given attention\u0026rdquo; (N1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Lack of implementation plans and regulatory measures\u003c/h2\u003e\u003cp\u003eThe behavioral norms theory domain corresponding to this theme refers to changes in objective, observable self-regulation processes. In this study, this manifests as the absence of standardized procedures and regulatory measures for thirst management in critically ill patients. Interviews revealed that there are currently no unified operational standards in clinical practice, with most healthcare providers relying on work experience to form specific operational habits. Thirst assessment is not standardized, and there is incomplete knowledge of assessment processes (tools) and intervention measures. Unclear intervention protocols hinder the clinical practice of thirst management in critically ill patients. Interviews suggest that effective regulatory measures would enhance the standardization of thirst management.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Generally, when we see a patient with dry, peeling lips, we use a cotton swab to wipe them or use a moist cotton ball to wipe the mouth. Sometimes we also use petroleum jelly, but we don\u0026rsquo;t know how to assess the severity of thirst, how long the effect of wiping lasts, or how often we need to reassess and intervene\u0026mdash;there are no unified requirements for this.\u0026rdquo; (N6, N13)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The department currently lacks standardized guidelines for thirst assessment. When busy, staff often neglect to assess patients' thirst levels or determine the need for timely intervention, instead relying on personal experience.\u0026rdquo; (N4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;During departmental training sessions, the importance of thirst management is mentioned, but there are no detailed operational guidelines to reference, and the effectiveness of thirst management is difficult to evaluate.\u0026rdquo; (N2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study found that healthcare professionals lack knowledge and skills in managing thirst in critically ill patients, leading to insufficient awareness among some healthcare professionals regarding thirst management in critically ill patients. In the current nursing education system, cultural competence training has been proven to significantly enhance nurses' cross-cultural sensitivity and clinical decision-making abilities(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). However, specialized teaching content on thirst management in critically ill patients remains significantly lacking in nursing curricula in China. Theoretical instruction primarily focuses on oral disease prevention (e.g., saline wipe techniques) rather than proactive intervention for thirst symptoms, resulting in nurses' insufficient understanding of the pathophysiological mechanisms of thirst and individualized relief strategies (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), which poses challenges for clinical implementation. Enhancing healthcare professionals' awareness of thirst management is a crucial foundation for conducting thirst management initiatives. ICU nurses primarily acquire knowledge about thirst through clinical practice, professional lectures, academic conferences, and peer exchanges. Among the desired supplementary channels, specialized training, expert lectures, and practical experience enhancement rank among the top three. This indicates that nurses seek to deepen their understanding through systematic training and theoretical learning and integrate this knowledge with clinical practice. Therefore, it is recommended to systematically advance specialized training on thirst management for ICU patients while consolidating practical exchanges and academic activities to comprehensively enhance nursing staff knowledge.\u003c/p\u003e\u003cp\u003eFrom a social influence perspective, a poor organizational atmosphere is one of the primary barriers to thirst management. Interference among team members, herd mentality, and inefficient collaboration patterns hinder the standardized implementation of thirst intervention measures. Related studies confirm that healthcare personnel are easily influenced by organizational environments when implementing thirst management, such as colleagues' negative attitudes or differences in process execution forming implicit constraints that weaken nursing compliance(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The interview results of this study further indicate that phenomena such as new members being assimilated and neglecting thirst assessment, as well as gaps in multidisciplinary collaboration, are prevalent in ICU nursing teams. The fundamental cause lies in the lack of emphasis on thirst management by management. It is recommended that department leaders incorporate thirst management into the new employee training system, strengthen team consensus through regular case discussions and standardized process drills, thereby enhancing intervention confidence and quality. Optimizing human and material resource allocation and regulatory processes for thirst management in critically ill patients requires evidence-based practice to integrate multi-dimensional resources and establish a standardized system.\u003c/p\u003e\u003cp\u003eIn terms of human resource allocation, the results of this study also confirm that excessive workloads are the primary reason ICU nurses neglect thirst issues. Under China's closed management model for ICUs, nurses are responsible for all daily care tasks, which are complex and physically and mentally exhausting, directly leading to a decrease in the implementation rate of thirst interventions(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In response, Shaanxi Province in China issued the \u0026ldquo;Implementation Plan for Strengthening the Construction of Critical Care Medical Service Capabilities,\u0026rdquo; explicitly requiring medical institutions to \u0026ldquo;equip critical care specialists according to standards\u0026rdquo; and \u0026ldquo;prioritize critical care medical staff,\u0026rdquo; while establishing performance evaluation and incentive mechanisms for critical care nursing positions. This aims to alleviate workload pressure through flexible human resource allocation and the establishment of dedicated positions. A multicenter trial(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)further validated the feasibility of the \u0026ldquo;human-machine collaboration\u0026rdquo; model, where smart devices monitor physiological indicators (such as heart rate and oxygen consumption) in real time, freeing nurses from basic monitoring tasks and allowing them to focus on personalized interventions. This model increased patient compliance by 40% and reduced readmission rates by 32%. Resource allocation must combine technological innovation with spatial optimization. The Department of Critical Care Medicine at Shanxi Cancer Hospital in China adopted the \u0026ldquo;oral spray method\u0026rdquo; to alleviate thirst. The 50-100ml sprayer is inexpensive but highly effective, with mist droplets evenly covering the oral mucosa to reduce the risk of lip cracking and infection. The Chegu Campus of Peking Union Medical College Hospital has established a \u0026ldquo;thirst-free ward\u0026rdquo; pilot program, integrating non-pharmacological measures such as ice stimulation therapy and warm water misting(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)for thirst management, effectively improving patients' thirst conditions. Regulatory processes and institutional frameworks must be based on standardization. Therefore, managers should address the negative effects of excessive workloads on nurses, regularly organizing psychological support activities to alleviate occupational stress and thereby enhance work enthusiasm. Additionally, hospital management should focus on improving the nursing support system, scientifically allocating nursing staff, and creating a healthy and orderly professional environment to ensure the sustainability of high-quality nursing services.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThe respondents in this study were only from one hospital, so the results may have certain limitations. Further multicenter clinical studies are needed to validate the findings. In the future, multi-center investigative studies combining quantitative and qualitative methods could be conducted based on this study to validate the results and provide reference and inspiration for managers.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThis study, based on a theoretical domain framework, identified six theoretical domain components related to barriers to thirst management behaviors among ICU nurses caring for critically ill patients. These findings provide a reference for setting goals for future clinical improvements, further standardizing ICU nurses' thirst management behaviors for critically ill patients, optimizing the thirst management process for critically ill patients\u0026rsquo; post-surgery, and narrowing the gap between evidence-based thirst management practices and clinical practice for critically ill patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all nurses who participated in this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made significant contributions to the conception of the article, the design and execution of the study, and the acquisition, analysis, and interpretation of the data. n the end, the version of the article for publication was unanimously endorsed and approved for submission to the journal. It was also agreed to assume responsibility for the content of the text.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive any funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData cannot be obtained from a third party and are not publicly available. The full dataset and data analysis code following receipt of ethics approval may be available from the corresponding author JYC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki. Ethical clearances and approvals were secured from the Ethics Committee of Puning People\u0026apos;s Hospital (Puning People\u0026apos;s Hospital Ethics Review [2025] No. 28). Informed consent was obtained from all study participants. Principles of voluntary participation, privacy, and confidentiality were observed. Only anonymous data were collected and analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional file 1: Appendix 1.\u003c/p\u003e\n\u003cp\u003eInterview Guide.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHalm MA. Managing Thirst in the Critically Ill. Am J Crit Care. 2022;31(2):161\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArai S, Stotts N, Puntillo K. Thirst in critically ill patients: from physiology to sensation. Am J Crit Care. 2013;22(4):328\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStotts NA, Arai SR, Cooper BA, Nelson JE, Puntillo KA. Predictors of thirst in intensive care unit patients. J Pain Symptom Manage. 2015;49(3):530\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlim M, Rustoen T, Blackwood B, Spronk PE. Thirst in adult patients in the intensive care unit: A scoping review. Intensive Crit Care Nurs. 2025;86:103787.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChanques G, Nelson J, Puntillo K. Five patient symptoms that you should evaluate every day. Intensive Care Med. 2015;41(7):1347\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePuntillo KA, Arai S, Cohen NH, Gropper MA, Neuhaus J, Paul SM, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38(11):2155\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKjeldsen CL, Hansen MS, Jensen K, Holm A, Haahr A, Dreyer P. Patients' experience of thirst while being conscious and mechanically ventilated in the intensive care unit. Nurs Crit Care. 2018;23(2):75\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin R, Li H, Chen L, He J. Prevalence of and risk factors for thirst in the intensive care unit: An observational study. J Clin Nurs. 2023;32(3\u0026ndash;4):465\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee CW, Liu ST, Cheng YJ, Chiu CT, Hsu YF, Chao A. Prevalence, risk factors, and optimized management of moderate-to-severe thirst in the post-anesthesia care unit. Sci Rep. 2020;10(1):16183.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFukunaga T, Ouchi A, Aikawa G, Okamoto S, Uno S, Sakuramoto H. Prevalence, risk factors, and treatment methods of thirst in critically ill patients: A systematic review and meta-analysis. PLoS ONE. 2025;20(3):e0315500.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSato K, Okajima M, Taniguchi T. Association of Persistent Intense Thirst With Delirium Among Critically Ill Patients: A Cross-sectional Study. J Pain Symptom Manage. 2019;57(6):1114\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYava A, Tosun N, \u0026Uuml;nver V, \u0026Ccedil;i\u0026ccedil;ek H. Patient and nurse perceptions of stressors in the intensive care unit. Stress Health. 2011;27(2):e36\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZengin N, \u0026Ouml;ren B, \u0026Uuml;st\u0026uuml;ndag H. The relationship between stressors and intensive care unit experiences. Nurs Crit Care. 2020;25(2):109\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiao C, Guan Q, Ma X, He X, Su Y, Fan D, et al. Construction of an assessment scale for thirst severity in critically ill patients and its reliability and validity. J Clin Nurs. 2025;34(3):795\u0026ndash;804.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePattison N. Symptom management of thirst for seriously ill and dying patients in critical care. Intensive Crit Care Nurs. 2025;86:103869.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoet S, Patey AM, Baron JS, Mohamed K, Pigford AE, Bryson GL, et al. Factors that influence effective perioperative temperature management by anesthesiologists: a qualitative study using the Theoretical Domains Framework. Can J Anaesth. 2017;64(6):581\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOyama Y, Yamase H, Fujita K, Tashita H, Honda T, Yoshida K, et al. Critically ill patients' experiences of discomfort and comfort in the intensive care unit: A qualitative descriptive study. Aust Crit Care. 2025;38(2):101115.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang Y, Gao Y, An R, Wan Q. Barriers and facilitators to exercise adherence in community-dwelling older adults: A mixed-methods systematic review using the COM-B model and Theoretical Domains Framework. Int J Nurs Stud. 2024;157:104808.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWright L, Bennett S, Meredith P. Using the Theoretical Domain Framework to understand what helps and hinders the use of different sensory approaches in Australian psychiatric units: A survey of mental health clinicians. Aust Occup Ther J. 2023;70(5):599\u0026ndash;616.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMichie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePOPE C, ZIEBLAND S, MAYS N. Analysing qualitative data[J/OL].[2024-03-\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e12].https://www.bmj.com/content/320/7227/114.DO1\u003c/span\u003e\u003cspan address=\"http://12].https://www.bmj.com/content/320/7227/114.DO1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.320.7227.114\u003c/span\u003e\u003cspan address=\"10.1136/bmj.320.7227.114\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePark HS, Jang HJ, Jeong GH. Effects of a cultural nursing course to enhance the cultural competence of nursing students in Korea. J Educ Eval Health Prof. 2019;16:39.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChang L-C, Lin H-L, Lin T-Y, Liao L-L. Evaluation of a Hybrid Learning Module on Cultural Competence for the Postgraduate Year of Nursing Programs in Taiwan: A Quasi-Experimental Study. SAGE Open. 2024;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFang CHEN, Zhixia J, Mingjing YANG, Qian LUO, Xia Z. A study on the perceptions and behaviors of ICU nursing staff on thirst in mechanically ventilated patients in Guizhou Province. Chin J Nurs. 2023;58(09):1104\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi S, Mi J, Tang Y. A qualitative study of nurses' perception on patients' thirst in intensive care units. Intensive Crit Care Nurs. 2022;69:103184.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamaoka K, Katsumata Y, Kohsaka S, Shiraishi Y, Kondo M, Nagashima K, et al. Patient-centered medical tools for sustained motivation in cardiac rehabilitation of patients with heart failure: protocol of a multicenter randomized controlled trial (EXERCISE-HF trial). Contemp Clin Trials Commun. 2025;47:101522.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao Peng X, Lijun L, Lin Y, Mingyu L, Linyan Z, Zhihui, et al. Network meta-analysis of non-pharmacological interventions to improve thirst in ICU patients. Evid Based Nurs. 2025;11(06):1015\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intensive Care Unit, Nurse, Critically ill patients, Thirst, Theoretical Domain Framework, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-7893573/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7893573/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThirst is a common and highly distressing core symptom in critically ill patients, ranking as the second most significant source of distress after death. However, healthcare providers often underestimate its severity. Nurses play a crucial role in identifying and alleviating thirst, making it essential to understand the barriers affecting their ability to manage this symptom.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo explore the barriers to thirst management behaviors among intensive care unit nurses for critically ill patients, providing a reference basis for developing thirst management strategies for critically ill patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ePurposeful sampling was used to develop an interview guide based on a theoretical domain framework. 13 intensive care unit nursing staff members were interviewed using a face-to-face semi-structured interview method, and the interview content was analyzed and coded using directed content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAnalysis of the interview results identified six theoretical domains influencing thirst management behaviors in critically ill patients: knowledge, skills, social/professional roles and identity, environment and resources, social influence, and behavioral norms. Key issues included healthcare providers' incomplete understanding of thirst management, weak awareness of thirst management, unfamiliarity with thirst assessment procedures, heavy daily workloads and equipment shortages, unfavorable organizational culture, and unclear processes and specific measures.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe implementation of thirst management for critically ill patients is influenced by multiple factors. The six areas identified in this study can serve as targets for improvement. Managers should explore strategies, and implementation plans for thirst management in critically ill patients to enhance the quality of thirst management for this population.\u003c/p\u003e","manuscriptTitle":"Analysis of barriers to thirst intervention in critically ill patients by ICU nurses: A qualitative study based on the Theoretical Domain Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 09:17:04","doi":"10.21203/rs.3.rs-7893573/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-17T15:53:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191093036212353598719802048877525622883","date":"2026-03-05T16:18:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-23T23:08:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-17T07:21:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-27T06:28:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-25T14:56:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-10-25T14:53:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5e66ea40-d3f1-48a6-b64e-4cd8f8e4a8a6","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-28T09:17:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-28 09:17:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7893573","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7893573","identity":"rs-7893573","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}