Using a general theory of implementation to plan the introduction of delirium prevention for older people in hospital.

AIM: To develop an implementation plan for delirium prevention. BACKGROUND: The use of non-pharmacological interventions to prevent hospital-acquired delirium is well established but their implementation has been notoriously difficult to achieve. Systematic analysis of context as part of implementation planning is critical. METHODS: Ethnographic study was conducted in a 24-bed general medical ward. Eleven patients and family members and 15 health service staff participated through observations, individual interviews and document review. Inductive analysis was used to generate themes that described enablers and barriers. RESULTS: Enablers included a ward culture that embraced safety and placing the person at the centre of care. Barriers were in tension with the enablers and included limited staff knowledge, specialist forms exclusive to the nursing discipline, inflexible ward routines and frequent disruptions. CONCLUSIONS: In addition to standard implementation strategies such as individual education and leadership, implementing delirium prevention requires consideration of team practices, review of policy document design and identification of outcomes data than can support collaborative reflexive practice. IMPLICATIONS FOR NURSING MANAGEMENT: The use of a theory-informed ethnographic approach exposed tensions that may be otherwise invisible. Understanding the tensions increases the likelihood of implementation success. Using a systematic assessment approach can create a comprehensive implementation plan.

Feasibility of a two-part person-centred care initiative for people living with dementia in acute hospitals: A mixed methods study.

Background: The personal profile offers a potentially useful tool to support person-centred care of people living with dementia in hospital. To date, how profiles can be implemented into nurses' work practices is not established. Objectives: The aim is to establish the feasibility of a Person-Centred Care package, including a personal profile and staff education program to enhance implementation. Design: Exploratory convergent mixed methods approach. Settings: Four units of a tertiary health service, two intervention units and two comparison units set in southeast Queensland, Australia. Participants: Person living with dementia and family carer dyads and staff. Methods: Practicality was determined using participation logs, audit and review of meeting minutes. Acceptability was determined using interviews with family carers and nursing staff. Efficacy was evaluated using pre-post comparison survey design, assessing staff knowledge using the Dementia Knowledge Assessment Scale and person-centred care using the Person-centredness of Older People with cognitive impairment in Acute Care-revised scale. Results: Practically, the personal profile was distributed to 95 and 73% of patients in the two intervention units. Of the 18 people living with dementia who consented to participate, only 6 (33%) had a This is Me form completed. The three-part education program was well attended (n = 190 participants). In terms of acceptability, carers' (n = 5) experienced variable quality of engagement from nurses. In interviews, nurses (n = 18) experienced increased confidence to engage carers, in part attributed to local leadership, but attitudes towards care appeared to be influenced by perceived time constraints. For efficacy, completion of both surveys at all time points and in all units was 50% and higher. Dementia knowledge significantly improved in the intervention group (p < .01) however there was no difference in self-ratings of person-centred care. Conclusions: The feasibility of a Person-Centred Care package, including a personal profile and a focused program of staff education was partially achieved, with the education component adopted into the organisation's continuing education program. Implementation research is required to enhance the element of coherence, how completing the personal profile is an investment in person-centred care rather than simply completing another form.

Education for delirium prevention: Knowing, meaning and doing.

Hospital-acquired delirium is a common complication for older patients. Delirium prevention programs have been shown to reduce incident delirium and decrease length of stay; however, incorporating delirium prevention into nursing practice continues to be challenging. A three-element delirium prevention educational program was conducted with 42 nurses in a medical ward in a tertiary hospital in southeast Queensland. The education program focused on knowing, meaning and doing, consisting of a brief online course, case discussions with experts, and a high-fidelity simulation. A repeated cross-sectional design was utilised, with data collected over four time points before (T0), during the education program (T1, T2) and three months post completion of the study (T3). There were high levels of participation in the elements (48%-85%). Correct responses on the knowledge survey increased over time from 74.5% (T0) to 86.4% (T3; p = .003), suggesting a program focused on knowing, meaning and doing, was effective in improving nurses' knowledge about delirium. The increase in knowledge post completion indicates that learning about delirium prevention continued without structured education. Further research into how knowledge might be shared between nurses as part of everyday work may reveal other practice-based learning techniques which support practice change.