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Montgomery A, Smerdely P, Hickman L, Traynor V. Comparing the delirium objective structured clinical examination (OSCE) education package to standard education for post-registration nurses: A randomised controlled trial. NURSE EDUCATION TODAY 2024; 139:106211. [PMID: 38676962 DOI: 10.1016/j.nedt.2024.106211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND A recent pilot study demonstrated that an interactive delirium educational intervention, The Delirium OSCE Education Package, had a positive impact on self-perceptions of confidence and competence in the use of delirium assessment tools and delirium knowledge; delirium knowledge scores; clinical practice; and planned practice change for participants. However, it is not known if The Delirium OSCE Education Package is superior to standard methods of professional development education. OBJECTIVE To determine if The Delirium OSCE Education Package is superior to standard methods of professional development education on observations of delirium care in practice scores for post-registration nurses. DESIGN Clustered randomised, controlled, and observer-blinded, multisite superiority trial with two parallel groups at each site. SETTINGS Three private hospitals across New South Wales, Australia. PARTICIPANTS Registered nurses (RNs) (n = 153) or enrolled nurses (ENs) (n = 37) working in the eligible inpatient medical or surgical wards at each site. METHODS Within each hospital site wards were clusters, with wards rather than individuals being randomised for The Delirium OSCE Education Package or standard professional development education at a ratio of 1:1. The primary outcome was observations of delirium care in practice, 6-weeks post (T1) allocated intervention. Secondary outcomes were self-perceived confidence and competence (self-efficacy) in delirium assessment tools and delirium knowledge; and delirium knowledge scores. RESULTS A total of 51.3 % (n = 20) in the intervention group obtained a satisfactory observation of delirium care in practice score, compared to 34.9 % (n = 15) in the control group (p = 0.134, χ2). The odds of a satisfactory observation of delirium care in practice score for the intervention group was 10.1 times higher than the control (p = 0.009). The mean MCQ score and perceptions of confidence and competence in the intervention and control group increased from baseline to six-weeks post-intervention, however, there was no significant difference between the groups. CONCLUSION The Delirium OSCE Education Package provides the foundation for facilitating change in delirium care. It is recommended that The Delirium OSCE Education Package is implemented as part of a multicomponent strategy involving a validation delirium screening and assessment tool, hospital-specific policy, interprofessional education, and delirium champions. Future studies are needed to evaluate the sustainability of the intervention and if there is a positive impact on patient-level outcomes.
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Affiliation(s)
- Amy Montgomery
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia.
| | - Peter Smerdely
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia; Aged Care Department, St. George Hospital, Kogarah, Australia; School of Public Health & Community Medicine, University of New South Wales, Australia.
| | - Louise Hickman
- Health University of Wollongong, Northfields Ave, Wollongong, NSW, 2522, Australia..
| | - Victoria Traynor
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia.
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Bianchi LA, Harris R, Fitzpatrick JM. Barriers to healthcare professionals recognizing and managing delirium in older adults during a hospital stay: A mixed-methods systematic review. J Adv Nurs 2024; 80:2672-2689. [PMID: 38108154 DOI: 10.1111/jan.16018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/17/2023] [Accepted: 11/26/2023] [Indexed: 12/19/2023]
Abstract
AIM To investigate barriers to healthcare professionals recognizing and managing delirium in hospitalized older people. DESIGN A mixed-methods systematic review. PROSPERO ID CRD42020187932. DATA SOURCES MEDLINE, EMBASE, PsycINFO and CINAHL were searched (2007 to February 2023). REVIEW METHODS Included studies focused on healthcare professionals' recognition and management of delirium for patients aged 65 years and over in a hospital ward or emergency department. Enhancing rigour, screening of results was conducted independently by two researchers. Qualitative and quantitative data were tabulated separately and grouped. Data were compared to identify similarities and differences. All studies were quality appraised. RESULTS 43 studies were included; 24 quantitative, 16 qualitative and three mixed-methods. Data synthesis highlighted synergy between qualitative and quantitative findings. Barriers were reflected in six themes: (1) healthcare professionals' knowledge and understanding; (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints. CONCLUSIONS Of significance, for older adults in hospital experiencing delirium, there is variability in whether and how well it is recognized and managed. To prevent adverse outcomes best practice guidance for screening, recognizing, diagnosing and managing delirium in older people needs to be agreed and disseminated widely. Supporting healthcare professionals to care for this patient population using an integrated approach is essential, how to involve and communicate with patients and their family and friends, how to recognize and manage delirium for patients with additional needs, e.g., those living with dementia and/or a learning disability. Hospitals need to have policy and guidance in place for the recognition and management of delirium in older adults presenting to a ward or to an emergency department. An IT infrastructure is needed that integrates assessments and care management plans in patient electronic records and makes them accessible within and across teams in hospital, primary and community care settings. PATIENT OR PUBLIC CONTRIBUTION There was no patient or public contribution to this systematic review. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE Healthcare professionals can be better supported to be able to recognize and manage delirium during an acute hospital stay for older adults. This includes maximizing best care for those patients living with dementia, involving families and friends to help understand patients' baseline status and changes and supporting families and friends during this process. Of significance, attention to hospital IT infrastructures is warranted, integrating screening, assessment and care management plans in patients' electronic records and making these accessible to healthcare professionals caring for this patient population across care settings. IMPACT What problem did the study address? Delirium is a common condition experienced by older hospitalized patients, but it is consistently under-recognized which has implications for patient and organization outcomes. To help address this, understanding barriers to healthcare professionals recognizing and managing delirium for this patient population is paramount. What were the main findings? Barriers to healthcare professionals recognizing and managing delirium for this patient population were synthesized in six themes: (1) healthcare professionals' knowledge and understanding, (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints. Where and on whom will the research have an impact? The findings of this original systematic review can contribute to hospital policy and protocol for the recognition and management of delirium in older patients. The findings can meaningfully contribute to workforce professional development for practitioners caring for older people during an acute hospital stay and for practitioners in primary and community settings involved in the follow-up of patients post hospital discharge. For researchers, the findings indicate several research recommendations including investigating the impact of an education programme for nurses and other healthcare professionals on the recognition and management of the condition and understanding and investigating how best to support delirium-related distress experienced by patients and their families and practitioners. REPORTING METHOD This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).
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Affiliation(s)
- Leda A Bianchi
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ruth Harris
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Joanne M Fitzpatrick
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Kim S, Choi E, Jung Y, Jang I. Postoperative delirium screening tools for post-anaesthetic adult patients in non-intensive care units: A systematic review and meta-analysis. J Clin Nurs 2021; 32:1691-1704. [PMID: 34881476 DOI: 10.1111/jocn.16157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/31/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To identify the most accurate postoperative delirium screening tools for detecting postoperative delirium among patients who underwent general anaesthesia surgery in general wards. BACKGROUND The lack of detection of postoperative delirium can negatively affect the patient's condition, along with their postoperative treatment and rehabilitation, and it can prolong their hospitalisation, persists cognitive dysfunction and increases mortality. Screening for postoperative delirium in hospitalised patients as nursing assessment is routine clinical practice for early detection. DESIGN A systematic review and meta-analysis. METHODS MEDLINE, Embase, CINAHL, KoreaMed and Cochrane electronic databases were searched using the key words delirium, postoperative, assessment or screening, and adult for articles published up to April 2020, with no limit on the year of publishing. Only prospective cohort studies reporting sensitivity and specificity values were included. We followed the recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews and the PRISMA checklist. The Quality Assessment of the Diagnostic Accuracy Studies-2 tool was used for data extraction and quality assessment, while a bivariate random-effects meta-analysis model was used for pooling and comparing diagnostic accuracy and providing a summary of evidence. RESULTS Six delirium assessment tools were evaluated from nine papers including 3088 patients. Due to the limited number of papers, the meta-analysis included the Confusion Assessment Method (CAM) and its variants, Delirium Detection Score (DDS) and Nurses' Delirium Screening Checklist (NuDESC). Overall, NuDESC demonstrated higher sensitivity than CAM or DDS, while all showed high specificity (0.90 or greater). CONCLUSION This review suggested that NuDESC can be employed as an accurate screening tool with high specificity for assessing postoperative delirium during routine checkups. However, it is necessary to consider suitable cut-off values, which is the reference point, in accordance with the clinical setting and the patients' condition. RELEVANCE TO CLINICAL PRACTICE NuDESC reported the best evidence of diagnostic accuracy, and we recommend clinical nurses to employ this easy-to-use and validated tool for daily screening of postoperative delirium in general wards to facilitate its early detection and the accurate estimation of its prevalence.
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Affiliation(s)
- Sujeong Kim
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Eunju Choi
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Youngsun Jung
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Insil Jang
- Department of Nursing, Chung-Ang University, Seoul, Korea
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Warnier RMJ, van Rossum E, Du Moulin MFMT, van Lottum M, Schols JMGA, Kempen GIJM. The opinions and experiences of nurses on frailty screening among older hospitalized patients. An exploratory study. BMC Geriatr 2021; 21:624. [PMID: 34732153 PMCID: PMC8565044 DOI: 10.1186/s12877-021-02586-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background Routine screening for frailty at admission by nurses may be useful to detect geriatric risks and problems at an early stage. However, the added value of this screening is not clear yet. Information about the opinions and attitudes of nurses towards this screening is also lacking. As they have a crucial role in conducting this screening, an exploratory study was performed to examine hospital nurses’ opinions and perspectives about this screening and how it influences their daily work. Methods A qualitative, exploratory approach was employed, using semi-structured interviews with 13 nurses working on different general medical wards (surgical and internal medicine) in three Dutch hospitals. Frailty screening had been implemented for several years in these hospitals. Results The participating nurses reported that frailty screening can be useful to structure their work, create more awareness of frail older patients and as starting point for pro-active nursing care. At the same time, they assess their clinical view as more important than the results of a standard screening tool. The nurses hardly used the overall screening scores, but were particularly interested in information regarding specific items, such as delirium or fall risk. Screening results are partly embedded systematically and in daily nursing care, e.g., in team briefings or during transfer of patients to other wards. The majority of the nurses had received little training about the background of frailty screening and the use of screening tools. Conclusions Most nurses stated that frailty screening tools are helpful in daily practice. However, nurses did not use the frailty screening tools in the referred way; tools were particularly used to evaluate patients on separate items of the tool instead of the summative score of the tool. When frailty screening tools are implemented in daily practice, training needs to be focused on. Additional research in this field is necessary to gain more insight into nurses’ opinions on frailty screening. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02586-z.
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Affiliation(s)
- Ron M J Warnier
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University, Maastricht, The Netherlands. .,Envida, Care for Elderly, Department of Treatment and Guidance, Vijverdalseweg 10, 6226, NB, Maastricht, The Netherlands.
| | - Erik van Rossum
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Academy of Nursing, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | | | - Marjolein van Lottum
- Academy of Nursing, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Jos M G A Schols
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Care and Public Health Research Institute (CAPHRI), Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Gertrudis I J M Kempen
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
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Jeong E, Chang SO. Can multifaceted educational intervention improve clinical practice and patient outcomes regarding delirium in nursing homes? Jpn J Nurs Sci 2021; 19:e12447. [PMID: 34396707 DOI: 10.1111/jjns.12447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/30/2021] [Indexed: 12/01/2022]
Abstract
AIM We aimed to develop and evaluate a multifaceted and evidence-based delirium educational program for practitioners in nursing home settings. METHODS A pre- and posttest comparison group design was employed. The recruited practitioners included nurses and care workers from two nursing homes. The intervention group (n = 51) received the developed delirium educational program for 3 weeks, whereas the control group (n = 23) received a delirium handbook. We examined pre- and posttest differences in the scores for delirium knowledge and confidence in providing delirium care. We also examined the nurses' ability to clinically detect delirium in patients and delirium incidence for 8-week periods both before and after the intervention. RESULTS There were significant improvements in the participants' aptitudes (delirium knowledge and confidence in providing delirium care) and clinical practice (ability to clinically detect delirium in the patients) only in the intervention group; however, there were no significant differences in patient outcomes (incidence of delirium) between either group. Additionally, it was observed that the nurses' improved understanding of distinct clinical features of delirium, such as acute change or fluctuation, was the key factor that directly affected the success of delirium screening. CONCLUSIONS This study revealed that implementation of a multifaceted and evidence-based delirium educational program for practitioners in nursing home settings was effective in promoting the knowledge, confidence, and ability to detect delirium. The developed program can also be implemented in settings where most patients are older individuals, such as geriatric care units, or long-term care hospitals.
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Affiliation(s)
- Eunhye Jeong
- College of Nursing, Shinhan University, Dongducheon, Republic of Korea
| | - Sung Ok Chang
- College of Nursing, Shinhan University, Dongducheon, Republic of Korea
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Featherstone I, Hosie A, Siddiqi N, Grassau P, Bush SH, Taylor J, Sheldon T, Johnson MJ. The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis. Palliat Med 2021; 35:988-1004. [PMID: 33784915 PMCID: PMC8189008 DOI: 10.1177/02692163211006313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. AIM To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts. DESIGN Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). DATA SOURCES The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. RESULTS A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. CONCLUSIONS Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.
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Affiliation(s)
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Pamela Grassau
- School of Social Work, Carleton University, Ottawa, ON, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Palliative Care, Bruyere Continuing Care, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Henao-Castaño AM, Pachón Cetina LE, Monroy Rodríguez JD. Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review. AQUICHAN 2020. [DOI: 10.5294/aqui.2020.20.4.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To analyze the context and use of the Nursing Delirium Screening Scale (Nu-DESC) for early detection of delirium in adult patients, compiling the available evidence.
Method: Searching for relevant articles on databases such as Cinahl, Medline, Ovid, Scopus, and Web of Science. Inclusion criteria: Articles written in English, Spanish, and Portuguese, published between January 2013 and October 2019. Search terms: “nursing delirium screen,” “inpatient delirium screening,” and “nursing assessment.” We identified 23 articles in which the Nu-DESC was used. Two reviewers independently assessed the articles using the CASPe (Critical Appraisal Skills Program in Spanish) tool.
Results: The Nu-DESC is employed in different contexts such as the adult intensive care unit (ICU), post-anesthetic care unit (PACU), palliative care unit, and hospitalization unit. It is more frequently used in the PACU with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % CI: 32.2–75.6) and specificity of 97.1 % (95 % CI: 95.3–98.4).
Conclusion: The Nu-DESC facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units.
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Jeong E, Park J, Lee J. Diagnostic test accuracy of the Nursing Delirium Screening Scale: A systematic review and meta‐analysis. J Adv Nurs 2020; 76:2510-2521. [DOI: 10.1111/jan.14482] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/18/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Eunhye Jeong
- College of Nursing Korea University Seoul Republic of Korea
| | - Jinkyung Park
- College of Nursing Korea University Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
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Papastavrou E, Papaioannou M, Evripidou M, Tsangari H, Kouta C, Merkouris A. Development of a Tool for the Assessment of Nurses' Attitudes Toward Delirium. J Nurs Meas 2019; 27:277-296. [PMID: 31511410 DOI: 10.1891/1061-3749.27.2.277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The prevalence of delirium during hospitalization is high in older patients and there is evidence of staff regarding them as unpopular or a burden. This study aims to develop an instrument examining nurses' attitudes toward patients with delirium. METHODS Stages included (a) content identification, (b) content development, (c) content critique, (e) pilot study with a test-retest reliability, (f) field study consisting of psychometric testing of the internal consistency and construct validity. RESULTS The Cronbach's alpha was 0.89 and the stability reliability was acceptable. The factor analysis resulted in three factors explaining a total of 56.5% of the variance. hese factors are "beliefs," "behavior," and "emotions," explaining 37.025%, 12.792%, and 5.652% of variance. CONCLUSIONS The Attitude Tool of Delirium (ATOD) is a reliable and valid instrument for the assessment of attitudes toward delirium.
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Heinrich TW, Kato H, Emanuel C, Denson S. Improving the Validity of Nurse-Based Delirium Screening: A Head-to-Head Comparison of Nursing Delirium-Screening Scale and Short Confusion Assessment Method. PSYCHOSOMATICS 2019; 60:172-178. [DOI: 10.1016/j.psym.2018.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 09/06/2018] [Accepted: 09/06/2018] [Indexed: 11/16/2022]
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Hosie A, Phillips J, Lam L, Kochovska S, Noble B, Brassil M, Kurrle SE, Cumming A, Caplan GA, Chye R, Le B, Ely EW, Lawlor PG, Bush SH, Davis JM, Lovell M, Brown L, Fazekas B, Cheah SL, Edwards L, Agar M. Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: study protocol for a phase II cluster randomised controlled trial. BMJ Open 2019; 9:e026177. [PMID: 30696686 PMCID: PMC6352777 DOI: 10.1136/bmjopen-2018-026177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group. METHODS AND ANALYSIS The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial. ETHICS AND DISSEMINATION Ethical approval was obtained for all four sites. Trial results, qualitative substudy findings and implementation of the intervention will be submitted for publication in peer-reviewed journals, and reported at conferences, to study sites and key peak bodies. TRIAL REGISTRATION NUMBER ACTRN12617001070325; Pre-results.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Lawrence Lam
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Beverly Noble
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meg Brassil
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Susan E Kurrle
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Healthcare, Sydney, New South Wales, Australia
| | - Gideon A Caplan
- Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Randwick, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Health Service, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Brian Le
- Palliative and Supportive Services, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University, and the Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville TN USA, Nashville, Tennessee, USA
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jan Maree Davis
- Palliative Care, Calvary Health Care Kogarah, Sydney, New South Wales, Australia
| | - Melanie Lovell
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
- HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Linda Brown
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Seong Leang Cheah
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Layla Edwards
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
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Wright DK, Brajtman S, Macdonald ME. Relational ethics of delirium care: Findings from a hospice ethnography. Nurs Inq 2018; 25:e12234. [PMID: 29573054 DOI: 10.1111/nin.12234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2018] [Indexed: 01/27/2023]
Abstract
Delirium, a common syndrome in terminally ill people, presents specific challenges to a good death in end-of-life care. This paper examines the relational engagement between hospice nurses and their patients in a context of end-of-life delirium. Ethnographic fieldwork spanning 15 months was conducted at a freestanding residential hospice in eastern Canada. A shared value system was apparent within the nursing community of hospice; patients' comfort and dignity were deemed most at stake and therefore commanded nurses' primary attention. This overarching commitment to comfort and dignity shaped all of nursing practice in this hospice, including practices related to end-of-life delirium. The findings of this study elaborate the ways in which hospice nurses interpreted and responded to the discomfort of their patients in delirium, as well as the efforts they made to understand their patients' subjective experiences and to connect with them in supportive ways. In addition to what is already known about clinical assessment and treatment of delirium in palliative care settings, the findings of this study offer points of reflection for nurses anywhere who are contending with the relational challenges that delirium presents in end-of-life care.
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Affiliation(s)
- David Kenneth Wright
- School of Nursing, University of Ottawa, Ottawa, ON, Canada.,Nursing Palliative Care Research and Education Unit, University of Ottawa, Ottawa, ON, Canada
| | - Susan Brajtman
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Mary Ellen Macdonald
- Division of Oral Health and Society, Faculty of Dentistry, McGill University, Montreal, QC, Canada
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Hosie A, Agar M, Lobb E, Davidson PM, Phillips J. Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis. Int J Nurs Stud 2017; 75:123-129. [PMID: 28783489 DOI: 10.1016/j.ijnurstu.2017.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 07/04/2017] [Accepted: 07/08/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Delirium is a serious acute neurocognitive condition frequently occurring for hospitalized patients, including those receiving care in specialist palliative care units. There are many delirium evidence-practice gaps in palliative care, including that the condition is under-recognized and challenging to assess. OBJECTIVES To report the meta-synthesis of a research project investigating delirium epidemiology, systems and nursing practice in palliative care units. METHODS The Delirium in Palliative Care (DePAC) project was a two-phase sequential transformative mixed methods design with knowledge translation as the theoretical framework. The project answered five different research questions about delirium epidemiology, systems of care and nursing practice in palliative care units. Data integration and metasynthesis occurred at project conclusion. RESULTS There was a moderate to high rate of delirium occurrence in palliative care unit populations; and palliative care nurses had unmet delirium knowledge needs and worked within systems and team processes that were inadequate for delirium recognition and assessment. The meta-inference of the DePAC project was that a widely-held but paradoxical view that palliative care and dying patients are different from the wider hospital population has separated them from the overall generation of delirium evidence, and contributed to the extent of practice deficiencies in palliative care units. CONCLUSION Improving palliative care nurses' capabilities to recognize and assess delirium will require action at the patient and family, nurse, team and system levels. A broader, hospital-wide perspective would accelerate implementation of evidence-based delirium care for people receiving palliative care, both in specialist units, and the wider hospital setting.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia.
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia
| | - Elizabeth Lobb
- Calvary Health Care Sydney, Palliative Care Department, 91-111 Rocky Point Rd, Kogarah, NSW 2217, Australia
| | - Patricia M Davidson
- Johns Hopkins University, School of Nursing, 525 N. Wolfe Street, Baltimore, MD 21205, United States
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia
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"Eight Days of Nightmares … " - Octogenarian Patients' Experiences of Postoperative Delirium after Transcatheter or Surgical Aortic Valve Replacement. Heart Lung Circ 2017; 27:260-266. [PMID: 28396186 DOI: 10.1016/j.hlc.2017.02.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/05/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are increasingly performed in octogenarian patients with severe aortic stenosis (AS), including those with high surgical risk. Postoperative delirium (PD) is a common and serious complication in older patients, characterised by reduced awareness, change in consciousness, disturbance in logical thinking and hallucinations. METHODS To explore how octogenarian patients experienced PD, a qualitative study was conducted including five women and five men between 81 and 88 years. The incidence of PD was assessed for five days using the Confusion Assessment Method. Cognitive function was assessed preoperatively and at a 6-month follow-up using the Mini-Mental State Examination. In-depth interviews were conducted 6-12 months post-discharge, transcribed, and analysed using Giorgi's phenomenological method. RESULTS Postoperative delirium experiences were grouped into six themes: "Like dreaming while awake", "Disturbed experiences of time", "Existing in a twilight zone", "Trapped in medical tubes", "Moving between different surroundings" and "Meeting with death and the deceased". CONCLUSIONS For the first time, we show that octogenarian patients who undergo SAVR or TAVI have strong and distressing memories of their delirious state that can persist for up to 12 months later. These findings provide valuable new information that will likely improve delivery of health services and enhance professional and empathic care of octogenarians after SAVR and TAVI.
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