Journal of Gerontological Nursing

CNE Article 

Is it My Job? The Role of RNs in the Assessment and Identification of Delirium in Hospitalized Older Adults: An Exploratory Qualitative Study

Miriam Anne Coyle, MPhil, MSc, RN; Pippa Burns, PhD, MPH, BSc(Hons); Victoria Traynor, PhD, BSc(Hons), RGN

Abstract

Delirium is characterized by acute and fluctuating cognitive decline, which is often missed in older adults who are assumed to be experiencing age-related changes or dementia. Delirium affects up to 50% of hospitalized older adults. The aim of the current study was to (a) explore current practices of RNs in assessing and identifying delirium in hospitalized older adults and (b) inform new educational initiatives. Qualitative methods were adopted using eight semi-structured group interviews with 24 RNs. Thematic analysis revealed a dichotomy in practice where RNs described delirium assessment and identification as (a) It's Not My Job, (b) It is My Job, and (c) It's Complex. The imperative to improve delirium assessment and identification to create safer and more caring health care environments means the current findings provide important evidence to build into practice and education strategies. The current authors have developed engaging educational interventions and begun implementation at the study site to develop delirium assessment and identification capacity, which moves clinicians beyond awareness and aims at practice adherence or the consistent application of evidence-based delirium assessment. [Journal of Gerontological Nursing, 43(4), 29–37.]

How to Obtain Contact Hours by Reading this Article

Instructions

1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must:

  1. Read the article, “Is it My Job? The Role of RNs in the Assessment and Identification of Delirium in Hospitalized Older Adults: An Exploratory Qualitative Study” found on pages 29–37, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

  2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

  3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until March 31, 2020.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Activity Objectives
  1. Identify themes nurses use in assessing delirium.

  2. Define how qualitative methodology provides strategies for practice and education.

Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

 Do you want to Participate in the CNE activity?

Abstract

Delirium is characterized by acute and fluctuating cognitive decline, which is often missed in older adults who are assumed to be experiencing age-related changes or dementia. Delirium affects up to 50% of hospitalized older adults. The aim of the current study was to (a) explore current practices of RNs in assessing and identifying delirium in hospitalized older adults and (b) inform new educational initiatives. Qualitative methods were adopted using eight semi-structured group interviews with 24 RNs. Thematic analysis revealed a dichotomy in practice where RNs described delirium assessment and identification as (a) It's Not My Job, (b) It is My Job, and (c) It's Complex. The imperative to improve delirium assessment and identification to create safer and more caring health care environments means the current findings provide important evidence to build into practice and education strategies. The current authors have developed engaging educational interventions and begun implementation at the study site to develop delirium assessment and identification capacity, which moves clinicians beyond awareness and aims at practice adherence or the consistent application of evidence-based delirium assessment. [Journal of Gerontological Nursing, 43(4), 29–37.]

How to Obtain Contact Hours by Reading this Article

Instructions

1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must:

  1. Read the article, “Is it My Job? The Role of RNs in the Assessment and Identification of Delirium in Hospitalized Older Adults: An Exploratory Qualitative Study” found on pages 29–37, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

  2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

  3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until March 31, 2020.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Activity Objectives
  1. Identify themes nurses use in assessing delirium.

  2. Define how qualitative methodology provides strategies for practice and education.

Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

 Do you want to Participate in the CNE activity?

Delirium is characterized by its sudden and acute onset, which may occur over a few hours, but the effects can be longstanding and permanent. Delirium presents as three distinct types: hypoactive (e.g., reduced motor activity, lethargy, staring into space, drowsiness, withdrawal, catatonic state), hyperactive (e.g., increased motor activity, disorientation, hallucinations, delusions, restlessness, agitation, aggression, disinhibition, rambling speech, fear, hyper-alertness, paranoia), and mixed (i.e., alternating between hypo- and hyperactive) (Melbourne Health & Delirium Clinical Guidelines Expert Working Group, 2006). Often the symptoms of delirium are ignored or misunderstood by health care staff, which results in large-scale underrecognition or misdiagnosis among older adults (Inouye et al., 1990; Traynor et al., 2016). Delirium is commonly ignored among older adults when symptoms are misattributed as an expected outcome of a chronic physical health problem, dementia, an exacerbation of dementia, or depression (Flaherty, 2011; Grover & Shah, 2011).

Delirium can affect any individual at any age, but children and older adults are the most vulnerable (Hatherill & Flisher, 2010). Up to 50% of hospitalized older adults experience delirium. It is frightening and associated with a range of adverse outcomes, yet continues to be undetected in 32% to 66% of individuals (Maclullich et al., 2013; Schofield, Tolson, & Fleming, 2011). The discomfort caused by delirium, although most keenly felt by older adults, extends to their families and the health care team, likely affecting the care they provide (McDonnell & Timmins, 2012). Delirium is preventable in at least one third of older adults, reflecting real opportunity for improvement (Maclullich et al., 2013). Clinical practice and research demonstrate that RNs are effective in identifying individuals in their care who are confused, but they do not use assessment tools to determine the presence of delirium (Hare, McGowan, Wynaden, Speed, & Landsborough, 2008; Steis & Fick, 2012) despite having the Confusion Assessment Method (CAM; Inouye et al., 1990) to screen for delirium and the Abbreviated Mental Test Scores (AMTS; Hodkinson, 1972) for monitoring changes in cognition (Australian Commission on Safety and Quality in Health Care, 2014). RNs have a 24-hour bedside role, placing them in a position to take the lead in assessing and identifying delirium, and thereby reduce the poor outcomes older adults experience in health care settings (Irving, Fick, & Foreman, 2006).

International and National Context

Interest in delirium is growing with policy development, research, educational interventions, and the launch of specialist professional groups (Maclullich et al., 2013). In Australia, delirium clinical practice guideline and care pathways were published (Australian Health Ministers' Advisory Council: Health Care of Older Australians Standing Committee, 2010; Melbourne Health & Delirium Clinical Guidelines Expert Working Group, 2006; Traynor, Burns, & Britten, in press), and there is now an Australasian Delirium Association. To promote improved care for hospitalized individuals with cognitive impairment, the Australian Commission on Safety and Quality in Health Care (2014) has launched a campaign seeking professional and community commitment, offering supportive resources and guidance through revised health care standards that reflect the importance of delirium care.

Within New South Wales, Australia, the Ministry of Health funded dementia/delirium clinical nurse consultant (CNC) positions—who are clinical leaders across community and acute care settings (known as local health districts). The first author (M.A.C.) is a district CNC in delirium and dementia and the current study was designed to inform this role.

Clinical Practice Experience

The first author found her experiences of confusion about the assessment of delirium and failure to identify delirium among health care practitioners were reported by other researchers (El Hussein & Hirst, 2015a). Nursing handover reports sometimes include the fluctuating cognitive levels of an older adult but without evidence from validated delirium assessment tools (Hare et al., 2008; Steis & Fick, 2012). Without the use of valid assessment tools, delirium is not identified and the older adult does not receive delirium prevention strategies or a delirium management plan (Irving et al., 2006). Concerned with improving assessment and identification of delirium in clinical practice, the current research enquiry began with the aim to describe how RNs assess and identify delirium in older adults.

Method

The research question framing the current study was: How do RNs assess and identify delirium? The question was used to explore the experience of others about the way in which RNs assess and identify delirium. The findings were used to generate meaning about this process from participating RNs (Sandelowski, 2010).

Setting and Sample

The study was performed with staff from a local health district located in New South Wales, Australia. The study hospital is a large regional emergency and trauma center that includes specialist aged-care and general wards where older adults are admitted for medical investigations, treatment, and surgical procedures. A flyer promoting participation in the study was distributed to wards where RNs cared for older adults, as well as e-mailed to the Director of Nursing, nurse unit managers, and clinical nurse educators. The flyer explicitly stated that volunteers with experience in assessing and identifying delirium were sought to participate in a group interview. Participant information sheets were issued and consent forms completed prior to commencement of group interviews.

This recruitment strategy resulted in a purposive sample of RNs with experience in assessing and identifying delirium. RNs working solely in intensive care and drug and alcohol care settings were excluded. All participants identified themselves as having prior experience in assessing and identifying delirium in older adults. The study was approved by the university and local health district's Health and Medical Human Research Ethics Committee, and access to the study site was approved by the local health district.

Data Collection

Semi-structured interviews were conducted by the principal investigator (M.A.C.) using a prompt guide developed by the research team, piloted in the clinical area, and amended to include the findings from the pilot exercise. Group interviews lasted an average of 1 hour and were conducted over 2 months and recorded using an audio digital recorder. Prior to each interview, demographic data, including gender, years of nursing experience, aged-care experience, and education, were obtained by questionnaire. A professional transcriber transcribed the interviews verbatim. All data were anonymized. Numerical codes were allocated to each participant and group interview (e.g., RN003:IV5:P3:L15 refers to Participant 003, Interview 5, page 3, line 15).

Data Analysis

Extraneous material (e.g., informal, social chitchat; interruptions by colleagues with personal or work-related enquiries not relevant to the interview) from the interviews was not transcribed or was left out of the data analysis, which ensured only relevant data important for answering the research question were analyzed (Hickson, 2008). Data collection and analysis occurred concurrently. Thematic analysis was used to generate understanding about how RNs assess and identify delirium (Koch, 2006). A template was adapted for reading and reviewing the data to guide analysis and demonstrated rigor in the process. The template enabled a systematic means for data analysis and formed part of an audit trail able to be verified by others (DePoy & Gitlin, 2011; O'Leary, 2010).

Coding was performed manually. Transcripts were typed using double-spaced paragraph settings and wide margins, and then each interview was printed on different colored paper. When each code was generated from the data analysis, the printed section from an interview was cut and placed in an allocated coding pile. The colored paper enabled a visual image of different codes being represented in different interviews. A mind map was then created to guide the ongoing concurrent data analysis and capture the themes, which were generated to identify links among the separate codes. Adoption of these techniques built interconnectedness and meaning to the raw data (Burnard, 1991; O'Leary, 2010). To ensure methodological rigor, thematic analysis was reviewed by two authors (P.B., V.T.) and one other researcher. Throughout the data analysis phase, the research team met to ensure the finding was credible and generated from the transcripts of the interview data. Amendments to the themes occurred as the in-depth interrogation of the raw data was performed (Burnard, 1991; O'Leary, 2010).

Results

A total of eight group interviews were conducted, comprising three to seven RNs (N = 24). Most participants (83%) worked at the large hospital where the study was conducted. Participants came from a range of hospital units, including emergency, renal, aged-care, and medical specialties. Most participants (67%) had more than 10 years of experience as RNs; more than one half (58%) had specialist aged-care roles or were clinical nurse specialists, clinical nurse educators, and CNCs; and more than one third (37%) had post-graduate qualifications. Thematic analysis of the interview transcripts generated three themes: (a) It's Not My Job, (b) It is My Job, and (c) It's Complex.

Theme 1: It's Not My Job

This theme explores how participants viewed their role in assessment and identification of delirium compared with others in the health care team. These responses are organized into four subthemes (i.e., It's Not My Role Here, It's Their Job, Maybe if I Had Training?, and Lack of Organizational Supports), reflecting the concern of overstepping specialist and discipline boundaries without organizational enablement or the confidence of having received specific education.

It's Not My Role Here. Although participants had some experience in using cognitive assessment tools, it was perceived that there was not an expectation to expressly assess and identify delirium. Participant 20 explained, “I probably have a few times in the past done a bit of a Mini Mental with somebody who was obviously really confused but…it's never sort of been perceived as my role.”

It's Their Job. Participants explained that cognitive assessment was formally attended by allied health staff (i.e., occupational therapists) in the hospital and, on occasion, the medical staff or specialist aged-care nurses, supporting their belief it was not their role, as Participant 23 said, “So it's more something [aged services] do than what we do.”

Aged-care specialists were also viewed as having the time to appropriately assess hospitalized older adults. Participant 24 noted, “They love that stuff and that's their niche...so they see it every day. Like we see it every day but they have the time.”

Maybe if I Had Training? Participants reported that they wanted more support from their employing organization in the form of training and resources to implement evidence-based assessment and identification of delirium. The perception that assessment and identification of delirium was not part of their job was further verified by the lack of mandatory training or workplace education on delirium. Participant 8 explained, “It's really only been…[because] of my own interest that I've been able to increase my own knowledge on delirium.”

Apart from specialist aged-care nurses, there was little knowledge among participants of evidence-based tools for delirium assessment and identification, such as the CAM and AMTS. The CAM is useful for validating concerns about the possible presence of delirium, drawing on nurses' previous experiences of caring for older adults with delirium. Participant 1 said, “[The CAM's] an indicator. It's a good thing to take to the geriatrician…. It's more the whole picture when you're assessing.”

Lack of Organizational Supports. Linked with the perceived lack of opportunity for training within the organization, participants expressed concerns about a lack of supportive processes and resources for assessing and identifying delirium. Validated delirium screening and assessment tools were not readily available, nor was there ready access to or knowledge of the delirium care clinical pathways, as Participant 2 noted, “The wards aren't using any sort of delirium assessment tool because they haven't got any.” Participant 21 added, “You don't necessarily always have the chance to… do everything that you would want to for the patient…. You're flat-out from the beginning of the shift to the end.”

Theme 2: It Is My Job

This theme explored participants' perceptions of their role in the assessment and identification of delirium in hospitalized older adults. Participant responses were framed by an understanding of RN responsibilities, generating three subthemes: I Do General Observations, I Gather Information, and We Describe What We See. These subthemes emphasized the nursing role in assessing and identifying delirium as monitoring vital signs and observing patients' physiological and behavioral changes. A range of barriers in the assessment and identification of delirium were discovered—predominately time and opportunity.

I Do General Observations. Apart from aged-care specialists, only one participant included reporting cognitive changes in his/her assessment for delirium. Participants understood their role to be pivotal in ensuring general observations were used to capture evidence of physical disease. Participant 11 explained, “[We check] the vital signs, temperatures…and we do things like urine dipstick.”

By focusing on pathophysiological laboratory results, little attention was paid to the possibility of hypoactive delirium. Hypoactive delirium was not well understood by participants, as Participant 21 noted, “The hypoactive…. I don't know that I would actually recognize that even now.”

Participants who understood hypoactive delirium explained this type of delirium was more likely to be assessed and identified retrospectively. Participants explained that hypoactive delirium is often missed because an older adult with hypoactive delirium does not attract attention in the same ways as those with hyperactive delirium. Participant 5 said, “I think maybe hypo-delirium needs to be pushed more. I think that it gets missed a lot because they're nice and quiet.”

I Gather Information. The importance of gaining a full clinical picture was acknowledged by participants; they described the necessity for collaboration to gain a clinical history, particularly to identify acute behavioral changes. Families were acknowledged as key informants. Aged-care specialists described a more diverse range of collaborations in seeking information. Participant 20 explained, “If the family member is there…you can say, ‘Is this how they would normally be…?’”

Having prior knowledge of the older adult through previous admissions and handover information were identified enablers for participants in assessing and identifying delirium, with Participant 17 noting, “If we had looked after the patient the previous day, we would suddenly notice a change. If you had not, then you would be inclined to ask the relatives, ‘How is this patient at home?’”

We Describe What We See. Participants reported recording their observations and information gathered from older adults and their carers to create a clinical picture. They did not acknowledge the presence of delirium or label the presenting symptoms of older adults as delirium. The term “delirium” was viewed as a medical diagnosis and the domain of medical officers, as Participant 18 noted, “We document what we observe…. We don't…I don't target it as delirium. The patient is having delirium—I don't write that.” Participant 2 added, “Doctors are the only ones that can actually diagnose…. You can say, ‘I suspect…’”

Overwhelmingly, participants preferred the term “confused” to “delirium,” as this was viewed as describing rather than labeling. Delirium was perceived as a modern construct and poorly understood. Participant 23 explained, “Once…the patient's diagnosis would have been confusion…not delirium…I think the words have changed but I'm not sure that the actual signs and symptoms have.” Participant 23 asked, “What's the actual definition of delirium? To me, a patient with delirium…is someone that's probably a bit confused—agitated—that turns out to have a UTI or a chest infection.”

This subtheme interrelates with the theme It's Complex, as RNs explained their concern with incorrectly labeling an older adult with delirium through their professional responsibilities and out of concern for the patient, who might be stigmatized.

Theme 3: It's Complex

Assessing and identifying delirium was found to be complex, and participants' experiences, training, and workplace settings varied, creating divergence in their practice. Four subthemes further describe the findings: Knowledge Gaps in Differentiating Dementia and Delirium, Working With Families and Carers, Emotionally Demanding, and RN and Community Attitudes.

Knowledge Gaps in Differentiating Dementia and Delirium. A lack of understanding about dementia and the interrelationship with delirium was evident. Participants were aware of the possibility of mistakes being made between the diagnoses of dementia or delirium, and were concerned about accurately differentiating between them. This concern overlaps with their concerns expressed in the We Describe What We See subtheme about an incorrect label or diagnosis being given to older adults. Participant 4 expressed, “I wouldn't feel… confident enough to…say that this person has delirium.”

Participants were also reliant on their previous experiences to understand differences between dementia and delirium, as Participant 20 explained, “So I think it is your past experiences where you've seen the delirium from. So I haven't had formal training….”

Behavioral and psychological symptoms of dementia (BPSD) were raised by participants as a confounding factor when determining whether older adults had dementia or delirium. Participants found challenges in finding the time to monitor changes in behavior and cognition and, excluding medical causes of confusion, this finding reinforces the time barrier identified in the theme, It's Not My Job. Participant 3 mentioned having to “decipher…[if] this is more about BPSD rather than a delirium.”

Working With Families and Carers. Family members were valued for the special knowledge they could share in assessing and identifying acute changes in the older adult. However, complexities emerged. Participants hinted at concerns about confidentiality and ensuring contact with the appropriate family member. A preference for contact initiated by family members was expressed and time was always a factor for consideration. Participant 11 noted, “It's quite helpful sometimes when the family…come[s] forward themselves.”

Emotionally Demanding. Participants acknowledged that delirium was distressing and sad for older adults. The resulting agitated behaviors from an untreated hyperactive delirium concerned and challenged participants as well as the patient and his/her family. Participant 2 noted, “The sad thing is that some-times…they remember that they punched the nurse and that they were swearing their heads off and stuff like that…. It's sad, really sad for them. It's terrible.”

In addition to the sadness expressed over caring for older adults with delirium, participants felt ill-prepared to provide effective support for patients' behavioral changes: “It's just…anxiety and stress for everyone involved” (Participant 14).

The challenges of managing emotionally demanding scenarios added complexity to the workload. Participants expressed a lack of competence in managing the stresses associated with providing care for older adults with hyperactive delirium. Evidence-based workplace strategies for managing these stresses were not reported.

RN and Community Attitudes. RNs' attitudes toward aging added complexity to the assessment and identification of delirium in hospitalized older adults. Although ageism was rarely overt in the interviews, there was evidence that delirium (which is most prevalent among older adults) was not perceived as a priority. Other conditions and nursing responsibilities were seen as more important despite the significance of assessing and identifying delirium in older adults. Participant 16 explained, “If you gave me a presentation of someone in their early twenties…[who might seem to be] delirious, I'm more likely to say it's acute psychosis…. You bring your prejudice to your assessment.”

The need to assess and identify delirium was not perceived as the main concern when individuals might need attention for medical conditions, such as a heart attack: “I don't initially think delirium…. I think heart attack” (Participant 24).

Similarly, delirium was acknowledged by some participants as a drug and alcohol concern rather than an issue related to aged-care, as noted by Participant 16: “When someone says ‘delirium,’ I think alcohol withdrawal.”

Some participants expressed personal agency as an outcome of unintentional learning, which prompted reflective practice and the development of professional competency in assessing and identifying delirium. Participant 7 said, “Now that I'm sort of learning…about delirium, it's like, ‘Oh, we could have done something.’” Participant 5 added, “I'd just think, ‘Oh, they're old and confused.’ I didn't…recognize that there was a medical cause… So it's only through learning that I actually am now more aware.”

Participants identified attitudes as a barrier to assessment and identification of delirium by colleagues and family members, as they described requirements for them to advocate with the health care team for the confused older adult and educate family members about dementia.

Discussion

The current study aimed to describe how RNs assess and identify delirium in older adults during admission to an acute care hospital. Participants identified themselves as experienced in assessing and identifying delirium. The findings, presented in the three themes (It's Not My Job, It is My Job, and It's Complex), provide insight into current practices of RNs in assessing and identifying delirium in hospitalized older adults. Similarities in the findings have been reported in recent research that described the discomfort RNs experience with delirium, noting they not only avoided using the word “delirium,” but the more experienced nurses distanced themselves from the older adult with delirium (El Hussein & Hirst, 2015b). These findings demonstrate a lack of evidence-based practice and acknowledgement by participants of the need for investment in training in assessment and identification processes, as well as education, on delirium. Although delirium is understood to be a medical condition, there is a continued stigma associated with delirium that results in it not being considered important by health care practitioners or organizations in which delirium care services are provided (Brown, Fitzgerald, & Walsh, 2007; Irving et al., 2006; Maclullich et al., 2013). Also evidenced is the interaction of four factors in the assessment and identification of delirium in older adults: the perceived roles of RNs, other health care professionals, and the organization, and the meaning of delirium.

The current exploratory, qualitative descriptive study was limited to a small sample of RNs, and recruitment was challenging in the busy acute hospital, particularly among RNs from surgical wards. However, saturation was achieved and the views of participants are likely to be representative of RNs working in other areas. The current study was conducted by a CNC in delirium and dementia, which allowed the findings to be integrated into the strategic plan for the study hospital and used specifically to inform initiatives to improve delirium care for older adults.

Where to From Here?

Participants reported contradictory clinical practices in the assessment and identification processes to assess and identify delirium in hospitalized older adults. They also described delirium care as complex and simultaneously perceived it as their job and not their job. The current findings were used to develop a model called Roles and Responsibilities in the Assessment and Identification of Delirium (Figure).


Roles and Responsibilities in the Assessment and Identification of Delirium model.

Figure.

Roles and Responsibilities in the Assessment and Identification of Delirium model.

This model acknowledges that RNs work within teams and systems that can enhance the implementation of evidence-based assessment and identification of delirium. The model promotes the role of RNs in the assessment and identification of delirium, illustrating their central role for partnering with others to develop shared understandings about delirium and improve clinical practice in delirium care. The model also acknowledges that RNs work within organizations whose priorities are expressed through policies, structure, and educational resources. At the study hospital, state-wide policy was introduced, including electronic medical records to implement the use of the CAM and AMTS on admission of older adults or when older adults are transferred between units. The statewide policy states that during a hospital admission, clinical changes in an individual should trigger the use of the CAM and AMTS to assess for and identify delirium. To date, there are no mechanisms in care plans or ongoing patient records to monitor delirium; nurses rely on clinical judgment, meaning the effectiveness of delirium care is determined by the competence of individual practitioners rather than the organization.

It is suggested that educational interventions remain key in promoting the role of RNs in the assessment and identification of delirium, and that they allow the implementation of evidence-based clinical practice. Although staff training can be costly, the cost savings from preventing delirium and instituting processes that reduce the length of delirium provide greater, ongoing cost savings to the organization (Maclullich et al., 2013). Safety and care quality is a central concern driving support for improved practice in delirium care at organizational and clinician levels. Guidelines direct the need for delirium assessment as part of admission procedures for all older adults (Australian Commission on Safety and Quality in Health Care, 2014; National Institute for Health and Care Excellence, 2010).

The current study has added to the CNC role, as reflection on the roles and responsibilities model provides a strategic and relevant means to developing multiple approaches to a complex role. Strengthened by partnerships with academics, along with initiatives (e.g., the Better Way to Care guidelines for clinicians, managers, and patients [Australian Commission on Safety and Quality in Health Care, 2014]), there is now increased engagement with all levels of stakeholders within the organization, resulting in the introduction and implementation of a delirium screening tool in the hospital and wider districts. Educational interventions to enhance the implementation have been developed to provide engaging educational presentations, supported by innovative methods, such as the delirium flipchart and objective structured clinical examinations (University of Wollongong, 2015), to raise awareness, develop competency, and promote adherence.

The current findings are supported by previous research that acknowledges the crucial role of RNs and how they contribute to the assessment and identification of delirium (Brown et al., 2007; Cole, Ciampi, Belzile, & Zhong, 2009; Irving et al., 2006; Rice et al., 2011). Web-based education interventions are growing in popularity due to accessibility, and users report high levels of satisfaction with the learning experience (McCrow, Sullivan, & Beattie, 2014). What is missing from web-based education is the challenge of engagement in an authentic work environment and the benefits of immediate feedback from mentors and colleagues, provided by interactive learning interventions, such as simulation methods (Wand, 2011). Simulation methods foster confidence and competence in participants as they engage in learning guided by adult learning principles and perform assessments through interventions, such as objective structured clinical examinations, to develop mastery (Mitchell et al., 2015). Research following this study has acknowledged the benefits of both approaches to education and an educational program has been developed that combines different educational strategies.

The research team used the current findings to implement a new education program for delirium care that focuses on RN skill development to assess and identify delirium (Table). This education comprises four learning activities:

  1. Preparation activity: 15-minute online delirium care module.

  2. Face-to-face education session: 15 minutes using delirium care flipchart resource.

  3. Reflective practice activity: 30-minute guided critical review of patient documentation of an older adult with delirium.

  4. Objective structured clinical examination: two examinations evaluating the assessment and identification of delirium with two patient role-play activities using the AMT and CAM.


Summary of Findings Informing New Education Program

Table:

Summary of Findings Informing New Education Program

To date, 65 practitioners have participated, role-playing as an older adult with delirium, objective structured clinical examination assessor, or learner in this program. What is crucial about this program of education is that the content includes guidance for training facilitators as well as role-play for participants and assessors, which means it can be sustained and has the capacity to build activities with a central tenet (Traynor, McAllan, Riley-Henderson, Coyle, & French, 2016). As such, the current findings demonstrate how qualitative research can achieve knowledge translation at the adherence end and not remain at the beginning level of awareness (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012; Mickan, Burls, & Glasziou, 2011).

Conclusion

The assessment and identification of delirium can be difficult for many RNs due to the interplay of factors identified in the Roles and Responsibilities in the Assessment and Identification of Delirium model. Interventions to improve the assessment and identification of delirium by RNs must target each of the four domains described in the model.

References

  • Australian Commission on Safety and Quality in Health Care. (2014). A better way to care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital. Retrieved from https://www.safetyan-dquality.gov.au/our-work/cognitive-impairment/better-way-to-care
  • Australian Health Ministers' Advisory Council: Health Care of Older Australians Standing Committee. (2010). Delirium care pathways. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/Delirium-Care-Pathways
  • Brown, S., Fitzgerald, M. & Walsh, K. (2007). Delirium dichotomy: A review of recent literature. Contemporary Nurse, 26, 238–247. doi:10.5172/conu.2007.26.2.238 [CrossRef]
  • Burnard, P. (1991). A method of analysing interview transcripts in qualitative research. Nurse Education Today, 11, 461–466. doi:10.1016/0260-6917(91)90009-Y [CrossRef]
  • Cole, M.G., Ciampi, A., Belzile, E. & Zhong, L. (2009). Persistent delirium in older hospital patients: A systematic review of frequency and prognosis. Age and Ageing, 38, 555–577. doi:10.1093/ageing/afn253 [CrossRef]
  • DePoy, E. & Gitlin, L. (2011). Introduction to research: Understanding and applying multiple strategies (4th ed.). St. Louis, MO: Elsevier Mosby.
  • El Hussein, M. & Hirst, S. (2015a). Chasing the mirage: A grounded theory of the clinical reasoning processes that registered nurses use to recognize delirium. Journal of Advanced Nursing, 72, 373–381. doi:10.1111/jan.12837 [CrossRef]
  • El Hussein, M. & Hirst, S. (2015b). Institutionalizing clinical reasoning: A grounded theory of the clinical reasoning processes RNs use to recognize delirium. Journal of Gerontological Nursing, 41(10), 38–44. doi:10.3928/00989134-20150728-12 [CrossRef]
  • Flaherty, J.H. (2011). The evaluation and management of delirium among older persons. Medical Clinics of North America, 95, 555–577. doi:10.1016/j.mcna.2011.02.005 [CrossRef]
  • Grimshaw, J., Eccles, M., Lavis, J., Hill, S. & Squires, J. (2012). Knowledge translation of research findings. Implementation Science, 7, 50. doi:10.1186/1748-5908-7-50 [CrossRef]
  • Grover, S. & Shah, R. (2011). Distress due to delirium experience. General Hospital Psychiatry, 33, 637–639. doi:10.1016/j.genhosppsych.2011.07.009 [CrossRef]
  • Hare, M., McGowan, S., Wynaden, D., Speed, G. & Landsborough, I. (2008). Nurses' descriptions of changes in cognitive function in the acute care setting. Australian Journal of Advanced Nursing, 26, 21–25.
  • Hatherill, S. & Flisher, A.J. (2010). Delirium in children and adolescents: A systematic review of the literature. Journal of Psychosomatic Research, 68, 337–344. doi:10.1016/j.jpsychores.2009.10.011 [CrossRef]
  • Hickson, M. (2008). Research handbook for health care professionals. Oxford, UK: Wiley-Blackwell.
  • Hodkinson, H.M. (1972). Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and Ageing, 41, 233–238. doi:10.1093/ageing/1.4.233 [CrossRef]
  • Inouye, S.K., van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P. & Horwitz, R.I. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941–948. doi:10.7326/0003-4819-113-12-941 [CrossRef]
  • Irving, K., Fick, D. & Foreman, M. (2006). Delirium: A new appraisal of an old problem. International Journal of Older People Nursing, 1, 106–112. doi:10.1111/j.1748-3743.2006.00017.x [CrossRef]
  • Koch, T. (2006). Establishing rigour in qualitative research: The decision trail. Journal of Advanced Nursing, 53, 91–100. doi:10.1111/j.1365-2648.2006.03681.x [CrossRef]
  • Maclullich, A., Anand, A., Davis, D.H., Jackson, T., Barugh, A.J., Hall, R.J. & Cunningham, C. (2013). New horizons in the pathogenesis, assessment and management of delirium. Age and Ageing, 42, 667–674. doi:10.1093/ageing/aft148 [CrossRef]
  • McCrow, J., Sullivan, K. & Beattie, E. (2014). Delirium knowledge and recognition: A randomized controlled trial of a web-based educational intervention for acute care nurses. Nurse Education Today, 34, 912–917. doi:10.1016/j.nedt.2013.12.006 [CrossRef]
  • McDonnell, S. & Timmins, F. (2012). A quantitative exploration of the subjective burden experienced by nurses when caring for patients with delirium. Journal of Clinical Nursing, 21, 2488–2498. doi:10.1111/j.1365-2702.2012.04130.x [CrossRef]
  • Melbourne Health & Delirium Clinical Guidelines Expert Working Group. (2006). Clinical practice guidelines for the management of delirium in older people–October 2006. Retrieved from http://docs.health.vic.gov.au/docs/doc/Clinical-Practice-Guidelines-for-the-Management-of-Delirium-in-Older-People---October-2006
  • Mickan, S., Burls, A. & Glasziou, P. (2011). Patterns of ‘leakage’ in the utilisation of clinical guidelines: A systematic review. Postgraduate Medical Journal, 87, 670–679. doi:10.1136/pgmj.2010.116012 [CrossRef]
  • Mitchell, M.L., Henderson, A., Jeffrey, C., Nulty, D., Groves, M., Kelly, M. & Glover, P. (2015). Application of best practice guidelines for OSCEs—An Australian evaluation of their feasibility and value. Nurse Education Today, 35, 700–705. doi:10.1016/j.nedt.2015.01.007 [CrossRef]
  • National Institute for Health and Care Excellence. (2010). Delirium: Prevention, diagnosis and management. Retrieved from https://www.nice.org.uk/guidance/cg103
  • O'Leary, Z. (2010). The essential guide to doing your research project (3rd ed.). London, UK: Sage.
  • Rice, K., Bennett, M., Gomez, M., Theall, K., Knight, M. & Foreman, M. (2011). Nurses' recognition of delirium in the hospitalized older adult. Clinical Nurse Specialist, 25, 299–311. doi:10.1097/NUR.0b013e318234897b [CrossRef]
  • Sandelowski, M. (2010). What's in a name? Qualitative description revisited. Research in Nursing & Health, 33, 77–84. doi:10.1002/nur.20362 [CrossRef]
  • Schofield, I., Tolson, D. & Fleming, V. (2011). How nurses understand and care for older people with delirium in the acute hospital: A critical discourse analysis. Nursing Inquiry, 19, 165–176. doi:10.1111/j.1440-1800.2011.00554.x [CrossRef]
  • Steis, M.R. & Fick, D.M. (2012). Delirium superimposed on dementia: Accuracy of nurse documentation. Journal of Gerontological Nursing, 38(1), 32–42. doi:10.3928/00989134-20110706-01 [CrossRef]
  • Traynor, V., Burns, P. & Britten, N. (in press). Developing the delirium care pathways. Journal of Research in Nursing. doi:10.1177/1744987116661377 [CrossRef]
  • Traynor, V., Cordato, N., Burns, P., Xu, Y., Britten, N., Duncan, K. & McKinnon, C. (2016). Is delirium being detected in emergency?Australasian Journal on Ageing, 35, 54–57. doi:10.1111/ajag.12255 [CrossRef]
  • Traynor, V., McAllan, P., Riley-Henderson, A., Coyle, M. & French, A. ( 2016, July. ). Evaluating an innovative delirium education programme: How do objective structured clinical examinations (OSCEs) improve practice? Poster session presented at the meeting of the DECLARED Bi-Annual Conference of the Australasian Delirium Society. , Sydney, Australia. .
  • University of Wollongong. (2015). Aged dementia health education and research (ADHERe). Retrieved from http://www.adhere.org.au/index.html
  • Wand, A.P.F. (2011). Evaluating the effectiveness of educational interventions to prevent delirium. Australasian Journal on Ageing, 30, 175–185. doi:10.1111/j.1741-6612.2010.00502.x [CrossRef]

Summary of Findings Informing New Education Program

ThemeEducational Content
It's Not My JobDelirium education sessions targeted at and conducted in non–aged-care units
It is My JobEducation sessions focused on enabling practitioners to develop clinical competence in assessment and identification of delirium
It's ComplexUsing the delirium care flipchart as a resource to demystify delirium care knowledge
Authors

Ms. Coyle is Acute Dementia Delirium Clinical Nurse Consultant Illawarra Shoalhaven Local Health District, Bulli Hospital, Bulli; Dr. Burns is Lecturer, School of Medicine, and Research Associate, and Dr. Traynor is Associate Professor of Rehabilitation Continuing and Aged Care and Associate Director NSW/ACT Dementia Training and Study Centre and Coordinator of the Graduate Certificates and Masters of Science in Gerontology and Rehabilitation Studies and Dementia Care, School of Nursing and Midwifery, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Professor Ken Walsh and Dr. Kylie Smith for their support and guidance in providing research supervision at formative times of this study; and all of the participating RNs and managers (particularly Ms. Narelle Evry) from the Illawarra and Shoalhaven Local Health District who supported this project.

Address correspondence to Miriam Anne Coyle, MPhil, MSc, RN, Acute Dementia Delirium Clinical Nurse Consultant Illawarra Shoalhaven Local Health District, Bulli Hospital, Hospital Road, Bulli NSW Australia 2516; e-mail: miriam.coyle@health.nsw.gov.au.

Received: July 28, 2016
Accepted: October 18, 2016
Posted Online: January 18, 2017

10.3928/00989134-20170111-02

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