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Educating staff working in long-term care about delirium: The Trojan horse for improving quality of care?

https://doi.org/10.1016/j.jpsychores.2008.05.014Get rights and content

Abstract

Objective

This study aimed to design a multicomponent intervention to improve delirium care in long-term care facilities for older people in the UK and to identify the levers and barriers to its implementation in practice.

Methods

The research incorporated the theoretical phase and Phase 1 of the Medical Research Council's framework. We designed a multicomponent intervention based on the evidence for effective interventions for delirium and for changing practice. We refined the intervention with input from care home staff and field visits to homes.

Our intervention incorporated the following features: targeting risk factors for delirium, a ‘delirium practitioner’ functioning as a facilitator, an education package for care home staff, staff working groups at each home to identify barriers to improving delirium care and to produce tailored solutions, a local champion identified from the working groups, consultation, liaison with other professionals, and audit or feedback.

The delirium practitioner recorded her experiences of delivering the intervention in a contemporaneous log. This was analysed using framework analysis to determine the levers and barriers to implementation.

Results

We introduced a multicomponent intervention for delirium in six care homes in Leeds. Levers to implementation included flexibility, tailoring training to staff needs, engendering pride and ownership amongst staff, and minimising extra work. Barriers included time constraints, poor organization, and communication problems.

Conclusion

We were able to design and deliver an evidence-based multicomponent intervention for delirium that was acceptable to staff. The next steps are to establish its feasibility and effectiveness in modifying outcomes for residents of care homes.

Introduction

Long-term care facilities (referred to as residential and nursing homes in the UK) have expanded in recent decades in response to the needs of an increasingly older demographic profile in developed countries [1]. Providing care that respects and supports these needs has proved challenging with recurring concerns about the quality of care provided for older people in long-term care [2]. Moreover, with increasingly frail and physically unwell residents [3], there is a concern that the education and training of staff have not kept pace with the changing demands and role [4], particularly because much of the care is delivered by non-nursing trained staff. In addition, recruitment difficulties have led to efforts to attract trained staff from overseas [5] who, although usually highly trained, may have had little experience of working in long-term care or with older people.

Few studies have investigated the burden of delirium in long-term care facilities. However, it is likely to be considerable given the clustering of known risk factors [6], [7], especially the high prevalence of dementia. Prevalence rates ranging from 6% to 60% have been reported [8], [9], [10], [11], [12], [13], [14], [15]. There is a strong argument that optimum delirium care is fundamentally the provision of good quality supportive care [16], [17], [18], [19]. Delirium prevention in hospitals has been successfully achieved through care systems that target modifiable risk factors such as dehydration, constipation, pain and sensory impairments, and encouraging mobility [20], [21], [22], [23], [24]—areas of care that are equally applicable to long-term care. Similarly, treatment involves early recognition of common precipitants such as urinary infections and possible culprit medications—again, issues important in long-term care. Thus, education and training in delirium prevention and treatment might serve as a useful lever to improve professional knowledge and skills of general relevance to the care of frail older people, and the desire to achieve greater competency with delirium management may act as a driver to improve care overall, with additional benefits of potentially reducing morbidity and hospital admissions. For staff inured to endless messages to improve quality of care, a focus on delirium may be the ‘Trojan horse’ through which to achieve this.

Successful implementation of any intervention for delirium is likely to be mediated not only by individual members of staff and availability of evidence-based guidance but also by the complexity of the intervention and the interplay of resident and organizational factors [25], [26]. The literature suggests that the specific barriers to change in any given setting must be attended to and that strategies must be ‘tailored’ to overcome these [27], [28]. Here, we describe our experience of developing and implementing such an intervention using the Medical Research Council's (MRC) framework for the design and evaluation of complex interventions [29]; this consists of a phased approach to designing the intervention, testing its feasibility, and developing and optimising evaluation parameters.

The aim of this study was to design a multicomponent intervention to improve delirium care in care homes for older people in the UK, to model its key components, and to identify the levers and barriers to implementation in practice.

Section snippets

Methods

The research incorporated the theoretical phase and Phase 1 of the MRC framework, namely, establishing the theoretical basis for the intervention, and modelling to gain an understanding of its components and possible effects [30], [31]. For clarity, the design and delivery of the intervention are described separately, but in practice, this was an iterative process; the intervention was refined throughout its delivery, with insights from earlier phases informing the contents of later stages. The

Results

The intervention was introduced into six care homes in Leeds (one residential and five mixed dementia and nursing homes, with a total of 286 residents) over 10 months in 2007 by two practitioners: a clinical psychologist (who left for maternity leave) and a registered general nurse with experience in nursing older people.

In the first 6 months, the practitioner delivered the delirium training at care homes whilst staff were on duty during day and night shifts; sessions were flexible in both

Discussion

We designed, delivered, and defined a multicomponent intervention for delirium in long-term care. Care home staff were receptive to training; support from managers was essential in enabling staff participation. Working groups were able to produce a range of solutions and high-quality written materials. We had anticipated that this output would be specific to each home, but in practice, many of the solutions were shared between homes.

Several care homes identified communication as a priority to

Acknowledgments

The project was funded by the Bupa Foundation, Leeds Primary Care Trust, University of Leeds, and Bradford Teaching Hospitals NHS Trust. We would like to acknowledge the contribution of the Stop Delirium! Research Team—Professor Allan House, Dr. Carol Martin, Imogen Featherstone, Ann Hopton, Dr. Jill Edwards, Dr. John Holmes, and Su McAlpin. We are also indebted to the staff of the care homes in the study, particularly to the staff who participated in workshops and in the Study Reference Group.

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