Factors that influence acute care nurses’ delirium management in older adults :An exploratory study Researchers: Cheryl Chan, RN, BSN, Silvia Nobrega, RN, BSN, Norm Greenway, RN, Charmaine Lawson, LPN
INTRODUCTION/BACKGROUND The purpose of this study was to identify specific barriers, challenges, and factors frontline nurses face that prevent them from managing delirium. This includes clarifying an assumption that one barrier may be lack of understanding of patient consent. Richmond Hospital (RH) is a 197 bed hospital, catering to a population of 190,473. It is reported that 59.5% of people in Richmond state English is not their official language (Stat Canada, 2011). RH has 3 medical units and 2 surgical units. We have a diverse group of Registered Nurses (RN) & Licensed Practical Nurses (LPN) with varied nursing training and educational levels. When this research was done, RH did not have a current practice standard for delirium management. It appeared that we were inconsistent in our delirium management of older adults in acute medical and surgical areas. Nurses found it challenging to manage delirium in hospitalized older adults.
RESULTS- Themes TOP 3 THEMES Participant’s statement •“Language barrier is huge!” 1. Language Barriers •“The patient didn’t speak English – No way to assess.”
2. Lack of Knowledge
3. Gaps in the Resources
•“Misdiagnosed quite a few times, the patient is climbing out because she needs to pee, no one could understand her, everyone is thinking she is getting delirium.” •“We start giving out the medications” even though they are unable to assess whether the patient is delirious. •“I don’t feel comfortable figuring out the difference between delirium and dementia all the time.” •“When is the first sign of it and when is the appropriate time to intervene than just have the patient fully acting out and giving the medication?” •“Some nurses know when to give prn, some don’t.” •“We didn’t have any set protocols or anything for all the delirium people.” •“Some kind of pre-screening for elective surgery.” •“Some kind of education for the family about delirium.”
METHODS
DISCUSSION/IMPLICATIONS
A qualitative exploratory design that consisted of three 2-hour focus group sessions was conducted. A total of 10 participants, RNs & LPNs from Medical and Surgical units, were involved.
•Even though the sample size was small, we obtained rich data from the analysis. •The assumption we had on nurses’ understanding of consent was dispelled. From the focus group interviews, nurses understood that a patient is usually incapable of giving consent when they are delirious, especially when receiving medications to treat symptoms of delirium.
Questions for the focus groups: 1. How do you feel about your current delirium management strategies? 2. How effective are we in our management of delirium in our patients? 3. What are the tools and strategies that are working well in our delirium management? 4. What do you think are the barriers in effectively managing delirium in our patients? 5. What do you understand about consent when giving medication to treat delirium?
Nurses were asked what strategies helped them to manage delirium in their older patients: •The revised nursing admission process, which has Confusion Assessment Method (CAM) embedded in the form, helped them in the identification of delirium. •During the research study, there was a Nurse Clinician specializing in Elder Care as their resource person, which many found beneficial to supporting their practice. •Engaging family to assist in delirium management (i.e. coming in to sit with patient).
The focus groups were digitally recorded and transcribed by a professional transcriptionist. Content analysis technique was used to explore the transcript data in a systematic manner. Staff words and phrases were grouped into themes. The top 3 themes were identified.
Currently, there is a pre-printed order (PPO) available for delirium management for older adults in RH. Additionally, an introduction of a 48/6 screen whereby within 48 hours of decision to admit, 6 functional areas (Pain, Medication, Nutrition, Mobility, Bowel & Bladder, and Cognition) are reviewed and identified for intervention. 48/6 documentation form assists in early identification, proper documentation, and care planning for our elderly patients who are identified with delirium. Unfortunately, language barriers have yet to be addressed as there are many variables to consider when addressing the issue.
We would like to thank Michael Smith Foundation for Health Research for funding our research project & Vancouver Coastal Health Research Institute for their support. Special thanks to Monica Redekopp, Shannon Long, Sandie Kocher & Harjender Walia for their support in this project.
THE NEXT STEP It will be worthwhile to have follow up focus groups to discuss whether the current strategies, such as the introduction of the delirium management PPO and 48/6 strategy, have minimized the barriers and challenges that frontline nurses face when managing delirium in older adults in acute medical and surgical units in RH.