Reasearch Awards nomination

Email updates

Keep up to date with the latest news and content from BMC Health Services Research and BioMed Central.

Open Access Highly Accessed Research article

Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study

Mary Godfrey1*, Jane Smith1, John Green1, Francine Cheater2, Sharon K Inouye3 and John B Young1

Author affiliations

1 Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK

2 School of Nursing Sciences, Faculty of Medicine and Health Sciences, Edith Cavell Building, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, UK

3 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Roslindale, MA 02131, USA

For all author emails, please log on.

Citation and License

BMC Health Services Research 2013, 13:341  doi:10.1186/1472-6963-13-341

Published: 3 September 2013

Abstract

Background

Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery.

Methods

We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data.

Results

Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier.

Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices.

Conclusions

Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly.

Study registration

ISRCTN65924234

Keywords:
Delirium; Prevention; Acute hospital care; Complex intervention; Implementation; Normalization process theory