The process of practice redesign in delirium care for hospitalised older people: A participatory action research study

Abstract 

Background

In 2007 three researchers completed a 6-month study in one 32-bed acute care medical ward in a large hospital in New South Wales, Australia. The problem drawn to the attention of researchers was that approximately 60% of older people were delirious on arrival or develop incident delirium during their hospital stay. Lack of recognition, underreporting and inadequate care responses to delirium in hospitalised older people signalled a major practice problem.

Aim

To collaboratively explore ways in which clinical practice could be improved.

Method

We selected Participatory Action Research (PAR) as the methodology to involve health practitioners in practice redesign. PAR is a process in which ‘we’, researchers and participants, systematically work together in cycles of ‘looking, thinking and acting’. Delirium and the high percentage of older people who succumb to this condition was the main practice problem requiring a response. Eight volunteer clinicians and three researchers met weekly as a group for 13 sessions over 6 months. Clinicians set the agenda for redesign of practice. Raising awareness about delirium and its prevention were the selected action strategies. A delirium alert protocol was developed for implementation by the clinicians and later evaluation as a separate study.

Findings

There was evidence that practice had changed. Physical and chemical restraints had not been used for 3 months subsequent to the study’s completion. The nurse manager reported that early detection strategies had prevented episodes of acute hyperactive delirium. Whilst there continued to be older people admitted with a diagnosis of delirium, there were fewer incidences of delirium developing on the ward and there was less disruption to other patients, especially at night. The strategy of raising the awareness of delirium in older people was successful. We are confident that working collaboratively with practitioners is the way to bring evidence to practice in delirium care for older people in acute care settings.

Keywords: Delirium, Older people, Participatory action research, Practice redesign