Special Article Feasibility and Acceptability of a Delirium Prevention Program for Cognitively Impaired Long Term Care Residents: A Participatory Approach Philippe Voyer RN, PhD a, b, *, Jane McCusker MD, DrPH c, d , Martin G. Cole MD e, f , Johanne Monette MD, MPH g , Nathalie Champoux MD, MSc h , Minh Vu MD i , Antonio Ciampi PhD c, e , Steven Sanche MSc c , Sylvie Richard OT, MSc b , Manon de Raad BCom c a Faculty of Nursing Sciences, Laval University, Quebec City, Quebec, Canada b Centre for Excellence in Aging-Research Unit, Quebec City, Quebec, Canada c St Mary’s Research Centre, St Mary’s Hospital, Montreal, Quebec, Canada d Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada e Department of Psychiatry, St Mary’s Hospital, Montreal, Quebec, Canada f Department of Psychiatry, McGill University, Montreal, Quebec, Canada g Division of Geriatric Medicine, Jewish General Hospital and Donald Berman Maimonides Geriatric Center, Montreal, Quebec, Canada h Département de médecine familiale, Institut Universitaire de Gériatrie de Montréal, Université de Montréal, Montreal, Quebec, Canada i Division of Geriatric Medicine, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montreal, Quebec, Canada Keywords: Delirium prevention long term care cognitive impairment abstract In this participatory action research study, researchers conducted a total of 3 implementation cycles to evaluate the feasibility and acceptability of a new delirium prevention program (DPP) for cognitively impaired residents in long term care (LTC) settings. Researchers interviewed 95 health care staff to obtain feedback on their use of the DPP and then modified the DPP and tested the changes in the next implementation cycle. Our results indicated that the DPP was feasible and that health care staff would accept it under certain conditions. We found there were 4 keys to successful implementation of the DPP: support for the program from both the administration and the users; effective clinician leadership to ensure proper delivery of the DPP (format, content and values) and its appropriate adaptation to the LTC facility’s internal culture and policies; a sense of ownership among the DPP users; and, last, practical hands-on training as well as theoretical training for staff. Copyright Ó 2014 - American Medical Directors Association, Inc. Delirium is a serious and frequent problem in long term care (LTC) settings. It has prevalence rates ranging from 3% to 70%. 1,2 Because the frail elder residents in these settings often present conditions, such as dementia, that predispose them for delirium, they are at increased risk for this syndrome. 3e5 Even when detected and managed appropri- ately, delirium can lead to significant morbidity and mortality. 6e9 This is especially true when delirium is superimposed on dementia. 10 For instance, delirium among individuals with Alzheimer disease is associated with an increased rate of cognitive deterioration that continues for up to 5 years after the episode. 11 Besides these compli- cations, delirium may also lead to increased nursing time per resident and higher health care costs. 12 This emphasizes the importance of putting into place preventive interventions to reduce the incidence of this syndrome among elderly residents with dementia. According to the literature, it is possible to prevent delirium during an acute care hospitalization by providing multicomponent delirium prevention interventions. Indeed, nonpharmacological interventions that target the modifiable risk factors of delirium among hospitalized elderly (eg, cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, dehydration, and drug use) can reduce the risk of delirium during hospitalization by 40% 13 and up to 60%. 14 The body of knowledge on risk factors of delirium superimposed on dementia among LTC residents has grown in the past decade. 15e17 Although the effectiveness of preventive interventions based on those risk factors still needs testing in clinical trials, there remains the equally important issue of determining the acceptability and feasi- bility of these interventions in the context of LTC. LTC facilities aim to provide supportive care in a homelike atmosphere. Therefore, an intervention developed in acute care settings would not necessarily be feasible and acceptable in the LTC context. Moreover, evidence suggests that translating evidence-based interventions into routine This study was funded by the Canadian Institutes of Health Research (IAO69519), Canadian Institute of Aging, Institute of Gender and Health (CRG-82953), the Alzheimer Society of Canada, and the Canadian Nurses Foundation (07-91). The authors declare no conflicts of interest. * Address correspondence to Philippe Voyer, RN, PhD, Faculty of Nursing Sciences, Laval University, Pavillon Ferdinand-Vandry, Room 3445, 1050, rue de la Médecine, Quebec City, Quebec, Canada, G1V 0A6. E-mail address: [email protected](P. Voyer). JAMDA journal homepage: www.jamda.com 1525-8610/$ - see front matter Copyright Ó 2014 - American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2013.08.013 JAMDA 15 (2014) 77.e1e77.e9
Transcript
JAMDA 15 (2014) 77.e1e77.e9
JAMDA
journal homepage: www.jamda.com
Special Article
Feasibility and Acceptability of a Delirium Prevention Program for CognitivelyImpaired Long Term Care Residents: A Participatory Approach
Philippe Voyer RN, PhD a,b,*, Jane McCusker MD, DrPH c,d, Martin G. Cole MD e,f,Johanne Monette MD, MPH g, Nathalie Champoux MD, MSc h, Minh Vu MD i, Antonio Ciampi PhD c,e,Steven Sanche MSc c, Sylvie Richard OT, MSc b, Manon de Raad BCom c
a Faculty of Nursing Sciences, Laval University, Quebec City, Quebec, CanadabCentre for Excellence in Aging-Research Unit, Quebec City, Quebec, Canadac St Mary’s Research Centre, St Mary’s Hospital, Montreal, Quebec, CanadadDepartment of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, CanadaeDepartment of Psychiatry, St Mary’s Hospital, Montreal, Quebec, CanadafDepartment of Psychiatry, McGill University, Montreal, Quebec, CanadagDivision of Geriatric Medicine, Jewish General Hospital and Donald Berman Maimonides Geriatric Center, Montreal, Quebec, CanadahDépartement de médecine familiale, Institut Universitaire de Gériatrie de Montréal, Université de Montréal, Montreal, Quebec, CanadaiDivision of Geriatric Medicine, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montreal, Quebec, Canada
Keywords:Deliriumpreventionlong term carecognitive impairment
This study was funded by the Canadian Institutes oCanadian Institute of Aging, Institute of Gender anAlzheimer Society of Canada, and the Canadian Nurse
The authors declare no conflicts of interest.* Address correspondence to Philippe Voyer, RN, PhD
Laval University, Pavillon Ferdinand-Vandry, Room 34Quebec City, Quebec, Canada, G1V 0A6.
1525-8610/$ - see front matter Copyright � 2014 - Ahttp://dx.doi.org/10.1016/j.jamda.2013.08.013
a b s t r a c t
In this participatory action research study, researchers conducted a total of 3 implementation cycles toevaluate the feasibility and acceptability of a new delirium prevention program (DPP) for cognitivelyimpaired residents in long term care (LTC) settings. Researchers interviewed 95 health care staff to obtainfeedback on their use of the DPP and then modified the DPP and tested the changes in the nextimplementation cycle. Our results indicated that the DPP was feasible and that health care staff wouldaccept it under certain conditions. We found there were 4 keys to successful implementation of the DPP:support for the program from both the administration and the users; effective clinician leadership toensure proper delivery of the DPP (format, content and values) and its appropriate adaptation to the LTCfacility’s internal culture and policies; a sense of ownership among the DPP users; and, last, practicalhands-on training as well as theoretical training for staff.
Copyright � 2014 - American Medical Directors Association, Inc.
Delirium is a serious and frequent problem in long term care (LTC)settings. It has prevalence rates ranging from 3% to 70%.1,2 Because thefrail elder residents in these settings often present conditions, such asdementia, that predispose them for delirium, they are at increased riskfor this syndrome.3e5 Even when detected and managed appropri-ately, delirium can lead to significant morbidity and mortality.6e9 Thisis especially true when delirium is superimposed on dementia.10 Forinstance, delirium among individuals with Alzheimer disease isassociated with an increased rate of cognitive deterioration thatcontinues for up to 5 years after the episode.11 Besides these compli-cations, delirium may also lead to increased nursing time per residentand higher health care costs.12 This emphasizes the importance of
f Health Research (IAO69519),d Health (CRG-82953), thes Foundation (07-91).
, Faculty of Nursing Sciences,45, 1050, rue de la Médecine,
yer).
merican Medical Directors Associa
putting into place preventive interventions to reduce the incidence ofthis syndrome among elderly residents with dementia.
According to the literature, it is possible to prevent delirium duringan acute care hospitalization by providing multicomponent deliriumprevention interventions. Indeed, nonpharmacological interventionsthat target the modifiable risk factors of delirium among hospitalizedelderly (eg, cognitive impairment, sleep deprivation, immobility,visual impairment, hearing impairment, dehydration, and drug use)can reduce the risk of delirium during hospitalization by 40%13 and upto 60%.14
The body of knowledge on risk factors of delirium superimposedon dementia among LTC residents has grown in the past decade.15e17
Although the effectiveness of preventive interventions based on thoserisk factors still needs testing in clinical trials, there remains theequally important issue of determining the acceptability and feasi-bility of these interventions in the context of LTC. LTC facilities aim toprovide supportive care in a homelike atmosphere. Therefore, anintervention developed in acute care settings would not necessarilybe feasible and acceptable in the LTC context. Moreover, evidencesuggests that translating evidence-based interventions into routine
P. Voyer et al. / JAMDA 15 (2014) 77.e1e77.e977.e2
clinical practice can be quite a challenge.18 For instance, despite theproven efficacy of the Hospital Elder Life Program at reducingdelirium in hospital settings,13 studies on the dissemination of thisprogram have identified common challenges faced by disseminationsites.19,20 These results highlight the importance of establishingcollaborative partnerships between researchers and end users tobridge the gap between scientific knowledge and its application.21,22
Participatory research is helpful because it lets researchers evaluatean intervention in routine clinical practice and make the necessaryadaptations for it to become more apt.23 The present study addressedthese issues by using a participatory approach to examine the feasi-bility and acceptability of an intervention program directed at pre-venting delirium among cognitively impaired LTC residents.
Methods
Design, Study Settings, and Selection of Participants
This participatory action research study used an integratedknowledge translation approach21 to develop (Phase 1) and imple-ment (Phase 2) a delirium prevention program (DPP) for cognitivelyimpaired LTC residents (Figure 1). We present the development phasebriefly here to provide some insight into the work that led to theinitial version of the DPP. The implementation phase examined thefeasibility and acceptability of using the DPP in the context of LTC.
Very early in the process we set up an advisory committee tooversee development and implementation of the DPP. The advisorycommittee members represented the various stakeholders andincluded clinicians, administrators of LTC facilities, and representa-tives from advocacy groups, such as the Canadian Coalition forSenior’s Mental HealtheLong Term Care Group and the AlzheimerSociety of Canada. This committee’s role was to support the researchteam in developing the DPP; primarily to alert researchers to theissues that might be obstacles to implementation of the DPP. Therewas also a second committee of LTC clinical nurse specialists whoserole was to analyze the DPP and make recommendations that wouldincrease its feasibility and the likelihood of its acceptance by thenursing staff. We consulted both committees many times throughoutthe research phases.
Phase 1: Development of the DPP
We developed the nursing tools using data from our previousprospective, observational, cohort study in 7 LTC facilities in Montrealand Quebec City.17 From the 206 residents in the original study, wekept only the 171 residents who met at least 1 of these 3 criteria:Mini-Mental State Examination (MMSE) <24; dementia diagnosis inthe medical chart; or cognitive impairment noted in the medicalchart. We applied statistical methods similar to those used in theoriginal study to identify the best subsets of items for prediction ofincident delirium among residents with cognitive impairment. Weused clinical judgment and statistical criteria to select the final5 items of the risk-screening tool. We wanted not only to select themost predictive items, but also items that nurses can easily assess.
Both committees had informed us that the existing heavy work-loads of the clinical staff would mean that they could not apply theDPP to many residents. We therefore felt it necessary to identify thoseresidents at greatest risk of developing delirium. A poll of clinical staffalso indicated that they could apply the DPP to about 10% to 15% ofresidents in their care. Consequently, we selected the cut point of3þ risk factors, based on the clinically feasible nursing workload. Thiscut point meant that 22 (13%) of the 171 residents in our originalstudy were at high risk of developing delirium. In this same sample(n ¼ 22), we identified those potentially modifiable risk factors for
delirium with a substantial prevalence: antipsychotic medicationsprescribed for regular use (82%), lack of access to a glass of water(77%), bedrails or other restraints (55%), and uncorrected visualimpairment (18%). We then searched the literature to determine whattools were available to screen for the presence of those modifiablerisk factors in a population of cognitively impaired LTC residents. Atthe same time, we also looked for interventions designed to eliminateor reduce these same risk factors. Based on this review, we addeda systematic intervention to the DPP, called Optimal Stimulation. Itincluded very basic but fundamental interventions, such as dailyorientation, a method for communicating with an individual withdementia, and optimal environmental stimulation (avoiding over-and understimulation).
Based on all the information collected in the previous steps, theresearch team developed the following DPP tools: a decision tree, anevaluation and intervention instruction manual, a delirium preven-tion toolkit, and PowerPoint presentations on the DPP specifically forthe health care participants (nurses, nursing assistants, and order-lies). The advisory committee and the LTC clinical nurse specialistcommittee both provided their input and this, together with theclinical judgment of the research team members, contributed to toolselection and the decision-making process.
The Following Are Descriptions of the DPP ToolsDecision Tree. This decision support tool underpins the DPP. It wasdesigned to guide nurses through the different steps of the DPP.The first component consists of the 5-item risk-screening tool foridentifying residents at greatest risk of developing a delirium. Thedecision tree guides the nurse through 3 further steps for thoseresidents judged at high risk: (1) application of a protocol designedto provide optimal stimulation, (2) evaluation for the presence of4 modifiable delirium risk factors (presence of physical restraints,use of antipsychotics, dehydration, and visual impairment), and (3)selection of a specific intervention to lessen the impact of the riskfactors found present. Figure 2 shows the final version of thedecision tree. It underwent multiple revisions based on feedbackreceived during the implementation phase from both committeesand the participants.
Evaluation and Intervention Instruction Manual. We designed thismanual for use by nurses. It contains all necessary instructions toevaluate the presence of the 4 modifiable delirium risk factors andprovides interventions for nurses to put into practice if they haveidentified these particular risk factors. The manual also includesspecific directives to include in the therapeutic nursing plan andthe work plan of nursing assistants (NAs) and orderlies. To facili-tate this evaluation and intervention process, we created acro-nyms for each intervention (eg, RESTR for the interventionintended to reduce the use of physical restraints, ANTIPSY forintervention aimed at reducing the use of antipsychotics). Themanual proposes a single intervention for each risk factor, withthe exception of dehydration. One basic intervention is fordehydration, but there are 2 more interventions possible if,according to nurse clinical judgment, the first intervention wasnot sufficient.
Delirium Prevention Toolkit. This is a box containing all the neces-sary material to (1) evaluate the residents for the presence ofmodifiable risk factors (eg, a red ball for the visual assessment),and (2) implement the selected interventions (eg, voice amplifiers,colorful plastic cups, magnifiers).
PowerPoint Presentations on the DPP. We tailored these presenta-tions to the health care participants (nurses and NAs/orderlies). Wealso designed the presentations with set time limits (40 minutes
Fig. 1. Development and implementation phases of the delirium prevention program.
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for nurses and 20 minutes for NAs/orderlies) and to cover all theinformation needed to adequately use the DPP.
Phase 2: Implementation of the DPP
We conducted a total of 3 implementation cycles to evaluate thefeasibility and acceptability of the DPP. We carried out Cycles 1 and 2in an LTC facility in Quebec City and Cycle 3 in an LTC facility in theMontreal area. In the 2 cycles in Quebec City, our research staffprovided the training and the coaching, whereas in Montreal, the LTCfacility’s staff gave these sessions. The research assistant’s role inCycle 3 was to assist with recruitment and conduct the end-of-cycleinterviews. The research ethics boards of both study sites approvedthe study protocol.
Each cycle was tightly structured (Figure 1). Cycles commencedwith a 2-week training/recruitment period. First, we invited thehealth care workers likely to use the DPP (nurses, NAs, andorderlies working on day and evening shifts) to attend the pre-sentations on how to apply the DPP. Following each presentation,research staff solicited participation in the study. The research stafffirst introduced the DPP tools to the health care workers whoagreed to take part, and then observed them over a 5-week period(except for Cycle 3). To learn how participants perceived the use ofthe DPP in their practice, we conducted individual interviews atthe end of each cycle, using a semistructured questionnaire. Wethen analyzed the data gathered in these interviews together withfeedback from the research team involved on the units. In light ofthis analysis we made several modifications to improve the DPP
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and tested the modified version in the following implementationcycle.
Measures
The researchers drew up questionnaires to gather informationabout DPP feasibility and its acceptability to participants. Sincethe roles of the health care staff involved in the DPP were
not the same, tailored questionnaires were made for nurses and NAs/orderlies. We used a combination of both closed- and open-endedquestions to obtain a rich data set about the DPP tools and theirease of use in clinical practice. We first conducted simple descriptivestatistical analyses of the answers to the closed-ended questions(mean, SD, percentages). We then grouped the answers to the open-ended questions by theme and adapted the DPP tools to answer thedifferent concerns and comments that emerged.
Table 1Participant Characteristics: Nurses, NAs, and Orderlies
Cycle 1 Cycle 2 Cycle 3
(N) Nurses (6) NAs (11) Orderlies (21) Nurses (5) NAs (14) Orderlies (19) Nurses (8) NAs (7) Orderlies (8)
NAs, nurse assistants.Missing data for Cycle 3 ranged from 1 to 3.
P. Voyer et al. / JAMDA 15 (2014) 77.e1e77.e9 77.e5
For Cycle 2, wemodified the questionnaires used for Cycle 1 to takeinto account the several adjustments made to the DPP following Cycle1. There were no changes to the questionnaire necessary from Cycle2 to Cycle 3. Here are 2 examples of questions asked in these ques-tionnaires: (1)What are the factors that facilitated the implementationof DPP as part of your practice? (2) In your opinion, how can weimprove this program for the prevention of delirium (training, tools,documentation, etc.)?
Results
Tables 1 and 2 present the characteristics of the health care staffwho took part in the study and of the residents eligible to participatein the DPP, respectively. Table 3 provides a summary of the majorfindings for the 3 cycles.
Results for Cycle 1
We recruited a total of 38 staff members (6 nurses, 11 NAs, and 21orderlies) through the PowerPoint presentations, for an overallrecruitment rate of 90%. Of the 38 participants, 29 (76%) completedthe end of cycle questionnaire. Reasons for noncompletion weretemporary leave of absence from work (1), job cessation (6), and notavailable for an interview (2).
Evaluation of the DPP Tools by the ParticipantsPowerPoint Presentation Designed for Nurses. All nurses whocompleted the questionnaire (3) were satisfied with the formatand length of the presentation and found the information suffi-ciently clear, complete, and relevant for them to feel comfortable
CCI, Charlson Comorbidity Index; LTCS, long term care setting.One missing datum for Cycle 1 (Sex).
using the decision tree and the evaluation and interventioninstruction manual.
PowerPoint Presentation Designed for NAs and Orderlies. All partic-ipants who completed the questionnaire (8 NAs and 16 orderlies)were satisfied with the format of the presentation and 75% (18/24)with its duration. Most (�21/24 [88%]) found that the informationabout the different interventions included in the DPP was clear,complete, and pertinent.
Decision Tree. All nurses who had to complete at least 1 decisiontree (3) during the course of Cycle 1, found it easy to complete thedifferent components. However, the research staff found someminor errors in the completed decision trees and so, deemedindividual coaching sessions necessary. The number of coachingsessions required varied from nurse to nurse.
Evaluation and Intervention Instruction Manual. Concerning theevaluation for the presence of the 4 modifiable risk factors ofdelirium, all respondents found it easy to assess the use of physicalrestraints and antipsychotics. All nurses (2/2) found evaluating thepresence of vision impairment difficult, whereas 1 nurse (1/3)perceived the evaluation of dehydration as difficult. To evaluatedehydration, nurses had to look for the presence of certain clinicalsigns: dry tongue, deep creases on the tongue, dryness of themucous membranes, and decrease in or absence of saliva. A nursereported that some residents did not want to open their mouths,which made it impossible to assess this risk factor. Evaluation forthe presence of vision impairment consisted of asking the residentto name or point to some shapes on a card and also to track anobject placed in their visual field. Residents with severe cognitivedeficits could not understand the instruction for the first part ofthis test and so could not carry it out. To score positive for physicalrestraints use, we considered their use during the day and at night.Because most residents on the units involved in the study usuallysleep with raised side rails, most of those evaluated were foundpositive for this factor. For all the risk factors found present, thenurse had to select an intervention and write specific directives inthe therapeutic nursing plan as well as in the work plan of the NAsand orderlies. All the nurses (3/3) found that the objective,method, and directive for the proposed interventions were clearexcept for the intervention regarding hydration. They did not fullycomprehend the distinction among the 3 proposed interventionsfor this risk factor.
Implementation of InterventionsIn the main, NAs and orderlies were responsible for the applica-
tion of the interventions involving stimulation, hydration, vision, andreduced use of physical restraints. We explained the actions to becarried out for each intervention protocol in the PowerPoint
Table 3Summary of Findings for Cycles 1, 2, and 3
Main Findings Solutions What We Have Learned
Cycle 1 (Quebec City) 1. The PowerPoint presentation alone wasnot enough for the health care staff to feelat ease using the DPP tools.
2. The evaluation for the presence of visionimpairment was too difficult to performamong residents with severe cognitiveimpairment.
3. Because most residents sleep with raisedside rails, most were ascertained positivefor this risk factor.
4. Nurses found it difficult to distinguishamong the 3 interventions proposed fordehydrated residents.
5. Health care staff needed memory aids onhow to use the DPP tools.
6. Health care staff requested a betteridentification of the residents targeted bythe DPP.
1. Improve training by adding individualcoaching sessions.
2. Simplify the vision assessment procedure.3. When evaluating this risk factor, consider
only the use of physical restraints duringthe day.
4. Reduce the hydration protocol to 2interventions.
5. Developmemory aid tools: leaflet, poster,handy card.
6. List the names of residents at risk ofdelirium on a specially designed noticeboard.
No matter how simple an intervention,providing practical training is essential tooptimize its integration.Although we consulted differentstakeholders familiar with the context of LTCsettings, actual users of the DPP (nurses, NAs,and orderlies) made a significantcontribution to improvements in the DPP.
Cycle 2 (Quebec City) 1. The modifications made to the DPPfollowing the Cycle 1 (coaching, remindertools, etc.) were found useful by most ofthe participants.
2. Most health care staff who participated inCycle 1 also participated in Cycle 2, whichfostered a sense of ownership.
Involvement of the clinical staff in thedecision-making process helped fostera sense of ownership of the DPP.
Cycle 3 (Montreal) 1. The format and content of the Power-Point presentation were not respected.This had a negative impact on the uptakeof the DPP by the health care staff.
2. TheDPP toolswerenotproperlyexplainedduring the presentation. Consequently,the participants did not use them duringDPP implementation.
3. Coaching was not provided as had beenplanned.
1e3. Ensure effective clinician leadership so asto provide proper transmission of the formatand content of tools.
Each LTC facility has its own internal cultureand policies. Therefore, it is crucial to lay thegroundwork before the implementation ofnew tools.It is important to gain internal support forthe use of the DPP tools, not only at theadministrative level but also from theclinical staff.
DPP, delirium prevention program; LTC, long term care.
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presentation and instructed the NAs and orderlies to apply a specificintervention protocol to a resident if the intervention acronym ap-peared in their work plan. Although most respondents (�21/24[88%]) found the information given in the presentation was clear andcomplete, when it came time to apply a specific intervention, theyoverlooked some elements. In addition, participants identified severalbarriers. For example, we proposed placing a colored plastic cup atthe bedside of residents with dehydration. Although participants sawthe presence of the cup as a good visual reminder to offer liquid to theresident, they raised some issues regarding their lack of time to washthis cup. They also mentioned that the residents selected for the DPPshould be more clearly identified. Several respondents reported thatthe DPP content was not new to them but the tools and the structurein the DPP were good reminders of the actions they were to performand that in many instances, they had gradually forgotten.
Modifications Based on the Results from Cycle 1We added clinical coaching sessions for all the participants. In
Cycle 2, a research assistant would supervise the nurses in thecompletion of at least 1 decision tree and 1 evaluation and inter-vention in the instruction manual. For NAs and orderlies, the researchassistant would go over the delirium DPP directives/acronymspresent in their work plan at least once to ensure everyone under-stood them fully. We also inserted an example of a work plan con-taining such directives into the PowerPoint presentation.
In the evaluation and intervention instruction manual, weremoved the first part of the vision impairment assessment involvingpointing to certain shapes. For the evaluation for the presence ofphysical restraints, only the physical restraints used during the daywere considered. For the hydration protocol, and to avoid confusion,
we kept only 2 interventions: a general hydrating protocol anda further one to add, should the nurse believe it necessary. To facili-tate writing the directives in the therapeutic nursing plan and workplan, a document containing all the possible directives for eachintervention was made available at the nurses’ work station. Thisexpedited insertion of the selected directives into the work plans. Aswell, a colored water pitcher that staff could send to the institution’skitchen for washing replaced the colored plastic cup.
We also developed tools to help participants recall the actions tocarry out for each intervention. There was a poster with theDPP logo, acronym, and summary of the corresponding actions foreach intervention, plus the same information on a handy card. Inaddition, we put together a leaflet on delirium, its prevention, andthe DPP, for distribution on the participating units. Last, we placeda notice board in the nursing station informing staff as to the resi-dents on the unit targeted by the DPP and the interventions staffwere to carry out.
Results for Cycle 2
We recruited a total of 38 staff members (5 nurses, 14 NAs, and 19orderlies) for an overall recruitment rate of 93%. Thirty-two of the 38participants (84%) completed the questionnaire at the end of thiscycle. Reasons for noncompletion were temporary leave of absencefrom work (3) and job cessation (3).
Evaluation of DPP Tools by the ParticipantsPowerPoint Presentation Designed for Nurses. All nurses whocompleted the questionnaire (3) were satisfied with both theformat and length of the presentation and the clinical coaching
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sessions given by the research assistant. They found the informa-tion sufficiently clear and complete to feel comfortable incompleting the decision tree, evaluating the risk factors, andselecting the necessary interventions.
PowerPoint Presentation Designed for NAs and Orderlies. All partic-ipants who completed the questionnaire (12 NAs and 16 orderlies)were happy with both the format of the presentation and theclinical coaching sessions given by the research staff. Most (27/28[96%]) were also satisfied with the length (20 minutes) of thepresentation. Most (� 96%) also found that the information on thedifferent interventions included in the DPP was clear, complete,and pertinent.
Decision Tree. All nurses who had to complete at least 1 decisiontree (3) during Cycle 2 found that completing its various compo-nents was easy. As in Cycle 1, the number of individual coachingsessions varied depending on the nurse.
Evaluation and Intervention Instruction Manual. All the nurses whohad to evaluate the 4 modifiable risk factors of delirium (3) foundit easy. They also found that writing directives in the therapeuticnursing plan and the work plan of NAs and orderlies following theevaluation of a risk factor was easy too. The document added to thecomputer at the nurses’ work station contains all the possibledirectives for each intervention. It serves to facilitate the task ofadding directives. However, the research staff had to provide someadditional training, especially for the nurses less familiar withcomputers.
Implementation of InterventionsMost participants found the memory aid tools developed after
Cycle 1 for the actions they needed to perform for each interventionwere useful: the poster with the logo, acronym, and summary of theactions for each intervention (nurses: 3/4 [75%]; NAs/orderlies: 24/28[86%]), the handy card with the same information (nurses: 3/4 [75%];NAs/orderlies: 24/28 [86%]) and the leaflet on delirium, its preven-tion, and the DPP (nurses: 100%; NAs/orderlies: 18/28 [64%]). All thenurses and 93% (26/28) of the NAs and orderlies found that the noticeboard listing residents selected for the DPP, together with the inter-ventions to carry out, was of use. Some mentioned that this noticeboard was particularly helpful for quickly calling to mind the neces-sary interventions, whereas in the work plan this information oftengets lost. Participants also mentioned that the DPP tools (poster,handy card, leaflet, notice board listing targeted residents, and thecolorful water pitcher at the bedside of residents who were dehy-drated) and the training they received (PowerPoint presentation andcoaching sessions), all facilitated DPP use. Staff identified a lack oftime and some difficulties orienting and hydrating certain residentsas the main barriers.
Modifications Based on the Results from Cycle 2This time the only modification made to the DPP was for the
intervention related to the presence of vision impairment. We inte-grated the actions for the NAs and orderlies to carry out (lighting,organization of space, use of assistive device) into the optimal stim-ulation protocol (STIMUL), whereas the nurse actions (advise thefamily and the physician, if the vision impairment is a recentproblem) remained the same.
Results for Cycle 3
We recruited a total of 23 staff members (8 nurses, 7 NAs, and 8orderlies) for an overall recruitment rate of 61%. Seventeen
participants (74%) completed the questionnaire at the end of thiscycle. Reasons for noncompletion were temporary leave of absencefromwork (2), job cessation (2), and not available for an interview (2).It should be noted that the LTC facility where Cycle 3 took place hasa zero physical restraint use policy and so the nurses did not evaluatethis risk factor.
Evaluation of the DPP Tools by the ParticipantsPowerPoint Presentation Designed for Nurses. Among the nurseswho completed the questionnaire, 83% (5/6) expressed theirsatisfaction with the presentation format, whereas 67% (4/6) werehappy with its length. However, we must mention that althoughresearchers trained the nurse responsible for giving the presen-tation in Cycle 3 to deliver it, keeping to a specific content and timelimit, this did not always happen. For example, the presentationsoften ran overtime and left out some important information aboutthe DPP. Furthermore the nurse responsible for giving the clinicalcoaching sessions did not, in fact, do so. As a result we could notevaluate these sessions. Nevertheless, 83% (5/6) of participantsfound the presentation sufficiently clear to complete the decisiontree and to evaluate the risk factors. Sixty-seven percent (4/6)found the information clear enough for them to select the inter-vention needed and to write directives in the therapeutic nursingplan and in the work plan of NAs and orderlies.
PowerPoint Presentation Designed for NAs and Orderlies. Among theNAs (6) and orderlies (5) who completed the questionnaire, 63%expressed their satisfaction with the presentation format, whereas38% were happy with its length. Even though 91% of the respon-dents said that the interventions proposed in the DPP werepertinent, only 36% indicated that the information about theseinterventions was sufficiently clear and complete to carry themout.
Decision Tree. Among the nurses who completed at least 1 decisiontree (4) during the course of the cycle, 50% found completing itsdifferent components was easy. Contrary to Cycles 1 and 2, thenurses reported difficulties concerning the interpretation ofcertain items (eg, fidgets, unable to sit still) in the 5-item screeningtool for identifying residents at greatest risk of developinga delirium. Once again, the planned coaching sessions did not takeplace.
Evaluation and Intervention Instruction Manual. The results ob-tained indicate that nurses did not always use the instructionmanual properly. In addition they did not always conduct theevaluation for the presence of modifiable risk factors. Nurses alsoreported some difficulties when evaluating dehydration and visionimpairment. For instance, certain residents were reluctant to opentheir mouths (dehydration evaluation) or could not follow thedirections for the vision assessment.
Implementation of InterventionsIntroduction during the PowerPoint presentation of the memory
aid tools for participants, developed following Cycle 1 and very muchappreciated in Cycle 2, was poorly handled and inadequate. Morethan half the respondents stated they did not find the tools useful andsome even mentioned not having seen these tools during the 5-weekperiod. In addition, although there were 15 residents evaluated as atrisk for delirium and who, therefore, should have received theoptimal stimulation protocol, no NA or orderly reported that thisdirective was in their work plan.
We identified the lack of proper training (PowerPoint presentationand coaching) as the major barrier.
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Discussion
The purpose of this study was to examine the feasibility andacceptability of an intervention program aimed at preventingdelirium among cognitively impaired LTC residents. The rationale forexamining the feasibility and acceptability of the DPP was to addressthe challenge of implementing evidence-based interventions inroutine clinical practice.19,22 Although the efficacy of the DPP toprevent delirium among the targeted population remains to betested, it is important to note that the research team developed theDPP based on the body of knowledge accumulated over the pastdecade about delirium superimposed on dementia. The literaturehighlights the need to develop stakeholder-researcher collaborativepartnerships and a closer connection to end-users in order to betterunderstand their needs and their clinical setting, as optimizingfactors for a successful implementation.21e23,24 In the present study,we formed advisory and LTC clinical nurse specialists committees andconsulted with them throughout the development and imple-mentation phases. To get closer to the end-users of the DPP, we optedfor a participatory approach that continued during the three 5-weekimplementation cycles in which we tested the DPP.
The results of this study corroborate the findings of otherresearchers23,24 on the necessity of being informed by the end-users.Although researchers consulted different stakeholders familiar withthe context of LTC settings, the actual DPP users (the nurses, NAs, andorderlies) made a significant contribution to its refinement. Indeed,participant feedback following Cycle 1 underscored the need to addpractical training, to develop additional tools to help users rememberthe actions they needed to perform for each intervention, and tomake changes to simplify the evaluation of vision. Not only did usinga participatory approach allow us to address the needs of the actualusers of the DPP, but it also gave rise to a sense of ownership. Theeffect of this sense of ownership on the DPP uptake by the caregiverparticipants in Cycle 2 was very strong. Caregivers would say, “with allthe changes you have made based on our comments, the DPP is very easyto use now.” The literature22 emphasizes the importance of estab-lishing research-practice relationships to enhance the sense ofownership.
Another finding consistent with the results of other imple-mentation studies conducted in acute care settings was the impor-tance of gaining internal support for the intervention before itsimplementation and ensuring effective clinician leadership.19,25,26 Inthat sense, the fact that a member of the LTC clinical nurse specialistscommittee was also in charge of nursing care at the LTC facilityinvolved, made DPP implementation at the first site (Cycles 1 and 2)easier. This person’s enthusiasm for the DPP, as well as strong lead-ership skills, may have had a positive impact on the acceptability ofthe project among the LTC staff members and also facilitated its im-plementation by providing support for the recruitment of partici-pants. For the second site in Cycle 3, the research staff selecteda trainer to whom they presented the DPP. They gave the trainer allthe details related to the DPP (content, tools, format, duration, and soforth) to enable her to undertake the health care staff training at thatfacility. The fact that the trainer had not participated in the earliersteps involving development of the DPP, was certainly an importantfactor that hampered effective clinical leadership and internalsupport for the DPP at this site. This was apparent in difficultiesrespecting the format and content of the training and it had reper-cussions on DPP uptake by the rest of the care team. The resultsobtained from Cycle 3 also support earlier findings on the challengeof maintaining program fidelity while adapting to local circum-stances.19,25 The trainer made some adaptations to the format andcontent of the DPP training given to the health care staff that unfa-vorably affected the integrity of the prevention program. In the
preparatory session for the instructor for Cycle 3, the research teamshould have put more emphasis on how they had developed the DPPand the rationale for all its components, including the need to followa particular approach in the DPP user training.
The results of this study also indicate, that no matter the relativesimplicity of an intervention, providing practical training is essentialto optimizing its integration. This finding is similar to those of otherhealth-related studies on the significance of practical training inlinking theoretical knowledge to practice.27e29 Although mostparticipants in Cycle 1 found the information in the PowerPointpresentation was sufficiently clear and complete for them to feelcomfortable using the DPP, the research staff observed that when itcame time for its implementation, participants had not fully inte-grated the knowledge. All the participants appreciated the addition ofindividual coaching sessions for Cycle 2. In addition, these coachingsessions also allowed research staff to rapidly detect errors or mis-understandings and so provide the necessary corrections promptly.During Cycle 3, the coaching sessions were not provided as planned,which had a detrimental impact on the quality of the DPPimplementation.
Several caveats concerning this study deserve comment. First, thisstudy was conducted in 2 LTC facilities. Each LTC facility has its ownadministrative structure and internal culture, which limits thegeneralizability of the findings to other LTC facilities. Second, thesample size was small and as a result subject to bias in one way oranother. Third, we collected both quantitative and qualitativemeasures in this study. The data generated by the open-endedquestions is subject to interpretation by the researchers. On theother hand, the objective of this study was to examine and gauge thefeasibility and acceptability of an intervention program directed atpreventing delirium among cognitively impaired LTC residents.Despite the limited scope of this study, we maintain that the DPP canbe implemented in LTC. Our next study will be to determine whetheror not the DPP can prevent the incidence of delirium among this frailpopulation.
In conclusion, the results of this study suggest that under certainconditions, the DPP is feasible in LTC settings and it is acceptable tothe health care staff. The key elements are (1) gaining internalsupport for the DPP not only at the administrative level but also fromthe caregiver users; (2) ensuring effective clinician leadership tocommunicate the DPP format, content and values correctly, while alsoadapting the DPP to take into account the LTC facility’s own internalculture and policies; (3) fostering a sense of ownership among theDPP users; and (4) finally, providing practical training in addition tothe rather theoretical presentation.
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