Translating Person-Centered Care Policy Into Practice: A Pre-Post Study of a Work-Based Learning Intervention for Nurses.

BACKGROUND: Person-centered care is critical to quality health care, but difficult to implement. This challenge is attributed to cultural factors derived from group values about work practices. Work-based educational interventions allow nurses to develop shared meanings of practice, in this case, promoting the value of person-centered care. METHOD: A 30-minute, work-based educational intervention incorporating reflection on videorecorded practice scenarios was evaluated with a quasi-experimental pre-post design. Nurses (N = 119) completed a survey, including a subset of 16 items from the Person-Centred Practice Inventory-Staff, before and immediately after the intervention. RESULTS: Nurses' awareness of what patients value about their care, the importance of connecting with the patient, and the value of integrating human elements into actions increased after the intervention. Nurses' perceptions of how they would include patients and their preferences in care decisions did not significantly change. CONCLUSION: Educational techniques that allow nursing teams to reflect on practice may help with implementation of person-centered care. [J Contin Educ Nurs. 2024;55(6):303-308.].

Barriers and enablers to embedding fundamental nursing care for older patients-Implications of a mixed methods study for nursing leadership.

AIMS: To understand the enablers and barriers for delivering fundamental care to hospitalized older patients. DESIGN: Explanatory sequential mixed methods design, with qualitative data used to elaborate quantitative results. METHODS: Set in one medical and one surgical unit of a tertiary hospital in southeast Queensland, Australia. Observations of nursing practice using the Work Sampling Technique were conducted over two 2-week periods in 2019. Data were analyzed and presented to groups of nurses who appraised the findings of the observations. RESULTS: There were 1176 and 1278 observations of care in the medical unit over two time periods and 1380 and 1398 observations over the same period in the surgical unit. Fundamental care activities were recorded in approximately 26% (i.e. medical) and 22% (i.e. surgical) of all observations. Indirect care was highest, recorded in 41% (i.e. medical) and 43% (i.e. surgical) of observations. Nurses prioritized the completion of reportable activities, which is perceived as a potential enabler of fundamental care. Potential barriers to fundamental care included frequent delays in indirect care and difficulty balancing care requirements across a group of patients when patients have high fundamental care needs. CONCLUSION: The cultural acceptance of missed nursing care has the potential to erode public confidence in health systems, where assistance with fundamental care is expected. Relational styles of nurse leadership should focus on: (1) making fundamental care important work in the nurses' scope thereby offering an opportunity for organizational change, (2) promoting education, demonstrating the serious implications of missed fundamental care for older patients and (3) investigating work interruptions. IMPACT: Fundamental care is necessary to arrest the risk of functional decline and associated hospital-acquired complications in older patients. However, nurses commonly report fundamental care as missed or omitted care. Understanding the challenges of implementing fundamental care can assist in the development of nurse leadership strategies to improve older patients' care. Fundamental care was observed between 22% (i.e. surgical) and 26% (i.e. medical) of all observations. Nurses explained that they were focused on prioritizing and completing reported activities, experienced frequent delays when delivering indirect care and found balancing care requirements across groups of patients more challenging when patients had fundamental care needs. Clinical nurses working in acute health services with increasing populations of older patients can lead improvements to fundamental care provision through relational leadership styles to demonstrate how this work is in nurses' scope of practice, promote education about the serious implications of missed fundamental care and investigate the root cause of work interruptions.

The DEMS-DOSS study: validating a delirium monitoring tool in hospitalised older adults.

OBJECTIVE: to evaluate the sensitivity, specificity and test-retest reliability of the Delirium Early Monitoring System-Delirium Observation Screening Scale (DEMS-DOSS). DESIGN: prospective diagnostic accuracy study of a convenience sample of admitted older adults with DEMS-DOSS and reference standard assessments. SETTING: 60-bed aged care precinct at a metropolitan hospital in Sydney, Australia. PARTICIPANTS: 156 patients (aged ≥65 years old) were recruited to participate between April 2018 and March 2020. One hundred participants were included in the analysis. MEASUREMENTS: Participants were scored on the DEMS-DOSS. Trained senior aged care nurses conducted a standardised clinical interview based on the Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV delirium criteria, within two hours of DEMS-DOSS completion. The senior aged care nurse undertaking the DSM-IV interview was blinded to the results of the DEMS-DOSS. RESULTS: Participants' mean age was 84 (SD ±7.3) years and 39% (n = 39) had a documented diagnosis of dementia. Delirium was detected in 38% (n = 38) according to the reference standard. The DEMS-DOSS had a sensitivity of 76.3% and a specificity of 75.8% for delirium. The area under the receiver operating characteristics curve for delirium was 0.76. The test-retest reliability of the DEMS-DOSS was found to be high (r = 0.915). CONCLUSION: DEMS-DOSS is a sensitive and specific tool to assist with monitoring new onset and established delirium in hospitalised older adults. Further studies are required to evaluate the impact of the monitoring tool on health outcomes.

Making clinical care decisions with people living with dementia in hospital: An integrative literature review.

BACKGROUND: As our population ages, the percentage of hospitalised patients diagnosed with dementia is expected to rise. However, there is emerging evidence that people living with dementia may experience discrimination and exclusion from decisions about their clinical care. Although dementia affects cognition, many patients living with dementia want to participate in decision-making processes relating to their clinical care in hospital. OBJECTIVE: Identify the processes associated with making decisions about clinical care with people living with dementia in hospital. DESIGN: An integrative literature review. DATA SOURCES: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, EMBASE (Ovid), MEDLINE (PubMED), PsycINFO and HeinOnline. REVIEW METHOD: One author conducted the initial screening of titles, and two authors screened in subsequent rounds for abstracts and full text. The process of making clinical decisions was the outcome of interest. Articles about people with cognitive impairment that did not include dementia, or decisions such as discharge planning or end of life care were excluded. An inductive synthesis of the findings was undertaken. RESULTS: Nine articles were identified for review and included expert opinion or hypothetical discussion (n=5), cross-sectional survey research (n=3), and qualitative research (n=1). Three themes were identified: capacity for decision-making is conceptualised as 'all or nothing'; there are no universal principles for including people living with dementia in decision-making in acute care settings; and autonomy is recognised but superseded by beneficence. CONCLUSIONS: Contemporary hospital practice is focused on determining capacity for decisions, with an all or nothing attitude to capacity, effectively excluding many people living with dementia from participation in decisions. While there is limited evidence to guide clinicians in this complex and situated process of making clinical decisions, emerging models of supported decision-making require further evaluation in the hospital setting.

Feasibility of a two-part person-centred care initiative for people living with dementia in acute hospitals: A mixed methods study.

Background: The personal profile offers a potentially useful tool to support person-centred care of people living with dementia in hospital. To date, how profiles can be implemented into nurses' work practices is not established. Objectives: The aim is to establish the feasibility of a Person-Centred Care package, including a personal profile and staff education program to enhance implementation. Design: Exploratory convergent mixed methods approach. Settings: Four units of a tertiary health service, two intervention units and two comparison units set in southeast Queensland, Australia. Participants: Person living with dementia and family carer dyads and staff. Methods: Practicality was determined using participation logs, audit and review of meeting minutes. Acceptability was determined using interviews with family carers and nursing staff. Efficacy was evaluated using pre-post comparison survey design, assessing staff knowledge using the Dementia Knowledge Assessment Scale and person-centred care using the Person-centredness of Older People with cognitive impairment in Acute Care-revised scale. Results: Practically, the personal profile was distributed to 95 and 73% of patients in the two intervention units. Of the 18 people living with dementia who consented to participate, only 6 (33%) had a This is Me form completed. The three-part education program was well attended (n = 190 participants). In terms of acceptability, carers' (n = 5) experienced variable quality of engagement from nurses. In interviews, nurses (n = 18) experienced increased confidence to engage carers, in part attributed to local leadership, but attitudes towards care appeared to be influenced by perceived time constraints. For efficacy, completion of both surveys at all time points and in all units was 50% and higher. Dementia knowledge significantly improved in the intervention group (p < .01) however there was no difference in self-ratings of person-centred care. Conclusions: The feasibility of a Person-Centred Care package, including a personal profile and a focused program of staff education was partially achieved, with the education component adopted into the organisation's continuing education program. Implementation research is required to enhance the element of coherence, how completing the personal profile is an investment in person-centred care rather than simply completing another form.

Interventions to prevent in-hospital falls in older people with cognitive impairment for further research: A mixed studies review.

BACKGROUND: While advances in falls prevention in the adult population have occurred, the care requirements for older patients with cognitive impairment at risk of falling are less established. OBJECTIVES: To identify interventions to prevent in-hospital falls in older patients with cognitive impairment for further research and describe the strategies used to implement those interventions. DESIGN: A seven-stage mixed studies review was used. METHODS: Seven electronic databases were searched. The SPIDER framework guided the review question and selection of search terms. The Mixed Methods Assessment Tool was used to appraise the quality of research studies, and the Quality Improvement Minimum Quality Data Set was used to appraise the quality of quality improvement projects. A convergent qualitative synthesis was used to analyse the extracted data. The adapted PRISMA guideline informed the procedures. RESULTS: Ten projects (five quality improvements and five researches) were included. Five themes emerged from the synthesis: engaging with families in falls prevention, assessing falls risk to identify interventions, extending nursing observation through technology, conducting a medication review and initiating nonpharmacological delirium prevention interventions. Implementation was not well described and commonly focused on capital investment to initiate a falls prevention programme and education to introduce staff to the new techniques for practice. CONCLUSIONS: Emerging research and quality improvement studies demonstrate that effective falls prevention with this vulnerable population is possible but requires further investigation before widespread practice recommendations can be made. Further research and quality improvement in this area should consider adoption of an implementation framework to address sustainability. RELEVANCE TO CLINICAL PRACTICE: Reducing falls in older people with cognitive impairment requires nurses to work more closely with pharmacists, occupational therapists and social workers to develop strategies that work and are sustainable.

Education for delirium prevention: Knowing, meaning and doing.

Hospital-acquired delirium is a common complication for older patients. Delirium prevention programs have been shown to reduce incident delirium and decrease length of stay; however, incorporating delirium prevention into nursing practice continues to be challenging. A three-element delirium prevention educational program was conducted with 42 nurses in a medical ward in a tertiary hospital in southeast Queensland. The education program focused on knowing, meaning and doing, consisting of a brief online course, case discussions with experts, and a high-fidelity simulation. A repeated cross-sectional design was utilised, with data collected over four time points before (T0), during the education program (T1, T2) and three months post completion of the study (T3). There were high levels of participation in the elements (48%-85%). Correct responses on the knowledge survey increased over time from 74.5% (T0) to 86.4% (T3; p = .003), suggesting a program focused on knowing, meaning and doing, was effective in improving nurses' knowledge about delirium. The increase in knowledge post completion indicates that learning about delirium prevention continued without structured education. Further research into how knowledge might be shared between nurses as part of everyday work may reveal other practice-based learning techniques which support practice change.

Using a general theory of implementation to plan the introduction of delirium prevention for older people in hospital.

AIM: To develop an implementation plan for delirium prevention. BACKGROUND: The use of non-pharmacological interventions to prevent hospital-acquired delirium is well established but their implementation has been notoriously difficult to achieve. Systematic analysis of context as part of implementation planning is critical. METHODS: Ethnographic study was conducted in a 24-bed general medical ward. Eleven patients and family members and 15 health service staff participated through observations, individual interviews and document review. Inductive analysis was used to generate themes that described enablers and barriers. RESULTS: Enablers included a ward culture that embraced safety and placing the person at the centre of care. Barriers were in tension with the enablers and included limited staff knowledge, specialist forms exclusive to the nursing discipline, inflexible ward routines and frequent disruptions. CONCLUSIONS: In addition to standard implementation strategies such as individual education and leadership, implementing delirium prevention requires consideration of team practices, review of policy document design and identification of outcomes data than can support collaborative reflexive practice. IMPLICATIONS FOR NURSING MANAGEMENT: The use of a theory-informed ethnographic approach exposed tensions that may be otherwise invisible. Understanding the tensions increases the likelihood of implementation success. Using a systematic assessment approach can create a comprehensive implementation plan.

Implementing Evidence-Based Guidelines for Falls Prevention: Observations of Nursing Activities During the Care of Older People With Cognitive Impairment.

BACKGROUND: Evidence-based guidelines assist clinicians in practice, but how the guidelines are implemented is less established. AIM: To describe the nurses' implementation of activities recommended in evidence-based guidelines for falls prevention and care of older people with cognitive impairment. METHODS: Structured observation with a categorical checklist was used. Nursing personnel were recruited from one subacute and two acute wards in two hospitals in one tertiary-level health service in south-eastern Queensland, Australia. The data collection instrument identified 31 activities drawn directly from the evidence-based guidelines, which were categorized into six domains of nursing practice: clinical care, comfort, elimination, mobility, nutrition and hydration, and social engagement. Four-hour observation periods, timed to occur across the morning and evening shifts, were conducted over 2 months. RESULTS: Nineteen registered nurses, six enrolled nurses, and 16 assistants in nursing (N = 41) were observed for 155 hr of observation. There was variability in adherence with specific activities, ranging from 21% to 100% adherence. Three categories with the highest adherence were nutrition and hydration, mobilization safety, and social engagement. The clinical care, comfort, and elimination categories had lower adherence, with lowest adherence in activities of education provision about falls risk, pain assessment, using a clock or calendar to reorient to time and place, and bowel care. LINKING EVIDENCE TO ACTION: Nursing care is delivered within an interdisciplinary team. Therefore, responsibility for the everyday fundamental care activities known to prevent falls in older people with cognitive impairment requires localized negotiation. A practical guide for preventing in-hospital falls in older people with cognitive impairment addressing the interdisciplinary context of practice is required. Interdisciplinary teams should develop strategies to enhance the implementation of pain assessment and prevention of constipation in the context of regularly implemented hydration, nutrition, and mobilization care strategies.

Relational thinking in later adulthood.

The research addressed the role of relational processing capacity in cognitive aging focusing on (a) age-differences in complex relational processing, (b) the domain-generality of complex relational processing, and (c) associations of complex relational processing with other processes. Participants were 125 adults in three groups with mean ages of 30.55 (younger), 53.43 (middle), and 74.41 years (older). Each relational processing task (sentence comprehension, n-term premise integration, Latin square) included items at three complexity levels. Accuracy was lower on more complex items and relational complexity had a greater effect in the older group. Confirmatory factor analyses confirmed a single complex relational processing factor, consistent with a domain-general capacity. Relational processing was related to other executive processes. This relationship was stronger in the older than younger and middle groups, possibly reflecting dedifferentiation or neural noise. In structural models with planning (Tower of London) and class reasoning as outcome variables, complex relational processing had a significant impact (ß = .455, p < .001 and ß = .661, p < .001, respectively) over and above age, processing speed, working memory, task switching, response inhibition, and Stroop interference. In the structural model with fluid intelligence (matrix reasoning) as the outcome variable, age had a significant impact (ß = -.222, p < .001), over and above all other variables, suggesting that the processes underpinning age-related declines in matrix reasoning are more diverse than those assessed in the current research. Complex relational processing is an important factor in cognitive aging, possibly reflecting its reliance on prefrontal brain regions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Caring for the older person with cognitive impairment in hospital: Qualitative analysis of nursing personnel reflections on fall events.

AIMS AND OBJECTIVES: To explore nurse and nursing assistant reflections on the care of older patients with cognitive impairment who have experienced a fall. BACKGROUND: While there are evidence-based clinical guidelines for the prevention and management of falls and for the care of older people with cognitive impairment, the falls rates for older people with cognitive impairment are three times as high as those without. DESIGN: Critical incident technique. METHODS: Eleven registered and two enrolled nurses and four assistants in nursing working in one subacute and two acute wards within two hospitals of a tertiary level health service in south-east Queensland. Individual semistructured interviews focused on two past events when a patient with cognitive impairment had fallen in hospital: one when there was minimal harm and the second when there was significant harm. Thematic analysis was undertaken. The COREQ checklist was followed. RESULTS: Three themes emerged from 23 reflective accounts of fall events: "direct observation is confounded by multiple observers" and "knowing the person has cognitive impairment is not enough," and "want to rely on the guideline but unsure how to enact it." While participants were aware of the falls prevention policy and techniques available to prevent falls, the implementation of these was challenging due to the complexity of care required by the older person with cognitive impairment. CONCLUSIONS: Falls prevention for older people with cognitive impairment is complex and belies the simple application of policy. RELEVANCE TO CLINICAL PRACTICE: To reduce falls, nurses can involve the family to support "knowing the patient" to enable prediction of impulsive actions; shift the focus of in-service from lectures to specific case presentations, with collaborative analysis on person-focused strategies to prevent falls in older people with cognitive impairment; and reconsider the sitter role from simple observer to assistant, focused on ambulation and supporting independence in activities of daily living.