title: Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study.
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.
  
  
  BACKGROUND
  ISRCTN65924234.
authors.affiliation: 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. m.godfrey@leeds.ac.uk.
authors.forename: Mary
authors.initials: M
authors.lastname: Godfrey
authors.forename: Jane
authors.initials: J
authors.lastname: Smith
authors.forename: John
authors.initials: J
authors.lastname: Green
authors.forename: Francine
authors.initials: F
authors.lastname: Cheater
authors.forename: Sharon K
authors.initials: SK
authors.lastname: Inouye
authors.forename: John B
authors.initials: JB
authors.lastname: Young
mesh_terms: D000368:Aged; D055812:Community-Based Participatory Research / Q000379:methods; D003693:Delirium / Q000517:prevention & control*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004493:Education; D004739:England; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D017146:Models, Organizational; D016730:Program Development; D013222:State Medicine / Q000458:organization & administration