Date of Award

2015

Degree Name

Doctor of Philosophy (College of Nursing)

Schools and Centres

Nursing and Midwifery

First Supervisor

Professor Jane Phillips

Abstract

Background: Delirium is a distressing and serious acute neurocognitive disorder frequently experienced by hospitalised patients yet under-recognised by nurses.

Aim: To identify the actions required to improve the capabilities of specialist inpatient palliative care nurses to recognise and assess delirium.

Design: A two-phase sequential transformative mixed methods project, involving five studies and underpinned by a knowledge translation conceptual framework – collectively termed the DePAC project.

Methods: A mixed methods design was used to examine delirium in palliative care inpatient settings from epidemiological, systems and nursing practice perspectives. Participants were nurses, physicians, allied health professionals, managers and patients of Australian palliative care inpatient services. Phase one focused on scoping the problem of delirium in palliative care and included a systematic review on delirium prevalence and incidence, cross sectional study and environmental scan. During Phase two, the Critical Incident Technique and focus groups were used to explore palliative nurses’ delirium experiences, perceptions and capabilities. Data from each phase were integrated at the conclusion of the project.

Results: Palliative care inpatients are a geriatric population at risk of delirium. Internationally, delirium prevalence in palliative care inpatient units ranged from 26% to 62% during admission, increasing up to 88% in the last hours of life. In the cross-sectional study, one in five (19%) palliative care inpatients were diagnosed as delirious in a 24-hour period. Almost all evidence-based guidelines for delirium exclude evidence and recommendations directly acknowledging the care needs of patients who are approaching the end of their life. Strategies for recognising and assessing delirium are missing from palliative care unit systems. Ambiguous terminology and nurses’ poor conceptual understanding of delirium contributes to under-recognition and inadequate assessment. The Nursing Delirium Screening Scale is brief, simple and feasible for use, yet optimal delirium recognition and assessment by nurses also requires rapport with patients, engagement of family, validation of delirium tools in this setting, point-of-care guidance, education relevant to palliative care contexts and interdisciplinary teamwork.

Conclusion: More careful navigation of palliative care patients away from an incipient or existing episode of delirium is entirely possible and must become core business within specialist palliative care inpatient units. Building the capacity of palliative care nurses to provide exemplary delirium care will be achieved by transforming the DePAC recommendations into concrete action.

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