1. Graham, Frederick BN, RN


Frederick Graham, a clinical nurse consultant from Princess Alexandra Hospital in Brisbane, Australia, presents this month's column focused on improving nursing care for people with dementia and delirium in hospitals.


Article Content

Hospitals are seriously challenged in their ability to provide high-quality care for patients with dementia and delirium. These patients often experience poor outcomes because of inappropriate environments, ineffectual systems, and poor staff knowledge.1-31-31-3 Quality outcomes for patients with cognitive impairment are achieved in care settings where caregivers value personhood and relationships, allow flexibility, and encourage nurse-patient reciprocity.4,54,5 Hospital environments have not traditionally been established to cater to these needs. This article outlines the journey being undertaken at the Princess Alexandra Hospital (PAH) toward recognizing the importance of creating a psychosocial environment conducive to the well-being and subsequent health of patients with cognitive impairment.

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Dementia and delirium are both highly prevalent among older people in hospitals.6 Even though dementia and delirium are not the primary reasons for most admissions, it is the coexistence of these conditions that can significantly complicate patient care and lead to high rates of adverse outcomes.7 Patients usually have difficulty communicating with staff, are sensitive to high or low stimulation, and have behavioral symptoms such as aggression, agitation, and wandering.8,98,9 Most hospital nurses do not have an adequate level of knowledge, training, or skills to appropriately manage these symptoms.1 Furthermore, as hospitals are risk-averse in nature and organized around throughput, processes, and procedures, nurses in this environment are focused on duty, responsibility, efficiency, and being in charge within time-poor, task-oriented environments.10-1210-1210-12 This allows little time for qualities such as flexibility, person-centeredness, and being relationship oriented. Within this culture, challenging behaviors of older, agitated patients are often perceived as "misbehavior" and are not interpreted as having a meaning or cause. Behavioral management responses of psychotropic sedation, physical restraint, and the use of 1-on-1 nurse-specials (sitters) to monitor and maintain safety become popular because they reduce workload for the nurse.12-1412-1412-14 Unfortunately, this short-term custodial focus does not allow the psychosocial and therapeutic opportunities afforded by 1-to-1 care to be realized.15,1615,16


It is clear that a different nursing approach is necessary. As a 3-time accredited Magnet(R) hospital, PAH is perhaps better prepared than most as an organization to implement cultural changes that improve patient outcomes. In 2008, leaders at PAH developed an innovative 8-bed high-dependency unit (HDU) for cognitively impaired patients. Patients relocated to the HDU receive care from specially trained staff with appropriate resources tailored to provide a rich psychosocial environment conducive to reducing behavioral and psychological symptoms. Across the 3 medical wards serviced by the HDU, there has been a 30% reduction in falls in cognitively impaired patients and a 62.7% reduction in nurse-specials (sitters) required after just 2 years. The HDU also provided a specialized environment in which tools and resources were developed and subsequently adopted across the hospital. One such tool was an innovative behavioral observation and pain assessment chart. Another resource was the "sunflower" chart, which provides information about the patient's "life story" as a quick reference for all staff to facilitate conversation, socialization, and activity.


As PAH is a large metropolitan hospital, it became abundantly clear that PAH could not improve care for all cognitively impaired patients in the hospital by using only 1 HDU. Changes at the bedside across all wards in the hospital would be required. All nursing staff would need to be educated about dementia and delirium. A clinical nurse consultant (CNC) role in dementia and delirium was sponsored by the executive director of nursing and began to support change across the organization by providing education and training while modeling best practices alongside the staff. The CNC role developed a mandatory educational program, which was rolled out across the hospital. It included written modules, interactive workshops, and a delirium-screening tool to aid in early identification and management of patients with cognitive impairment.


Through this education, a network of 120 passionate change-champion nurses was recruited. These "cognition champions" have established high-profile "cognition corners" in their nursing stations that provide staff with immediate access to clinical tools and resources to facilitate and engage patients in recreation, exercise, and social activity. The sunflower chart is also available, along with the behavioral observation chart and the delirium-screening tool. Cognition champions meet monthly to exchange ideas and update resources such as indwelling urinary catheter decoy aprons and fiddle blankets (blankets covered in texturally stimulating materials for distraction) made to order by hospital volunteers.


When the journey commenced, it was targeted and local. Now a hospital-wide approach is clearly visible, and nurses are starting to display flexibility in their approach to caring for patients with cognitive impairment by creatively working to provide an improved psychosocial environment. Alongside specialized clinical assessments, emphasis is placed on meaningful interaction, dignity, and person-centeredness. Nurse-specials work closely with RNs in delivering individualized care plans. The goal of a therapeutic psychosocial environment is collectively understood. Nurse-specials (sitters) routinely take patients outside for walks. They skillfully engage patients in daily activities, including recreation and exercise, and use person-centered communication drawn from the sunflower chart. The RNs use evidence-based tools to conduct behavioral assessments and to identify and treat behavioral triggers such as pain and delirium.


To date, improvements in care for this patient cohort at PAH are described anecdotally on a daily basis. As the recipient of a federally funded research grant in 2015 (Department of Social Services, Australian Government), the hospital will now use robust outcome measures to evaluate the effect of using cognition champions to improve the quality of care for people with cognitive impairment. Armed with these data, we hope to fine-tune our advances through feedback and evaluation. The improved delivery of flexible person-centered care in busy hospital environments is an exciting new frontier in acute care nursing.




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