General discussion thesis

This thesis looked at how patient safety and quality of care for older hospitalised patients at-risk for delirium can be improved, specifically focusing on the effects of e-learning on the implementation of the national Frail Elderly Project (FEP). In this final chapter the main findings of this research are discussed, as well as some methodological considerations. This chapter also looks at the implications of this research for practice, policy and future research. In the Netherlands, efforts have been made to improve delirium care, as part of the national Frail Elderly Project (FEP). Because there were indications that the implementation of FEP and its delirium guideline was not as successful as hoped (IGZ 2012), we first decided to look into possible barriers to this implementation. 1. Which barriers exist to adherence to the FEP delirium guideline by nurses? We found that individual, social and organisational factors play a role in nurse's adherence to the FEP delirium guideline. Barriers were identified regarding motivation and goals, knowledge and skills, professional role and identity, and context and resources. Overall, nurses lack the motivation to use the risk-screening instrument aimed at identifying patients at risk for delirium, despite the recommendation in the guideline. This is mainly influenced by the apparent lack of clarity of the benefits and goals of screening. Nurses stated that they did have sufficient knowledge and skills to use the screening instrument to identify patients at risk, or the Delirium Observation Screening Scale (DOSS) in order to observe possibly delirious patients. Whether nurses considered themselves capable of taking subsequent preventive or treatment measures is less clear: some indicated high levels of confidence, while others had doubts about their own and others' level of knowledge. Physicians mainly emphasized the importance of additional education for nurses on delirium screening and treatment. Nurses report having a shortage of time in which to perform their day-today tasks, leading to the professed inability to perform time-consuming or perceived non-essential activities such as screening, or observing patients using the DOSS. Nurses do not consider delirium risk screening to be an intrinsic part of their job, and in addition some nurses disagreed with the General discussion 129 content of the guideline. The screening instrument is sometimes seen as limiting their autonomy, while they have little faith in the usefulness of the instrument itself. A negative influence on delirium care is the general view that nurses on general wards consider …