Table 3 Qualitative analysis of guideline evaluation interviews and focus groups with staff: key themes and subthemes

Personal or prior knowledge and experiences that may impact practices with respect to delirium

This theme included knowledge or experiences from prior to the implementation of the guideline, including from working in a palliative care context for a length of time. This previous knowledge or experience also included practices that the participant already put into use or guidelines they were already familiar with

Physician 1: “It’s useful for an introductory for people coming from clinical background where they may not be as familiar with delirium, but for those of us who have a fair bit of experience, I think that section definitely files under the basic or introductory category”

Nurse 4: “I think what happens is we also learned by experience. From each case to each case because every single patient is unique, here, and every single patient reacts differently to medication and there’s family dynamics and the whole thing. So as much as you may have learned back a few years ago when we did the modules, it’s an ongoing learning process, and I think when you take that into consideration, your experience is what’s going to teach you how to as well, even though you have the base, you have the education that’s there”

Challenges of facilitating change through implementation of the guideline

Any difficulties encountered during the implementation of the guideline and/or management of delirium

Situational factors

Some challenges experienced by participants involved specific situations impacting guideline implementation and training, such as reduced staff presence at night-time, symptoms being difficult to manage, and different hierarchical or corporate priorities

Nurse 1: “So then what if you get a confused patient who’s agitated and wants to get out of bed or they want us to get them out of bed, which is no problem during the day, but how’s night shift supposed to do that?”

Physician 2: “In theory, we all really want to try and manage if we can any episode of delirium with a non-pharmacological approach, but the reality is that we find, not infrequently, we find situations where patients are extremely distressed, agitated. Families are very distressed seeing that, and there was a compelling need for us to intervene more pharmacologically. But yet our knowledge of how we are to best intervene pharmacologically is limited. So that makes that very difficult”

Sustaining change

In other cases, participants shared difficulties associated with sustaining continued use of the guideline. Ensuring that practice changes were sustained over time involved the incorporation of the guideline as a reminder, keeping guideline elements at the forefront of care, and changing practices at a pace that enabled uptake

Guideline adaptation group member 1: “And also being attentive to, from a nursing side of things the pace of change, as well, because in the last few years there have been a lot of changes to bedside nursing practice. Like when you think of all the electronic documentation that’s relatively new, and so it’s making sure that when we’re bringing changes that it can be at a pace that’s absorbed and supported, as well”

Time

Other challenges and barriers to implementation of the guideline involved staff time or the length of time since completion of guideline training. Protected staff time to complete the guideline training was described as a method of overcoming this challenge

Guideline adaptation group member 1: “There was a coordination piece to make sure that we had protected time for staff to attend… for the online modules, for staff who were already on the unit, they were asked to do it on their own time, which—that can account for why people may not have done it, if you’re continuously really busy with patients. But over time, integrated that into protected time within the unit orientation for nurses, as a way to say, you have paid time to learn and understand this stuff”

Impacts on practice post-implementation

Any specific things participants noted have or have not changed in their own practice or in their observations of others’ practices as a result of the guideline training and implementation; includes considerations for future practice

Changes in practice

Participants described elements that changed and/or improved, such as increased delirium screening proficiency, better communication, and facilitation of delirium prevention strategies

Physician 1: “There’ve been a few situations where I’ve really noticed the nurses do things like be descriptive around filling out the Nu-DESC. Maybe they’ll write a note about why they rated highly on certain features. Or I’ve just seen that in certain cases they now will actually rate a very high Nu-DESC quite appropriately, where in the past I hadn’t seen that done… more often now I’ve seen a bit better description of this is the behaviour, medication was given, this is how long it took to work and this is how the behaviour changed. So I almost never saw those descriptions before and now I’m starting to see them…”

No changes in practice

Participants also reported elements that had not changed as a result of the guideline. The guideline was seen as a reinforcement of practice elements that were already being done

Physician 1: “My impression was that maybe it [the guideline] wasn’t really adding new information for the physicians or trying to change their practice. It was just reinforcing what we’re already doing”

Collaborative effort of change

Participants described the team approach to identifying areas for improvement and implementing change in practices for delirium prevention and management

Staff member 1: “…it [the guideline] works in non-nursing, it increases something, like we communicate with the nurse, with the doctor, so, yeah. It’s a thing where it can actually prevent this especially for evening and at night, if we can protect them during the day time so this evening can have easy going on, same things for nights”

Guideline adaptation group member 1: “I think having a role of professional nursing leadership on the unit where the role is certainly to support evidence-based practice best practices as it’s for that unit I think are certainly elements that are needed and obviously the involvement of the inter-professional team. And in terms of the clinical manager being immensely supportive, in terms of finding financial resources and [being] emotionally invested and supportive as well, I mean, certainly everyone plays a part in that, but I think it takes champions in different pockets to really make things work and certainly from more upper management, as well, from the directors as well… The other piece that has been important is also having the starter kit integrated into the education for volunteers who are going to be on the Palliative Care Unit. So that’s an important enabler in terms of the inter-professional education”

General importance of having standardised guidelines

Participants conveyed the general benefits of having standardised guidelines as a reference as part of clinical or teaching practices. These benefits included having a common language or reference point for delirium management across the whole PCU team

Physician 1: “I find for the most part it [the guideline] becomes part of our habitual practice and then we’re not using them on a case-by-case and day-by-day practice, but they’re useful for those instances where you do just to refer back. Sometimes useful from a teaching perspective, as well… And, lastly, I think, just in terms of practice standardization for the interaction between physicians and nurses and understanding when we talk about whether it’s palliative sedation or delirium or a bowel protocol, that we all have a similar framework or reference point, and we’re talking the same language”

Elements of guideline or guideline training that individual found important, helpful, or useful

Participants also noted items or aspects of the delirium guideline or provided training that were important or helpful to caring for someone with delirium, including: i) the ‘Big Picture’ summary format of the guideline; ii) multi-module nature and user-friendliness; iii) helpfulness in increasing knowledge for non-nursing PCU staff

Guideline adaptation group member 1: “In terms of design and consideration to the accessibility of the guidelines, I think it’s really excellent because it’s very user-friendly. It’s also, in terms of being able to think about clinical problems overall with a similar approach, I think that that’s really thought out. It’s accessible in terms of having a variety of learning strategies and ways to support practices on the unit, so it’s multi-modal in terms of in-class time, online modules, having components that are visual, having it reinforce with things in the MAR. So it’s accessible on different fronts, so I think that’s really positive, and I think it also really ties in—and, again, I’m speaking from a nursing side of things—but to really tie into really practical examples of what nurses encounter in their clinical practice into the role of the guidelines I think is a very important piece”