Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study

Abstract

Background: Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials. Aim: To explore patient, family, clinician and volunteer (‘stakeholder’) perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the ‘PRESERVE pilot study’. Design: A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie’s Behaviour Change Wheel and the Theoretical Domains Framework. Setting/participants: Thirty-nine people involved in the trial: nurses ( n = 17), physicians ( n = 6), patients ( n = 6), family caregivers ( n = 4), physiotherapists ( n = 3), a social worker, a pastoral care worker and a volunteer. Results: Participants’ perspectives aligned with the ‘capability’, ‘opportunity’ and ‘motivation’ domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention). Conclusion: This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care. Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168

‘It’s tough. It is hard’: A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium

“… 8 , 9 A pilot study, reporting low adherence to a delirium prevention intervention, found that clinicians were more strongly motivated to enact responsive care than anticipatory. 44 Our theoretically informed analysis of the influences on this ‘reactive approach’ can be used to inform further research to develop effective interventions.…”

“…A previous systematic review recommended inter-professional education for complex delirium care. 44 There is a need to develop a shared team understanding to enable a structured approach to delirium care; reflected by recent calls for effective and strong interdisciplinary collaboration in this field. 45 …”

“…A previous systematic review recommended inter-professional education for complex delirium care. 44 There is a need to develop a shared team understanding to enable a structured approach to delirium care; reflected by recent calls for effective and strong interdisciplinary collaboration in this field. 45 Our finding that staff's emotional responses (automatic motivation) are important in driving their focus on managing hyperactive symptoms, including the use of medication, is consistent with the results of an Australian survey study, which found that 82% of palliative care clinicians reported emotional influences, including patient, family and staff distress, on their delirium treatment behaviours.…”

Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices (the DAMPen-D study): Feasibility study of a flexible and scalable implementation strategy to deliver guideline-adherent delirium care

“…14 Knowledge sharing within teams, incorporation of screening documentation into workflow and a culture of compassionate and collaborative working is important. 15,16 It is therefore as vital to find strategies to implement guideline-adherent care as it is to identify the optimal way to assess, manage and prevent delirium through clinical interventions. The Detection, Assessment, Management and Prevention of Delirium in Hospices (DAMPen-D) study 17 addresses this current gap.…”

“… 14 Knowledge sharing within teams, incorporation of screening documentation into workflow and a culture of compassionate and collaborative working is important. 15 , 16 …”