People displaying behavioural and psychological symptoms (BPS) associated with neurocognitive disorders (including dementia and delirium) are at high risk for preventable harm when in hospital (Kinnunen-Luovi, Saarnio & Isola, 2014; Martinez, Tobar & Hill, 2015). Tailored, individualised, multi-faceted interventions can help reduce symptoms and risk of harm or complications (Duceppe et al., 2017; Jackson et al., 2017). However, the care of people experiencing neurocognitive disorders in acute hospital settings is often inconsistent with best practice recommendations (Tomlinson, Phillips, Mohebbi, & Hutchinson, 2017). Co-design of knowledge translation strategies with end users has potential to address the complex barriers to translation of best available evidence into practice (Rycroft-Malone et al., 2016).
The aim of this study was to increase uptake of best practice guidelines by nurses caring for people displaying BPS related to a neurocognitive disorder in hospital.
The study objectives were to:
- co-produce a knowledge translation strategy to promote nurses’ use of best practice guidelines in order to prevent harm to people displaying BPS of a neurocognitive disorder in hospital
- evaluate the uptake and perceived acceptability, usability, and feasibility of the strategy for use by nurses in inpatient settings.
Methods
A four-stage integrated knowledge translation approach was used to co-produce, implement, and evaluate the strategy. The setting was two general medical in-patient wards at two hospital sites (one ward per site) within a public health service in Victoria, Australia. In Stage 1 (3-months), baseline data were collected and information sessions were held with staff. During Stage 2 (4-months), up to five nurses from each ward were recruited as nurse facilitators, to work with the research team and a consumer representative to co-design the knowledge translation strategy. The co-design team developed and tested a three-part strategy comprising: online education, ward-based peer facilitation, and a point-of-care decision-support application (i.e., an App referred to as BRAIN-TRK [Behavioural Resource App for Interventions for Neurocognitive disorders – Translating Research Knowledge]). The strategy’s components were informed by evidence on the effectiveness of knowledge translation interventions (e.g., education, facilitation, and reminders). During this stage, the BRAIN-TRK App was tested with nurses in the two inpatient wards and iteratively refined to improve its function and usability. Stage 3 was a 90-day implementation period in which all nursing staff on the two participating wards were invited to complete the online education module, and use the App at the point-of-care to identify and implement strategies for patients experiencing BPS, with the support of the nurse facilitators. In Stage 4 (2-months), evaluation data were collected.
Data collection included: (1) 171.25 hours of naturalistic observation (n = 80 patients); (2) individual and focus group interviews with nurses and unit managers (Pre-implementation: n = 22 participants; Post-implementation: n = 25 participants); (3) tests of nurses’ knowledge before and after completing the education module, using the validated Dementia Knowledge Assessment Scale (Annear et al., 2015; Pre-implementation: n = 48 participants; Post-implementation: n = 15) and the Module Knowledge Quiz (an assessment of content specific to the module, developed by the researchers and clinical experts; Pre-implementation: n = 48 participants; Post-implementation: n = 24 participants); and (4) data extracted from the BRAIN-TRK App (n = 32 patients).
Primary outcomes of interest were:
- Changes in nurses’ level of knowledge and uptake of best practice interventions in the day-to-day care of people with BPS related to neurocognitive disorders.
- Nurses’ perceptions regarding acceptability, usability and feasibility of the knowledge translation strategy.
Results
Nurses’ knowledge of and adherence to best practice increased. Specifically, following completion of the module, nurses had increased levels of knowledge of dementia, delirium and best-practice interventions to address BPS. Participants’ mean scores on the Dementia Knowledge Assessment Scale increased by 20.55% (Pre-implementation: M = 34.07, SD = 5.61; Post-implementation: M = 41.07, SD = 7.07; t (14) = -5.67, p < .001, η2 = 0.70). Participants’ scores on the Module Knowledge Quiz increased by 16.67% (Pre-implementation: M = 15.54, SD = 2.09; Post-implementation: M = 18.13, SD = 1.78; t (23) = -6.79, p < .001, η2 = 0.67).
Observation data showed a 147.3% increase in the mean number of strategies nurses used to manage BPS for patients identified as at risk (Pre-implementation: M = 1.67, SD = 1.44; Post-implementation: M = 4.13, SD = 1.67; t (78) = -7.10, p < .001, η2 = 0.39). Nurses were observed using the BRAIN-TRK App with 17 (44.7%) of the 38 eligible patients. Data extracted directly from the BRAIN-TRK App identified that the App was used with a total of 32 patients during the implementation period. The App usage data showed a cognitive screen was completed for all patients at least once and 146 risk factor assessments were conducted (M = 4.71, SD = 5.12; range 1 - 23 per patient). Tailored recommendations, drawn from the 22 individual strategies available in the BRAIN-TRK App, were provided on 99 occasions across the 32 patients, ranging from 1 to 18 different strategies per entry (Mean = 7.81, SD = 4.14).
Qualitative data indicated the acceptability of the knowledge translation strategy was enhanced by increased knowledge of BPS, an understanding of the potential benefits of best practice to patients and staff, useful and usable content, and familiarity with the App. Reported acceptability was reduced by perceptions of increased workload (e.g., cognition assessment results were recorded in the patient care record as well as the App) and lack of time, inconsistent use of the App by peers, and resistance to change. Feasibility and usability were perceived to be enhanced by management support and teamwork, and a flexible and tailored approach to implementation. Factors perceived to hinder feasibility and usability were an entrenched workplace culture and practices, the nature of the acute environment and workflows, and patient factors (e.g., acuity, non-English speaking).
Conclusion
Our results indicated that the knowledge translation strategy, comprising facilitation, education and a point-of-care decision support tool in the form of an App, was: (1) associated with an increase in nurses’ knowledge and use of best practice strategies to address patients’ BPS; and (2) perceived as usable, acceptable, feasible and relevant for use in hospital settings. Future work will involve refinement of the strategy and testing of its impact on a wider health care population over a longer period of time.
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