实施和提供预防谵妄护理系统的过程：一项混合方法初步研究。
Process of implementing and delivering the Prevention of Delirium system of care: a mixed method preliminary study.
机构信息
Academic Unit of Elderly Care and Rehabilitation, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, West Yorkshire, UK.
Leeds Institute of Health Sciences, University of Leeds, Leeds, West Yorkshire, UK.
出版信息
BMC Geriatr. 2019 Dec 31;20(1):1. doi: 10.1186/s12877-019-1374-x.
BACKGROUND
Delirium is a frequent complication of hospital admission among older people. Multicomponent interventions which can reduce incident delirium by ≈one-third are recommended by the National Institute of Health and Care Excellence. Currently, a standardised delirium prevention system of care suitable for adoption in the UK National Health Service does not exist. The Prevention of Delirium (POD) system of care is a theory informed, multicomponent intervention and systematic implementation process which includes a role for hospital volunteers. We report POD implementation and delivery processes in NHS hospital wards, as part of a feasibility study.
METHODS
A comparative case study design and participatory, multi-method evaluation was performed with sequential six month preparatory and six month delivery stages. Six wards in five hospitals in Northern England were recruited. Methods included: facilitated workshops; observation of POD preparatory activities; qualitative interviews with staff; collection of ward organisational and patient profiles; and structured observation of staff workload.
RESULTS
POD implementation and delivery was fully accomplished in four wards. On these wards, implementation strategies informed by Normalization Process Theory operated synergistically and cumulatively. An interactive staff training programme on delirium and practices that might prevent it among those at risk, facilitated purposeful POD engagement. Observation of practice juxtaposed to action on delirium preventive interventions created tension for change, legitimating new ways of organising work around it. Establishing systems, processes and documentation to make POD workable in the ward setting, enhanced staff ownership. 'Negotiated experimentation' to involve staff in creating, appraising and modifying systems and practices, helped integrate the POD care system in ward routines. Activating these change mechanisms required a particular form of leadership: pro-active 'steer', and senior ward 'facilitator' to extend 'reach' to the staff group. Organisational discontinuity (i.e. ward re-location and re-modelling) disrupted and extended POD implementation; staff shortages adversely affected staff capacity to invest in POD. Findings resulted in the development of 'site readiness' criteria without which implementation of this complex intervention was unlikely to occur.
CONCLUSIONS
POD implementation and delivery is feasible in NHS wards, but a necessary context for success is 'site readiness.'
背景
谵妄是老年人住院的常见并发症。英国国家卫生与保健卓越研究所推荐使用可将谵妄发生率降低约三分之一的多组分干预措施。目前，英国国民保健制度不存在适合采用的标准化谵妄预防护理系统。护理谵妄预防（POD）系统是一种基于理论的多组分干预和系统实施过程，包括医院志愿者的作用。我们报告了 NHS 病房中 POD 的实施和提供过程，这是一项可行性研究的一部分。
方法
采用比较案例研究设计和参与式、多方法评估，进行了为期 6 个月的预备阶段和 6 个月的实施阶段。在英格兰北部的 5 家医院的 6 个病房进行了招募。方法包括：促进性研讨会；观察 POD 预备活动；对员工进行定性访谈；收集病房组织和患者概况；以及对员工工作量进行结构化观察。
结果
4 个病房全面完成了 POD 的实施和提供。在这些病房中，正常化进程理论指导的实施策略协同作用，且逐渐累积。对有风险的患者进行谵妄和预防实践的互动式员工培训计划，促进了有针对性的 POD 参与。对实践的观察与针对谵妄预防干预的行动并列，为变革创造了紧张局势，使围绕它组织工作的新方法合法化。建立使 POD 在病房环境中可行的系统、流程和文件，增强了员工的所有权。“协商性实验”使员工参与创建、评估和修改系统和实践，有助于将 POD 护理系统融入病房常规。激活这些变革机制需要一种特殊形式的领导力：积极主动的“引导者”和高级病房“促进者”，以扩大“影响力”至员工群体。组织不连续性（即病房重新定位和重新设计）中断并延长了 POD 的实施；员工短缺对员工投入 POD 的能力产生了不利影响。研究结果导致制定了“现场准备”标准，如果没有这些标准，实施这种复杂的干预措施是不可能的。
结论
POD 在 NHS 病房中的实施和提供是可行的，但成功的必要条件是“现场准备”。
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