http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(4): 345–351 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.891979
ORIGINAL ARTICLE
Interprofessional education for delirium care: a systematic review Sanjeev Sockalingam1,2, Adrienne Tan1,2, Raed Hawa1,2, Heather Pollex3, Susan Abbey1,2 and Brian David Hodges1,2 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada, 2Department of Psychiatry, University Health Network, Toronto, Ontario, Canada, and 3Education and Collaborative Academic Practice Portfolio, University Health Network, Toronto, Ontario, Canada
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1
Abstract
Keywords
Recent delirium prevention and treatment guidelines recommend the use of an interprofessional team trained and competent in delirium care. We conducted a systematic review to identify the evidence for the value of interprofessional delirium education programs on learning outcomes. We searched several databases and the grey literature. Studies describing an education intervention, involving two or more healthcare professions and reporting on at least one learning outcome as classified by Kirkpatrick’s evaluation framework were included in this review. Ten out of 633 abstracts reviewed met the study inclusion criteria. Several studies reported on more than one learning outcome. Two studies focused on learner reactions to interprofessional delirium education; three studies focused on learning outcomes (e.g. delirium knowledge); six studies focused on learner behavior in practice; and six studies reported on learning results (e.g. patient outcomes), mainly changes in delirium rates postintervention. Studies reporting changes in patient outcomes following the delirium education intervention used an interprofessional practice (IPP) intervention in combination with interprofessional education (IPE). Our review of the limited evidence suggests that IPE programs may influence team and patient outcomes in delirium care. More systematic studies of the effectiveness of interprofessional delirium education interventions are needed.
Interprofessional care, interprofessional education, interprofessional outcomes, systematic review
Introduction Delirium is a common condition in acute care settings and is associated with significant rates of morbidity and mortality (McCusker, Cole, Abrahamowicz, Primeau, & Belzile, 2002). The prevalence of delirium ranges from 6 to 56% in hospital settings, with higher rates in elderly patients and patients with acute medical illnesses (Fong, Tulebaev, & Inouye, 2009). In the United States, delirium has increased healthcare costs by $2500 per patient and, as a result, delirium is now considered a quality indicator of inpatient care (Inouye, 2006). The management of delirium can be complex, requiring the collective expertise of multiple health professionals (Teodorczuk, Reynish, & Milisen, 2012). In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) has published guidelines for delirium care (O’Mahony, Murthy, Akunne, & Young, 2011), which states that treatment of delirium should include a multidisciplinary intervention delivered by a team of healthcare professionals trained and competent in delirium prevention and management. As a result, effective interprofessional education (IPE) and training programs for delirium care are needed to improve team competency in this area. Several studies have shown gaps in healthcare professionals’ knowledge, skills and comfort regarding management of delirium, including inconsistent use of delirium screening instruments
Correspondence: Sanjeev Sockalingam, MD, FRCPC, Department of Psychiatry, University of Toronto, Toronto General Hospital, 200 Elizabeth St, 8EN-228, Toronto, Ontario, M5G 2C4, Canada. E-mail: [email protected]
History Received 30 July 2013 Revised 14 November 2013 Accepted 4 February 2014 Published online 4 March 2014
and poor adherence to delirium management protocols (Ely et al., 2004; Patel et al., 2009). These gaps could and have been addressed by multi-faceted education programs targeting specific healthcare professions caring for delirious patients, most commonly nurses (Gesin et al., 2012; Wand, 2011). Effective education interventions to enhance delirium management should go beyond uniprofessional education and instead include multiple health professions that learn with and from one another (Brajtman, Higuchi, & McPherson, 2006). The concept of ‘‘multidisciplinary’’ and ‘‘interdisciplinary’’ care has evolved over the past decade to also include ‘‘interprofessional care’’ or ‘‘interprofessional collaborative practice’’. Whilst the term ‘‘interprofessional’’ emphasizes the different professions involved in care, the term interdisciplinary focuses on various disciplines within each profession (e.g. psychiatry, nephrology, internal medicine). The addition of these terms reflect growing evidence for the positive impact of interprofessional as well as interdisciplinary collaborative practice interventions on team performance (Hall & Weaver, 2001) and patient care (Reeves et al., 2010). This shift is particularly salient in delirium care settings, given the range of healthcare professionals and disciplines involved in the care of delirious patients in hospitals. It is important to further clarify the definition of interprofessional collaboration and education to determine the impact of IPE interventions on delirium outcomes. Reeves et al. (2011) use three dimensions in their framework for interprofessional interventions: ‘‘IPE’’, ‘‘interprofessional practice (IPP)’’ and ‘‘interprofessional organization (IPO)’’. IPE interventions are defined as education programs that foster interactive learning
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between individuals and groups in two or more professions with the goal of improving collaboration and the quality of care. IPP interventions focus on improving the quality of care by incorporating interprofessional activities or procedures into clinical practice. IPO interventions focus on organizational changes, such as workspace changes, to foster interprofessional care, and in turn to enhance patient care. Those who design educational programs for improving delirium care should consider the impact of all three types of interprofessional interventions on patient outcomes. Two previously published reviews have focused on the effect of delirium education on learner and patient outcomes. Wand (2011) reviewed 19 studies which showed that interventions using complex, multi-modal instructional strategies, such as a nurse reinforcing formal teaching, in practice, in addition to seminars and workshops, had the greatest effect on patient outcomes. Her review did not include the grey literature. She classified study outcomes using a continuing medical education framework that may not apply across all health professions. Teodorczuk, Welfare, Corbett, and Mukaetova-Ladinska (2010) reviewed 13 experimental studies focused on education interventions for managing ‘‘confused’’ (i.e. delirious or demented) elderly patients in acute care hospital settings and found that eight studies showed changes in health outcomes related to delirium. Their paper was neither a systematic review nor exclusive to delirium and was limited to geriatric patients. Although their review reported that eight of the 13 studies had an interprofessional focus, the type of interprofessional intervention and the impact on interprofessional outcomes was not distinguished or discussed. Furthermore, neither Ward nor Teodorczuk specifically distinguished between uniprofessional and interprofessional interventions in their analysis of outcomes. To determine the effect of IPE interventions on delirium care, we conducted a systematic review of all education intervention studies that assessed the efficacy of education interventions on learner and patient outcomes. Based on previously published reviews, it was hypothesized that IPP interventions would result in achievement of the highest level of educational effectiveness, namely improvements in patient health status as demonstrated by a decrease in the prevalence of delirium and related problems.
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different healthcare professionals participating in the education intervention together. Third, the studies had to include clearly defined learner outcomes. We excluded studies if they failed to provide a sufficient description of the education intervention, specifically the type of education intervention, the participants and frequency or duration of the education intervention. We classified outcomes using Kirkpatrick’s (1996) four-level model for evaluation of educational interventions (expanded by Barr and colleagues (2005) at levels 2 and 4): Level 1 – Participants’ reaction (satisfaction) Level 2 – Participants’ learning, assessed in tests (2a – changes in perceptions and attitudes; 2b – changes in knowledge and/or skills) Level 3 – Behavioral change: participants’ performance in practice Level 4 – Results (4a – Changes in organizational practice; 4b – Benefits to patients) Analysis Two researchers (SS, AT) independently reviewed abstracts and used the study inclusion and exclusion criteria to determine if the full article would be read. A total of 633 articles were identified from the initial database search. A total 601 articles did not satisfy the inclusion criteria or were duplicate studies and were excluded from the review. The remaining 32 articles were reviewed in greater detail by the two researchers to determine if they clearly met inclusion criteria. Of the 32 articles, 22 were excluded for the following reasons: uniprofessional focus (n ¼ 9); poorly defined education intervention (n ¼ 8); lack of learner specific outcomes (n ¼ 3); and did not focus specifically on delirium (n ¼ 2). A total of 10 studies fully met the inclusion criteria (Figure 1). A single researcher (SS) extracted and entered the data on a computerized spreadsheet from the 10 studies, with one study per row. Data extraction included study design, participant information, study setting, program or course details, and learner outcomes. Using Reeves’ interprofessional framework, education interventions were coded as an IPE, IPP and IPO intervention (Reeves et al., 2011). The data from the studies were summarized 633 Abstracts for Review
Methods We searched for English language studies in five databases (Medline, PsychINFO, EMBASE, Web of Science and ERIC) using the following search terms: delirium, education and interprofessional. The five databases were selected based upon their medical, psychological, education (i.e. ERIC) and multidisciplinary (Web of Science) focus, which encompass aspects of delirium care and training. Each database was searched for studies published between 1965 and 1 March 2013. In addition, we searched MedEdPortal and Best Evidence in Medical Education (BEME) Reviews, and reference lists from delirium education review articles for interprofessional curricula related to delirium prevention and management. Finally, 12 websites from delirium societies and organizations, including Critical Care Medicine societies and Psychiatry organizations, were searched for additional references related to delirium education.
601 Abstracts Excluded Duplicate Abstracts or Not Relevant
32 Arcles for Review
22 Excluded Arcles 9 Uniprofessional 8 Poorly definned educaon intervenon 3 No learner outcomes idenfed 2 Not delirium specific
Study inclusion criteria We used three inclusion criteria, all including delirium as a major focus of the education intervention. First, we included studies describing a program or course related to delirium care education. Second, studies had to include two or more
10 Studies Included in Review
Figure 1. PRISMA flow diagram.
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in the text and tables, and descriptive statistics were used in the summary where appropriate.
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Results The results regarding study designs and participants will be presented first, followed by a description and classification of the IPE interventions and a summary of the impact of delirium education interventions using Kirkpatrick’s evaluation framework. Four studies were cohort studies (Brajtman et al., 2008; Naughton et al., 2005; Speciale, Bellelli, & Trabucchi, 2005; Wong Tin Niam, Bruce, & Bruce, 2005), four were case-control studies (Lundstrom et al., 2005; Mudge, Maussen, Duncan, & Denaro, 2012; Tabet et al., 2005; Vidan et al., 2009), one was a post-intervention survey study without a comparison group (Ramaswamy et al., 2011), and one was a quasi-experimental study (Brajtman, Wright, Hall, Bush, & Bekele, 2012) (see Table I, column 2 for details). Five studies were conducted in inpatient geriatric settings (Lundstrom et al., 2005; Naughton et al., 2005; Ramaswamy et al., 2011; Speciale et al., 2005; Vidan et al., 2009), with one of these studies also involving healthcare professionals from the emergency department (Naughton et al., 2005) (see Table I, column 4). Two studies were conducted in a medical ward, two in a palliative care setting and one in an orthopedic setting. Regarding the mix of professions, four studies were conducted with two healthcare professions (Lundstrom et al., 2005; Naughton et al., 2005; Tabet et al., 2005; Vidan et al., 2009). The number of healthcare professions participating in the delirium education program for the remaining six studies ranged from three (Speciale et al., 2005; Wong Tin Niam et al., 2005) to 11, with trainees considered as one healthcare profession (Ramaswamy et al., 2011). The most frequently represented healthcare professionals in the 10 studies were staff nurses (n ¼ 9) and physicians (n ¼ 9). Other healthcare professionals included dietitians (n ¼ 1), nurse managers (n ¼ 2), nurse assistants (n ¼ 1), chaplains (n ¼ 1), pharmacists (n ¼ 2) and physiotherapists (n ¼ 2) (see Table I, column 3). One study (Brajtman et al., 2012) did not specify the types of caregivers in the palliative care setting participating in the delirium education intervention but provided details about the comprehensive interprofessional approach to delirium care education used in their setting. Four studies provided specific details on the number of participants in the education program, ranging from 10 to 119 (Brajtman et al., 2008, 2012; Naughton et al., 2005; Ramaswamy et al., 2011). The education interventions and outcomes varied across studies. All 10 studies reported use of a lecture, either in combination with other instructional methods or as the sole instructional method (see Table I, column 5). Other instructional methods included small-group sessions (Brajtman et al., 2008; Naughton et al., 2005; Ramaswamy et al., 2011; Tabet et al., 2005), self-learning modules (Brajtman et al., 2012), team objective-structured clinical encounters (TOSCEs) (an instructional and assessment method used to improve and to assess teams’ IP collaborative performance) (Brajtman et al., 2008), and workshops (Naughton et al., 2005). Four studies reported distribution of educational materials to participants, such as patient brochures (Mudge et al., 2012), delirium guidelines (Tabet et al., 2005), delirium cards (Vidan et al., 2009), delirium education packages (Mudge et al., 2012; Ramaswamy et al., 2011; Tabet et al., 2005), and delirium posters for the nursing station (Vidan et al., 2009). Using Reeves and colleagues’ (2011) interprofessional classification, all 10 studies had an IPE component, that is, interactive learning between practitioners in two or more professions to
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improve team collaboration and/or the quality of delirium care. Seven studies had IPP components including: training support by a designated delirium specialist for participating teams (Tabet et al., 2005); reorganization of delirium care in order to provide more individualized patient-centered care (Lundstrom et al., 2005); implementation of delirium prevention and management guideline-based protocols (Mudge et al., 2012; Naughton et al., 2005; Tabet et al., 2005; Vidan et al., 2009); use of delirium care checklists reviewed by a dedicated project team (Wong Tin Niam et al., 2005); use of a patient care coordinator (Vidan et al., 2009) and adoption of specific delirium assessment tools for all patients (Speciale et al., 2005). Ramaswamy and colleagues used an IPO approach, in combination with IPE, for the adoption of mandatory delirium education for department directors, who then supported participation of their clinical team members in the education program (Ramaswamy et al., 2011). In this study, the delirium education intervention involved hospital administrators, departmental leaders, clinical and volunteer staff, and the hospital’s quality group. Learner outcomes spanned the four evaluation levels in the Barr–Kirkpatrick framework (Barr et al., 2005; Kirkpatrick, 1996) (Table II). Two studies reported learner reactions (Level 1), including one study using the ‘‘W(e) Learn’’ scale to measure overall satisfaction (Brajtman et al., 2012) and a second study using a survey showing high satisfaction with the overall educational activity (79% rating of the activity as ‘‘excellent’’ and 21% as ‘‘good’’) (Ramaswamy et al., 2011). Three studies with different study designs focused on learning outcomes (Level 2), specifically delirium knowledge (Level 2b) (Table II). Of these three studies, one cohort study showed an improvement in scores on the Interprofessional Delirium Knowledge Test (Brajtman et al., 2008). A second study, a survey study, showed an improvement in delirium knowledge test scores for participants who attended two or more education sessions (Ramaswamy et al., 2011). The third study, a quasi-experimental study, examined the effect of a self-learning module on delirium knowledge and showed no difference between the group that used the self-learning module versus the group that did not (Brajtman et al., 2012). In this latter study, both groups still received delirium education via TOSCEs and a brief didactic session providing background information on delirium care. No studies examined learner attitudes or perceptions (Level 2a). Six studies examined the effect of the educational interventions on learner behaviors in practice (Level 3) (Table II). Two of these studies showed an increase in specific team performance scales (the Interprofessional Collaborative Competencies Attainment Survey and the Interprofessional Team Performance Scale) following the delirium education intervention (Brajtman et al., 2008, 2012). Improvements in delirium detection and documentation were reported in two of these studies (Speciale et al., 2005; Tabet et al., 2005). One of these studies showed a higher diagnosis and documentation rate of delirium in the intervention ward compared with a control (non-intervention) ward (67 versus 23%, p50.01) (Tabet et al., 2005). In a second study, Speciale et al. (2005) focused primarily on delirium screening and assessment, showing an increased rate of delirium detection after the education intervention. Level 3 effects also included a reduction in the use of deliriogenic medications (i.e. opiates, benzodiazepines, antihistamines) (Naughton et al., 2005) and an increase in referral rate to the inpatient geriatric psychiatry consultation service (Mudge et al., 2012). There were six total studies that focused on Level 4 outcomes with three studies examining organizational benefit (Level 4a) and five studies examining patient outcomes. Two studies examined Level 4a outcomes. One prospective case-control study in a geriatric setting (Vidan et al., 2009) showed a change in the
Prospective case control
Cohort
Prospective casecontrol
Cohort
Cohort
Cohort
Prospective casecontrol
Cross-sectional survey
Naughton et al. (2005)
Tabet et al. (2005)
Wong et al. (2005)
Speciale et al. (2005)
Brajtman (2008)
Vidan et al. (2009)
Ramaswamy et al. (2011)
Type of study
Lundstrom et al. (2005)
Study
Geriatric
Geriatric
Palliative care
Geriatric
Orthopedic (hip fracture)
Medical wards
Emergency Department and Geriatric
Geriatric
Setting
Four session presentation series, small interactive group session, practical case conferences.
Delirium education session. Poster in nursing station and cards with delirium prevention recommendations. Dedicated geriatric nurse supporting intervention.
Delirium education sessions (4 h/10 weeks) and introduction of delirium treatment strategies with checklists and project team support. Four month delirium training program with focus on delirium assessment. Three interactive one hour sessions (case study, discussions, presentation).
Two-day course focusing on delirium care. Reorganization of care to focus on more individualized care. Small group learning, grand rounds, eight hour workshop. Reminders for delirium screening embedded in charting and triaging procedures. One-hour formal presentation with small group discussions. Guideline dissemination.
Education intervention
Level 3: Increased documentation of delirium by physicians in medical charts. Level 4b: Lower point prevalence of delirium compared to pre-intervention group (OR ¼ 0.45). Level 4b: Reduction in the rates of delirium post-intervention (37.5 versus 12.7%).
IPE, IPP
Level 2b: Greater interprofessional delirium knowledge test scores post-intervention. Level 3: Self-reported improvement in team performance following intervention. Level 4a: Increased use of specific delirium preventative interventions (i.e. limiting physical restraints, use of glasses and audiophone, mobilization, minimizing drug administration while asleep). Level 4b Lower rates of delirium in the intervention group (11.7 versus 18.5%). Level 1: High attendee satisfaction with education activity (79% rated as excellent). Level 2b: Improved delirium knowledge test scores for those attending 2 sessions (3.8 versus 2.9 test score change).
IPE
IPE, IPO
IPE, IPP
Level 3: Increased detection of delirium post-intervention.
IPE, IPP
IPE, IPP
Level 3: Reduced benzodiazepine, antihistamine and opiate use after intervention. Level 4b: Reduction in the prevalence of delirium (40.9 versus. 19.1% at 9-months) post-intervention.
IPE, IPP
Outcomes (Kirkpatrick levels) Level 4b: Lower rates of delirium in intervention group after seven days. No difference in independent living.
IPE, IPP
IP component
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Physician (18), nurses (58), staff from other departments or disciplines* (24), trainees (19)
Nurses and geriatricians*
Physicians (2), medical student (1), nurses (3), dietitians (1), pharmacist (1), chaplain (1), volunteer (1)
Physicians, physiotherapists, nurses*
Physicians (mainly interns), allied health professionals, nurses*
Nurses and physicians*
Nurses (67) and physicians (25)
Nurses and physicians*
Participants (n)
Table I. Summary data from the 10 studies analyzed.
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IPE for delirium
n ¼ number of healthcare professionals; IPE – Interprofessional Education; IPP – Interprofessional Practice; IPO – Interprofessional Organization. *Staff from other departments included hospital administrators, pharmacists, social workers, volunteers, laboratory personnel, radiology technicians, nutritionists, physical therapists.
IPE Self-learning modules, brief presentation sessions and team objective structured clinical encounters (TOSCEs). Quasiexperimental Brajtman et al. (2012)
Caregivers from a hospice and long-term care facility (22)
Palliative care
IPE, IPP Education sessions reinforcing guidelines, education materials, one-onone training and monthly case-based learning, patient brochures. General medical Physicians, nurses, nurse managers, nursing assistant, volunteers* Prospective casecontrol Mudge et al. (2012)
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Level 3: Increased geriatric psychiatry consults in intervention group. Level 4a: No change in 1-to-1 nursing care needs. Reduction in the number of patients discharged delirious in intervention group (32 versus 71%). Level 1: High satisfaction with participation in an interprofessional activity for intervention group. Level 2b: No difference in end-of-life delirium knowledge test. Level 3: Self-reported improvement in collaborative competencies for intervention group.
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hospital unit’s use of preventative interventions for delirium, specifically early mobilization, reduced use of restraints, and increased use of audiophone and glasses, after exposure to the education intervention (Level 4a). Another study showed a reduction in the number of patients discharged home who were still delirious (Mudge et al., 2012), but did not show a decrease in one-to-one nursing care needs following the delirium education intervention. Five out of six studies reported on patient care results (Level 4b) and showed a reduction in delirium rates (Lundstrom et al., 2005; Naughton et al., 2005; Tabet et al., 2005; Vidan et al., 2009; Wong Tin Niam et al., 2005) (Table II). The five studies reporting on the rate of delirium as an education outcome used validated measures for delirium detection, namely the Confusion Assessment Method (n ¼ 4) (Inouye et al., 1990) and a modified version of the Organic Brain Syndrome Scale (n ¼ 1) (Jensen, Delhin, & Gustafson, 1993). The study that did not use a validated delirium detection tool relied on the assessment of a single psychiatrist to determine the presence of delirium (Tabet et al., 2005).
Discussion All 10 of the studies reviewed used IPE interventions with either a didactic or interactive presentation component. Studies using an IPE approach alone reported only changes in learner reaction (Level 1) and delirium knowledge (Level 2b). The evidence from the 10 studies reviewed suggests that a combined IPE and IPP (or IPO) approach to delirium education can result in higher order education outcomes, that is, changes in team behaviors in clinical settings (e.g. delirium documentation and team performance) and improved patient outcomes (e.g. rates of delirium detection). Wand (2011) in her review used a continuing medical education (CME) framework (Davis, Thomson, Oxman, & Haynes, 1992), focused on predisposing (e.g. information dissemination, didactic teaching), enabling (e.g. use of protocols) and reinforcing factors (e.g. feedback from peers or experts) to classify delirium training studies. She found that educational interventions that included enabling factors (i.e. providing guidelines or resources) or reinforcing interventions (i.e. delirium expert feedback or reminders) had a greater impact on patient outcomes. We also found in our review of interprofessional interventions that higher-level educational outcomes (i.e. Level 3 and Level 4) are most likely to be associated with interventions that integrate interactive instructional methods and practice-based interventions that are consistent with enabling and reinforcing strategies. In our review, many IPP interventions could be classified as using enabling or reinforcing factors, given Davis et al.’s CME framework (Davis et al., 1992). For example, IPP delirium education interventions that used enabling factors included the following: dissemination of guidelines (Mudge et al., 2012; Tabet et al., 2005) and use of delirium care posters or cards (Vidan et al., 2009). In addition, IPP interventions in our review included the following reinforcing factors: one-on-one case discussions with a designated delirium resource nurse or physician (Mudge et al., 2012; Vidan et al., 2009; Wong Tin Niam et al., 2005), charting procedure modifications to enhance Emergency Department delirium screening (Naughton et al., 2005), and reorganization of patient flow to allow nurses to provide more patient-centered care or individualized care (Lundstrom et al., 2005). The use of a delirium resource person for case discussions resulted in changes in organizational practice in two studies (Mudge et al., 2012; Vidan et al., 2009), namely the implementation of delirium preventative strategies and the reduction in the number of patients discharged delirious.
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Table II. Summary of delirium training programs according to Kirkpatrick’s modified outcomes typology. Kirkpatrick level Level 1: Learner Reaction Level 2: Learning (2a – Changes in perceptions and attitudes; 2b – Changes in knowledge and/or skills) Level 3: Behavior
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Level 4: Results (4a – Changes in organizational practice; 4b – benefits to patients)
Number and type of studies Quasi-experimental (n ¼ 1) Survey (n ¼ 1) Quasi-experimental (n ¼ 1) Cohort (n ¼ 1) Survey (n ¼ 1) Cohort (n ¼ 3) Prospective case-control (n ¼ 2) Quasi-experimental (n ¼ 1) Cohort (n ¼ 2) Prospective case-control (n ¼ 4)
Thus, interprofessional delirium training should benefit from using an IPP approach in addition to more traditional IPE interventions, such as workshops and didactic presentations, in order to have an impact on higher order educational outcomes (i.e. Level 3 or Level 4a/4b) affecting patient care. Although Reeves et al. (2011) indicated that IPO interventions can also improve patient outcomes, only one study (Ramaswamy et al., 2011) in our review used IPO strategies in combination with IPE interventions. In that study, the IPO intervention involved hospital leaders and clinical directors in the delirium education program and aimed to change the institutional culture regarding delirium care. Further research is needed to determine the specific effect of IPO interventions on delirium education and care. Our review identified two additional studies not previously included in prior reviews that focused exclusively on interprofessional performance and process outcomes (Brajtman et al., 2008, 2012). Nonetheless, no studies to date have examined resource implications and barriers to IPE for managing delirious patients. In their review of education interventions for confused patients, Teodorczuk et al. (2010) recommend an onsite education approach to improve education outcomes; however, it is unclear as to whether barriers to IPE, such as resources, time and availability, will thwart the widespread implementation of interprofessional delirium education programs from moving forward. Higher patient workloads on hospital units may compromise team flexibility to train together in these clinical settings. Qualitative studies exploring perceived barriers and resource implications for IPE programs in delirium care could provide greater insights into how to address these challenges. The limitations of our study included the following. Our review included only 10 studies with very different study designs and outcomes, thus preventing us from doing a meta-analysis. The lack of controlled trials and qualitative studies on interprofessional delirium education programs limits our understanding of the effectiveness of such programs in relation to learning outcomes. Thus, we could not determine if the reported effect of the delirium education intervention on learner and patient outcomes were due to the intensity of the IPE intervention, the type of IPE intervention or a result of the institution’s readiness for adopting change during the delivery of the intervention. Second, as with any systematic review, we searched only published studies and studies in the grey literature. Our results may reflect a publication bias, as negative studies for delirium education interventions are less likely to be published. Lastly, only two studies examined the impact of interprofessional delirium education programs on team processes using team
Outcomes Perceived satisfaction with delirium IPE intervention (n ¼ 2) Increase in delirium knowledge (n ¼ 2) (Level 2b) No change in delirium knowledge (n ¼ 1) (Level 2b) Self-reported increase in team competence and performance (n ¼ 2) Increased delirium documentation and detection (n ¼ 2) Reduction in deliriogenic medication use (n ¼ 1) Increased geriatric psychiatry consultation (n ¼ 1) Implementation of specific delirium preventative interventions (Level 4a) No change to nursing 1-to-1 care needs (Level 4a) Reduction in rates of patients discharged delirious (n ¼ 1) (Level 4a) Reduction in rates of delirium post-intervention (n ¼ 5) (Level 4b)
performance measures. For the remaining studies, it was difficult to quantify the degree of IPE (i.e. focus on collaboration) in each intervention. In summary, this review of the literature on IPE programs for delirium care offers new insights into education approaches to increase healthcare providers’ competence in caring for patients with delirium. The importance of an interprofessional approach to delirium care has been highlighted in recent delirium guidelines and our review suggests that combined IPE and IPP interventions can potentially impact delirious patient outcomes, mainly reducing rates of delirium post-intervention. In addition, our review provided new evidence that IPE interventions in delirium prevention and management can also improve team performance and collaborative competency in managing delirious patients, outcomes that have not been previously reported in delirium education reviews. The lack of randomized controlled trials (RCTs) and qualitative studies on interprofessional delirium education interventions preclude us from making more conclusive recommendations. More systematic studies are needed to clarify the effectiveness of specific kinds of interprofessional delirium education interventions, where limited and specific types of interventions are systematically compared. As described by Cook, Bordage, and Schmidt (2008), ‘‘such research will deepen our understanding and advance the art and science of medical education’’. These types of studies require a program of research rather than opportunistic one-time studies. Until more robust evidence is available, our review provides an updated summary of the emerging interprofessional delirium education literature and provides readers with a preliminary understanding of the evidence for delirium IPE interventions on learning and clinical outcomes.
Acknowledgements We would like to thank Dr Georges Bordage and Dr Ilene Harris for their thoughtful feedback on previous iterations of this manuscript. We would also like to thank Dr Meenakshy Aiyer for her helpful comments during manuscript preparation.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the writing and contents of this paper.
References Barr, H., Koppel, I., Reeves, S., Hammick, M., & Freeth, D. (2005). Effective interprofessional education: Argument, assumption and evidence. Oxford: Blackwell.
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Brajtman, S., Hall, P., Weaver, L., Higuchi, K., Allard, P., & Mullins, D. (2008). An interprofessional educational intervention on delirium for health care teams: Providing opportunities to enhance collaboration. Journal of Interprofessional Care, 22, 658–660. Brajtman, S., Higuchi, K., & McPherson, C. (2006). Caring for patients with terminal delirium: Palliative care unit and home care nurses’ experiences. International Journal of Palliative Nursing, 12, 150–156. Brajtman, S., Wright, D., Hall, P., Bush, S.H., & Bekele, E. (2012). Toward better care of delirious patients at the end of life: A pilot study of an interprofessional educational intervention. Journal of Interprof Care, 26, 422–425. Cook, D.A., Bordage, G., & Schmidt, H.G. (2008). Description, justification and clarification: A framework for classifying the purposes of research in medical education. Medical Education, 42, 128–133. Davis, D.A., Thomson, M.A., Oxman, A.D., & Haynes, R.B. (1992). Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA: The Journal of the American Medical Association, 268, 1111–1117. Ely, E.W., Stephens, R.K., Jackson, J.C., Thomason, J.W., Truman, B., Gordon, S., Dittus, R.S., & Bernard, G.R. (2004). Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: A survey of 912 healthcare professionals. Critical Care Medicine, 32, 106–112. Fong, T.G., Tulebaev, S.R., & Inouye, S.K. (2009). Delirium in elderly adults: Diagnosis, prevention and treatment. Nature Reviews Neurology, 5, 210–220. Gesin, G., Russell, B.B., Lin, A.P., Norton, H.J., Evans, S.L., & Devlin, J.W. (2012). Impact of a delirium screening tool and multifaceted education on nurses’ knowledge of delirium and ability to evaluate it correctly. American Journal of Critical Care, 21, e1–e11. Hall, P., & Weaver, L. (2001). Interdisciplinary education and teamwork: A long and winding road. Medical Education, 35, 867–875. Inouye, S.K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157–1165. Inouye, S.K., Van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P., & Horwitz, R.I. (1990). Clarifying confusion: The Confusion assessment method. Annals of Internal Medicine, 113, 941–948. Jensen, E., Delhin, O., & Gustafson, L.A. (1993). A comparison between three psychogeriatric rating scales. International Journal of Geriatric Psychiatry, 8, 215–229. Kirkpatrick, D.L. (1996). Evaluation of training. In R.L. Craig (Ed.), Training and development handbook (2nd ed., pp. 294–312). New York: McGraw-Hill. Lundstrom, M., Edlund, A., Karlsson, S., Brannstrom, B., Bucht, G., & Gustafson, Y. (2005). A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. Journal of the American Geriatric Society, 53, 622–628. McCusker, J., Cole, M., Abrahamowicz, M., Primeau, F., & Belzile, E. (2002). Delirium predicts 12-month mortality. Archives of Internal Medicine, 162, 457–463.
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Mudge, A.M., Maussen, C., Duncan, J., & Denaro, C.P. (2012). Improving quality of delirium care in a general medical service with established interdisciplinary care: A controlled trial. Internal Medicine Journal, 43, 270–277. Naughton, B.J., Saltzman, S., Ramadan, F., Chadha, N., Priore, R., & Mylotte, J.M. (2005). A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. Journal of the American Geriatric Society, 53, 18–23. O’Mahony, R., Murthy, L., Akunne, A., & Young, J. (2011). Synopsis of the National Institute for Health and Clinical Excellence guideline for prevention of delirium. Annals of Internal Medicine, 154, 746–751. Patel, R.P., Gambrell, M., Speroff, T., Scott, T.A., Pun, B.T., Okahashi, J., Strength, C., et al. (2009). Delirium and sedation in the intensive care unit: Survey of behaviors and attitudes of 1384 healthcare professionals. Critical Care Medicine, 37, 825–832. Ramaswamy, R., Dix, E.F., Drew, J.E., Diamond, J.J., Inouye, S.K., & Roehl, B.J.O. (2011). Beyond grand rounds: A comprehensive and sequential intervention to improve identification of delirium. Gerontologist, 51, 122–131. Reeves, S., Goldman, J., Gilbert, J., Tepper, J., Silver, I., Suter, E., & Zwarenstein, M. (2011). A scoping review to improve conceptual clarity of interprofessional interventions. Journal of Interprofessional Care, 25, 167–174. Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Koppel, I., & Hammick, M. (2010). The effectiveness of interprofessional education: Key findings from a new systematic review. Journal of Interprofessional Care, 24, 230–241. Speciale, S., Bellelli, G., & Trabucchi, M. (2005). Staff training and use of specific protocols for delirium management. Journal of the American Geriatric Society, 53, 1445–1446. Tabet, N., Hudson, S., Sweeney, V., Sauer, J., Bryant, C., Macdonald, A., & Howard, R. (2005). An educational intervention can prevent delirium on acute medical wards. Age and Ageing, 34, 152–156. Teodorczuk, A., Reynish, E., & Milisen, K. (2012). Improving recognition of delirium in clinical practice: A call for action. BMC Geriatrics, 12, 55. Teodorczuk, A., Welfare, M., Corbett, S., & Mukaetova-Ladinska, E. (2010). Developing effective educational approaches for Liaison Old Age Psychiatry teams: A literature review of the learning needs of hospital staff in relation to managing the confused older patient. International Psychogeriatrics, 22, 874–885. Vidan, M.T., Sanchez, E., Alonso, M., Montero, B., Ortiz, J., & Serra, J.A. (2009). An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. Journal of the American Geriatric Society, 57, 2029–2036. Wand, A.P. (2011). Evaluating the effectiveness of educational interventions to prevent delirium. Australasian Journal on Ageing, 30, 175–185. Wong Tin Niam, D.M., Bruce, J.J., & Bruce, D.G. (2005). Quality project to prevent delirium after hip fracture. Australasian Journal on Ageing, 24, 174–177.
ORIGINAL ARTICLE
Interprofessional education for delirium care: a systematic review Sanjeev Sockalingam1,2, Adrienne Tan1,2, Raed Hawa1,2, Heather Pollex3, Susan Abbey1,2 and Brian David Hodges1,2 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada, 2Department of Psychiatry, University Health Network, Toronto, Ontario, Canada, and 3Education and Collaborative Academic Practice Portfolio, University Health Network, Toronto, Ontario, Canada
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Abstract
Keywords
Recent delirium prevention and treatment guidelines recommend the use of an interprofessional team trained and competent in delirium care. We conducted a systematic review to identify the evidence for the value of interprofessional delirium education programs on learning outcomes. We searched several databases and the grey literature. Studies describing an education intervention, involving two or more healthcare professions and reporting on at least one learning outcome as classified by Kirkpatrick’s evaluation framework were included in this review. Ten out of 633 abstracts reviewed met the study inclusion criteria. Several studies reported on more than one learning outcome. Two studies focused on learner reactions to interprofessional delirium education; three studies focused on learning outcomes (e.g. delirium knowledge); six studies focused on learner behavior in practice; and six studies reported on learning results (e.g. patient outcomes), mainly changes in delirium rates postintervention. Studies reporting changes in patient outcomes following the delirium education intervention used an interprofessional practice (IPP) intervention in combination with interprofessional education (IPE). Our review of the limited evidence suggests that IPE programs may influence team and patient outcomes in delirium care. More systematic studies of the effectiveness of interprofessional delirium education interventions are needed.
Interprofessional care, interprofessional education, interprofessional outcomes, systematic review
Introduction Delirium is a common condition in acute care settings and is associated with significant rates of morbidity and mortality (McCusker, Cole, Abrahamowicz, Primeau, & Belzile, 2002). The prevalence of delirium ranges from 6 to 56% in hospital settings, with higher rates in elderly patients and patients with acute medical illnesses (Fong, Tulebaev, & Inouye, 2009). In the United States, delirium has increased healthcare costs by $2500 per patient and, as a result, delirium is now considered a quality indicator of inpatient care (Inouye, 2006). The management of delirium can be complex, requiring the collective expertise of multiple health professionals (Teodorczuk, Reynish, & Milisen, 2012). In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) has published guidelines for delirium care (O’Mahony, Murthy, Akunne, & Young, 2011), which states that treatment of delirium should include a multidisciplinary intervention delivered by a team of healthcare professionals trained and competent in delirium prevention and management. As a result, effective interprofessional education (IPE) and training programs for delirium care are needed to improve team competency in this area. Several studies have shown gaps in healthcare professionals’ knowledge, skills and comfort regarding management of delirium, including inconsistent use of delirium screening instruments
Correspondence: Sanjeev Sockalingam, MD, FRCPC, Department of Psychiatry, University of Toronto, Toronto General Hospital, 200 Elizabeth St, 8EN-228, Toronto, Ontario, M5G 2C4, Canada. E-mail: [email protected]
History Received 30 July 2013 Revised 14 November 2013 Accepted 4 February 2014 Published online 4 March 2014
and poor adherence to delirium management protocols (Ely et al., 2004; Patel et al., 2009). These gaps could and have been addressed by multi-faceted education programs targeting specific healthcare professions caring for delirious patients, most commonly nurses (Gesin et al., 2012; Wand, 2011). Effective education interventions to enhance delirium management should go beyond uniprofessional education and instead include multiple health professions that learn with and from one another (Brajtman, Higuchi, & McPherson, 2006). The concept of ‘‘multidisciplinary’’ and ‘‘interdisciplinary’’ care has evolved over the past decade to also include ‘‘interprofessional care’’ or ‘‘interprofessional collaborative practice’’. Whilst the term ‘‘interprofessional’’ emphasizes the different professions involved in care, the term interdisciplinary focuses on various disciplines within each profession (e.g. psychiatry, nephrology, internal medicine). The addition of these terms reflect growing evidence for the positive impact of interprofessional as well as interdisciplinary collaborative practice interventions on team performance (Hall & Weaver, 2001) and patient care (Reeves et al., 2010). This shift is particularly salient in delirium care settings, given the range of healthcare professionals and disciplines involved in the care of delirious patients in hospitals. It is important to further clarify the definition of interprofessional collaboration and education to determine the impact of IPE interventions on delirium outcomes. Reeves et al. (2011) use three dimensions in their framework for interprofessional interventions: ‘‘IPE’’, ‘‘interprofessional practice (IPP)’’ and ‘‘interprofessional organization (IPO)’’. IPE interventions are defined as education programs that foster interactive learning
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between individuals and groups in two or more professions with the goal of improving collaboration and the quality of care. IPP interventions focus on improving the quality of care by incorporating interprofessional activities or procedures into clinical practice. IPO interventions focus on organizational changes, such as workspace changes, to foster interprofessional care, and in turn to enhance patient care. Those who design educational programs for improving delirium care should consider the impact of all three types of interprofessional interventions on patient outcomes. Two previously published reviews have focused on the effect of delirium education on learner and patient outcomes. Wand (2011) reviewed 19 studies which showed that interventions using complex, multi-modal instructional strategies, such as a nurse reinforcing formal teaching, in practice, in addition to seminars and workshops, had the greatest effect on patient outcomes. Her review did not include the grey literature. She classified study outcomes using a continuing medical education framework that may not apply across all health professions. Teodorczuk, Welfare, Corbett, and Mukaetova-Ladinska (2010) reviewed 13 experimental studies focused on education interventions for managing ‘‘confused’’ (i.e. delirious or demented) elderly patients in acute care hospital settings and found that eight studies showed changes in health outcomes related to delirium. Their paper was neither a systematic review nor exclusive to delirium and was limited to geriatric patients. Although their review reported that eight of the 13 studies had an interprofessional focus, the type of interprofessional intervention and the impact on interprofessional outcomes was not distinguished or discussed. Furthermore, neither Ward nor Teodorczuk specifically distinguished between uniprofessional and interprofessional interventions in their analysis of outcomes. To determine the effect of IPE interventions on delirium care, we conducted a systematic review of all education intervention studies that assessed the efficacy of education interventions on learner and patient outcomes. Based on previously published reviews, it was hypothesized that IPP interventions would result in achievement of the highest level of educational effectiveness, namely improvements in patient health status as demonstrated by a decrease in the prevalence of delirium and related problems.
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different healthcare professionals participating in the education intervention together. Third, the studies had to include clearly defined learner outcomes. We excluded studies if they failed to provide a sufficient description of the education intervention, specifically the type of education intervention, the participants and frequency or duration of the education intervention. We classified outcomes using Kirkpatrick’s (1996) four-level model for evaluation of educational interventions (expanded by Barr and colleagues (2005) at levels 2 and 4): Level 1 – Participants’ reaction (satisfaction) Level 2 – Participants’ learning, assessed in tests (2a – changes in perceptions and attitudes; 2b – changes in knowledge and/or skills) Level 3 – Behavioral change: participants’ performance in practice Level 4 – Results (4a – Changes in organizational practice; 4b – Benefits to patients) Analysis Two researchers (SS, AT) independently reviewed abstracts and used the study inclusion and exclusion criteria to determine if the full article would be read. A total of 633 articles were identified from the initial database search. A total 601 articles did not satisfy the inclusion criteria or were duplicate studies and were excluded from the review. The remaining 32 articles were reviewed in greater detail by the two researchers to determine if they clearly met inclusion criteria. Of the 32 articles, 22 were excluded for the following reasons: uniprofessional focus (n ¼ 9); poorly defined education intervention (n ¼ 8); lack of learner specific outcomes (n ¼ 3); and did not focus specifically on delirium (n ¼ 2). A total of 10 studies fully met the inclusion criteria (Figure 1). A single researcher (SS) extracted and entered the data on a computerized spreadsheet from the 10 studies, with one study per row. Data extraction included study design, participant information, study setting, program or course details, and learner outcomes. Using Reeves’ interprofessional framework, education interventions were coded as an IPE, IPP and IPO intervention (Reeves et al., 2011). The data from the studies were summarized 633 Abstracts for Review
Methods We searched for English language studies in five databases (Medline, PsychINFO, EMBASE, Web of Science and ERIC) using the following search terms: delirium, education and interprofessional. The five databases were selected based upon their medical, psychological, education (i.e. ERIC) and multidisciplinary (Web of Science) focus, which encompass aspects of delirium care and training. Each database was searched for studies published between 1965 and 1 March 2013. In addition, we searched MedEdPortal and Best Evidence in Medical Education (BEME) Reviews, and reference lists from delirium education review articles for interprofessional curricula related to delirium prevention and management. Finally, 12 websites from delirium societies and organizations, including Critical Care Medicine societies and Psychiatry organizations, were searched for additional references related to delirium education.
601 Abstracts Excluded Duplicate Abstracts or Not Relevant
32 Arcles for Review
22 Excluded Arcles 9 Uniprofessional 8 Poorly definned educaon intervenon 3 No learner outcomes idenfed 2 Not delirium specific
Study inclusion criteria We used three inclusion criteria, all including delirium as a major focus of the education intervention. First, we included studies describing a program or course related to delirium care education. Second, studies had to include two or more
10 Studies Included in Review
Figure 1. PRISMA flow diagram.
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in the text and tables, and descriptive statistics were used in the summary where appropriate.
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Results The results regarding study designs and participants will be presented first, followed by a description and classification of the IPE interventions and a summary of the impact of delirium education interventions using Kirkpatrick’s evaluation framework. Four studies were cohort studies (Brajtman et al., 2008; Naughton et al., 2005; Speciale, Bellelli, & Trabucchi, 2005; Wong Tin Niam, Bruce, & Bruce, 2005), four were case-control studies (Lundstrom et al., 2005; Mudge, Maussen, Duncan, & Denaro, 2012; Tabet et al., 2005; Vidan et al., 2009), one was a post-intervention survey study without a comparison group (Ramaswamy et al., 2011), and one was a quasi-experimental study (Brajtman, Wright, Hall, Bush, & Bekele, 2012) (see Table I, column 2 for details). Five studies were conducted in inpatient geriatric settings (Lundstrom et al., 2005; Naughton et al., 2005; Ramaswamy et al., 2011; Speciale et al., 2005; Vidan et al., 2009), with one of these studies also involving healthcare professionals from the emergency department (Naughton et al., 2005) (see Table I, column 4). Two studies were conducted in a medical ward, two in a palliative care setting and one in an orthopedic setting. Regarding the mix of professions, four studies were conducted with two healthcare professions (Lundstrom et al., 2005; Naughton et al., 2005; Tabet et al., 2005; Vidan et al., 2009). The number of healthcare professions participating in the delirium education program for the remaining six studies ranged from three (Speciale et al., 2005; Wong Tin Niam et al., 2005) to 11, with trainees considered as one healthcare profession (Ramaswamy et al., 2011). The most frequently represented healthcare professionals in the 10 studies were staff nurses (n ¼ 9) and physicians (n ¼ 9). Other healthcare professionals included dietitians (n ¼ 1), nurse managers (n ¼ 2), nurse assistants (n ¼ 1), chaplains (n ¼ 1), pharmacists (n ¼ 2) and physiotherapists (n ¼ 2) (see Table I, column 3). One study (Brajtman et al., 2012) did not specify the types of caregivers in the palliative care setting participating in the delirium education intervention but provided details about the comprehensive interprofessional approach to delirium care education used in their setting. Four studies provided specific details on the number of participants in the education program, ranging from 10 to 119 (Brajtman et al., 2008, 2012; Naughton et al., 2005; Ramaswamy et al., 2011). The education interventions and outcomes varied across studies. All 10 studies reported use of a lecture, either in combination with other instructional methods or as the sole instructional method (see Table I, column 5). Other instructional methods included small-group sessions (Brajtman et al., 2008; Naughton et al., 2005; Ramaswamy et al., 2011; Tabet et al., 2005), self-learning modules (Brajtman et al., 2012), team objective-structured clinical encounters (TOSCEs) (an instructional and assessment method used to improve and to assess teams’ IP collaborative performance) (Brajtman et al., 2008), and workshops (Naughton et al., 2005). Four studies reported distribution of educational materials to participants, such as patient brochures (Mudge et al., 2012), delirium guidelines (Tabet et al., 2005), delirium cards (Vidan et al., 2009), delirium education packages (Mudge et al., 2012; Ramaswamy et al., 2011; Tabet et al., 2005), and delirium posters for the nursing station (Vidan et al., 2009). Using Reeves and colleagues’ (2011) interprofessional classification, all 10 studies had an IPE component, that is, interactive learning between practitioners in two or more professions to
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improve team collaboration and/or the quality of delirium care. Seven studies had IPP components including: training support by a designated delirium specialist for participating teams (Tabet et al., 2005); reorganization of delirium care in order to provide more individualized patient-centered care (Lundstrom et al., 2005); implementation of delirium prevention and management guideline-based protocols (Mudge et al., 2012; Naughton et al., 2005; Tabet et al., 2005; Vidan et al., 2009); use of delirium care checklists reviewed by a dedicated project team (Wong Tin Niam et al., 2005); use of a patient care coordinator (Vidan et al., 2009) and adoption of specific delirium assessment tools for all patients (Speciale et al., 2005). Ramaswamy and colleagues used an IPO approach, in combination with IPE, for the adoption of mandatory delirium education for department directors, who then supported participation of their clinical team members in the education program (Ramaswamy et al., 2011). In this study, the delirium education intervention involved hospital administrators, departmental leaders, clinical and volunteer staff, and the hospital’s quality group. Learner outcomes spanned the four evaluation levels in the Barr–Kirkpatrick framework (Barr et al., 2005; Kirkpatrick, 1996) (Table II). Two studies reported learner reactions (Level 1), including one study using the ‘‘W(e) Learn’’ scale to measure overall satisfaction (Brajtman et al., 2012) and a second study using a survey showing high satisfaction with the overall educational activity (79% rating of the activity as ‘‘excellent’’ and 21% as ‘‘good’’) (Ramaswamy et al., 2011). Three studies with different study designs focused on learning outcomes (Level 2), specifically delirium knowledge (Level 2b) (Table II). Of these three studies, one cohort study showed an improvement in scores on the Interprofessional Delirium Knowledge Test (Brajtman et al., 2008). A second study, a survey study, showed an improvement in delirium knowledge test scores for participants who attended two or more education sessions (Ramaswamy et al., 2011). The third study, a quasi-experimental study, examined the effect of a self-learning module on delirium knowledge and showed no difference between the group that used the self-learning module versus the group that did not (Brajtman et al., 2012). In this latter study, both groups still received delirium education via TOSCEs and a brief didactic session providing background information on delirium care. No studies examined learner attitudes or perceptions (Level 2a). Six studies examined the effect of the educational interventions on learner behaviors in practice (Level 3) (Table II). Two of these studies showed an increase in specific team performance scales (the Interprofessional Collaborative Competencies Attainment Survey and the Interprofessional Team Performance Scale) following the delirium education intervention (Brajtman et al., 2008, 2012). Improvements in delirium detection and documentation were reported in two of these studies (Speciale et al., 2005; Tabet et al., 2005). One of these studies showed a higher diagnosis and documentation rate of delirium in the intervention ward compared with a control (non-intervention) ward (67 versus 23%, p50.01) (Tabet et al., 2005). In a second study, Speciale et al. (2005) focused primarily on delirium screening and assessment, showing an increased rate of delirium detection after the education intervention. Level 3 effects also included a reduction in the use of deliriogenic medications (i.e. opiates, benzodiazepines, antihistamines) (Naughton et al., 2005) and an increase in referral rate to the inpatient geriatric psychiatry consultation service (Mudge et al., 2012). There were six total studies that focused on Level 4 outcomes with three studies examining organizational benefit (Level 4a) and five studies examining patient outcomes. Two studies examined Level 4a outcomes. One prospective case-control study in a geriatric setting (Vidan et al., 2009) showed a change in the
Prospective case control
Cohort
Prospective casecontrol
Cohort
Cohort
Cohort
Prospective casecontrol
Cross-sectional survey
Naughton et al. (2005)
Tabet et al. (2005)
Wong et al. (2005)
Speciale et al. (2005)
Brajtman (2008)
Vidan et al. (2009)
Ramaswamy et al. (2011)
Type of study
Lundstrom et al. (2005)
Study
Geriatric
Geriatric
Palliative care
Geriatric
Orthopedic (hip fracture)
Medical wards
Emergency Department and Geriatric
Geriatric
Setting
Four session presentation series, small interactive group session, practical case conferences.
Delirium education session. Poster in nursing station and cards with delirium prevention recommendations. Dedicated geriatric nurse supporting intervention.
Delirium education sessions (4 h/10 weeks) and introduction of delirium treatment strategies with checklists and project team support. Four month delirium training program with focus on delirium assessment. Three interactive one hour sessions (case study, discussions, presentation).
Two-day course focusing on delirium care. Reorganization of care to focus on more individualized care. Small group learning, grand rounds, eight hour workshop. Reminders for delirium screening embedded in charting and triaging procedures. One-hour formal presentation with small group discussions. Guideline dissemination.
Education intervention
Level 3: Increased documentation of delirium by physicians in medical charts. Level 4b: Lower point prevalence of delirium compared to pre-intervention group (OR ¼ 0.45). Level 4b: Reduction in the rates of delirium post-intervention (37.5 versus 12.7%).
IPE, IPP
Level 2b: Greater interprofessional delirium knowledge test scores post-intervention. Level 3: Self-reported improvement in team performance following intervention. Level 4a: Increased use of specific delirium preventative interventions (i.e. limiting physical restraints, use of glasses and audiophone, mobilization, minimizing drug administration while asleep). Level 4b Lower rates of delirium in the intervention group (11.7 versus 18.5%). Level 1: High attendee satisfaction with education activity (79% rated as excellent). Level 2b: Improved delirium knowledge test scores for those attending 2 sessions (3.8 versus 2.9 test score change).
IPE
IPE, IPO
IPE, IPP
Level 3: Increased detection of delirium post-intervention.
IPE, IPP
IPE, IPP
Level 3: Reduced benzodiazepine, antihistamine and opiate use after intervention. Level 4b: Reduction in the prevalence of delirium (40.9 versus. 19.1% at 9-months) post-intervention.
IPE, IPP
Outcomes (Kirkpatrick levels) Level 4b: Lower rates of delirium in intervention group after seven days. No difference in independent living.
IPE, IPP
IP component
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Physician (18), nurses (58), staff from other departments or disciplines* (24), trainees (19)
Nurses and geriatricians*
Physicians (2), medical student (1), nurses (3), dietitians (1), pharmacist (1), chaplain (1), volunteer (1)
Physicians, physiotherapists, nurses*
Physicians (mainly interns), allied health professionals, nurses*
Nurses and physicians*
Nurses (67) and physicians (25)
Nurses and physicians*
Participants (n)
Table I. Summary data from the 10 studies analyzed.
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IPE for delirium
n ¼ number of healthcare professionals; IPE – Interprofessional Education; IPP – Interprofessional Practice; IPO – Interprofessional Organization. *Staff from other departments included hospital administrators, pharmacists, social workers, volunteers, laboratory personnel, radiology technicians, nutritionists, physical therapists.
IPE Self-learning modules, brief presentation sessions and team objective structured clinical encounters (TOSCEs). Quasiexperimental Brajtman et al. (2012)
Caregivers from a hospice and long-term care facility (22)
Palliative care
IPE, IPP Education sessions reinforcing guidelines, education materials, one-onone training and monthly case-based learning, patient brochures. General medical Physicians, nurses, nurse managers, nursing assistant, volunteers* Prospective casecontrol Mudge et al. (2012)
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Level 3: Increased geriatric psychiatry consults in intervention group. Level 4a: No change in 1-to-1 nursing care needs. Reduction in the number of patients discharged delirious in intervention group (32 versus 71%). Level 1: High satisfaction with participation in an interprofessional activity for intervention group. Level 2b: No difference in end-of-life delirium knowledge test. Level 3: Self-reported improvement in collaborative competencies for intervention group.
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hospital unit’s use of preventative interventions for delirium, specifically early mobilization, reduced use of restraints, and increased use of audiophone and glasses, after exposure to the education intervention (Level 4a). Another study showed a reduction in the number of patients discharged home who were still delirious (Mudge et al., 2012), but did not show a decrease in one-to-one nursing care needs following the delirium education intervention. Five out of six studies reported on patient care results (Level 4b) and showed a reduction in delirium rates (Lundstrom et al., 2005; Naughton et al., 2005; Tabet et al., 2005; Vidan et al., 2009; Wong Tin Niam et al., 2005) (Table II). The five studies reporting on the rate of delirium as an education outcome used validated measures for delirium detection, namely the Confusion Assessment Method (n ¼ 4) (Inouye et al., 1990) and a modified version of the Organic Brain Syndrome Scale (n ¼ 1) (Jensen, Delhin, & Gustafson, 1993). The study that did not use a validated delirium detection tool relied on the assessment of a single psychiatrist to determine the presence of delirium (Tabet et al., 2005).
Discussion All 10 of the studies reviewed used IPE interventions with either a didactic or interactive presentation component. Studies using an IPE approach alone reported only changes in learner reaction (Level 1) and delirium knowledge (Level 2b). The evidence from the 10 studies reviewed suggests that a combined IPE and IPP (or IPO) approach to delirium education can result in higher order education outcomes, that is, changes in team behaviors in clinical settings (e.g. delirium documentation and team performance) and improved patient outcomes (e.g. rates of delirium detection). Wand (2011) in her review used a continuing medical education (CME) framework (Davis, Thomson, Oxman, & Haynes, 1992), focused on predisposing (e.g. information dissemination, didactic teaching), enabling (e.g. use of protocols) and reinforcing factors (e.g. feedback from peers or experts) to classify delirium training studies. She found that educational interventions that included enabling factors (i.e. providing guidelines or resources) or reinforcing interventions (i.e. delirium expert feedback or reminders) had a greater impact on patient outcomes. We also found in our review of interprofessional interventions that higher-level educational outcomes (i.e. Level 3 and Level 4) are most likely to be associated with interventions that integrate interactive instructional methods and practice-based interventions that are consistent with enabling and reinforcing strategies. In our review, many IPP interventions could be classified as using enabling or reinforcing factors, given Davis et al.’s CME framework (Davis et al., 1992). For example, IPP delirium education interventions that used enabling factors included the following: dissemination of guidelines (Mudge et al., 2012; Tabet et al., 2005) and use of delirium care posters or cards (Vidan et al., 2009). In addition, IPP interventions in our review included the following reinforcing factors: one-on-one case discussions with a designated delirium resource nurse or physician (Mudge et al., 2012; Vidan et al., 2009; Wong Tin Niam et al., 2005), charting procedure modifications to enhance Emergency Department delirium screening (Naughton et al., 2005), and reorganization of patient flow to allow nurses to provide more patient-centered care or individualized care (Lundstrom et al., 2005). The use of a delirium resource person for case discussions resulted in changes in organizational practice in two studies (Mudge et al., 2012; Vidan et al., 2009), namely the implementation of delirium preventative strategies and the reduction in the number of patients discharged delirious.
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Table II. Summary of delirium training programs according to Kirkpatrick’s modified outcomes typology. Kirkpatrick level Level 1: Learner Reaction Level 2: Learning (2a – Changes in perceptions and attitudes; 2b – Changes in knowledge and/or skills) Level 3: Behavior
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Level 4: Results (4a – Changes in organizational practice; 4b – benefits to patients)
Number and type of studies Quasi-experimental (n ¼ 1) Survey (n ¼ 1) Quasi-experimental (n ¼ 1) Cohort (n ¼ 1) Survey (n ¼ 1) Cohort (n ¼ 3) Prospective case-control (n ¼ 2) Quasi-experimental (n ¼ 1) Cohort (n ¼ 2) Prospective case-control (n ¼ 4)
Thus, interprofessional delirium training should benefit from using an IPP approach in addition to more traditional IPE interventions, such as workshops and didactic presentations, in order to have an impact on higher order educational outcomes (i.e. Level 3 or Level 4a/4b) affecting patient care. Although Reeves et al. (2011) indicated that IPO interventions can also improve patient outcomes, only one study (Ramaswamy et al., 2011) in our review used IPO strategies in combination with IPE interventions. In that study, the IPO intervention involved hospital leaders and clinical directors in the delirium education program and aimed to change the institutional culture regarding delirium care. Further research is needed to determine the specific effect of IPO interventions on delirium education and care. Our review identified two additional studies not previously included in prior reviews that focused exclusively on interprofessional performance and process outcomes (Brajtman et al., 2008, 2012). Nonetheless, no studies to date have examined resource implications and barriers to IPE for managing delirious patients. In their review of education interventions for confused patients, Teodorczuk et al. (2010) recommend an onsite education approach to improve education outcomes; however, it is unclear as to whether barriers to IPE, such as resources, time and availability, will thwart the widespread implementation of interprofessional delirium education programs from moving forward. Higher patient workloads on hospital units may compromise team flexibility to train together in these clinical settings. Qualitative studies exploring perceived barriers and resource implications for IPE programs in delirium care could provide greater insights into how to address these challenges. The limitations of our study included the following. Our review included only 10 studies with very different study designs and outcomes, thus preventing us from doing a meta-analysis. The lack of controlled trials and qualitative studies on interprofessional delirium education programs limits our understanding of the effectiveness of such programs in relation to learning outcomes. Thus, we could not determine if the reported effect of the delirium education intervention on learner and patient outcomes were due to the intensity of the IPE intervention, the type of IPE intervention or a result of the institution’s readiness for adopting change during the delivery of the intervention. Second, as with any systematic review, we searched only published studies and studies in the grey literature. Our results may reflect a publication bias, as negative studies for delirium education interventions are less likely to be published. Lastly, only two studies examined the impact of interprofessional delirium education programs on team processes using team
Outcomes Perceived satisfaction with delirium IPE intervention (n ¼ 2) Increase in delirium knowledge (n ¼ 2) (Level 2b) No change in delirium knowledge (n ¼ 1) (Level 2b) Self-reported increase in team competence and performance (n ¼ 2) Increased delirium documentation and detection (n ¼ 2) Reduction in deliriogenic medication use (n ¼ 1) Increased geriatric psychiatry consultation (n ¼ 1) Implementation of specific delirium preventative interventions (Level 4a) No change to nursing 1-to-1 care needs (Level 4a) Reduction in rates of patients discharged delirious (n ¼ 1) (Level 4a) Reduction in rates of delirium post-intervention (n ¼ 5) (Level 4b)
performance measures. For the remaining studies, it was difficult to quantify the degree of IPE (i.e. focus on collaboration) in each intervention. In summary, this review of the literature on IPE programs for delirium care offers new insights into education approaches to increase healthcare providers’ competence in caring for patients with delirium. The importance of an interprofessional approach to delirium care has been highlighted in recent delirium guidelines and our review suggests that combined IPE and IPP interventions can potentially impact delirious patient outcomes, mainly reducing rates of delirium post-intervention. In addition, our review provided new evidence that IPE interventions in delirium prevention and management can also improve team performance and collaborative competency in managing delirious patients, outcomes that have not been previously reported in delirium education reviews. The lack of randomized controlled trials (RCTs) and qualitative studies on interprofessional delirium education interventions preclude us from making more conclusive recommendations. More systematic studies are needed to clarify the effectiveness of specific kinds of interprofessional delirium education interventions, where limited and specific types of interventions are systematically compared. As described by Cook, Bordage, and Schmidt (2008), ‘‘such research will deepen our understanding and advance the art and science of medical education’’. These types of studies require a program of research rather than opportunistic one-time studies. Until more robust evidence is available, our review provides an updated summary of the emerging interprofessional delirium education literature and provides readers with a preliminary understanding of the evidence for delirium IPE interventions on learning and clinical outcomes.
Acknowledgements We would like to thank Dr Georges Bordage and Dr Ilene Harris for their thoughtful feedback on previous iterations of this manuscript. We would also like to thank Dr Meenakshy Aiyer for her helpful comments during manuscript preparation.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the writing and contents of this paper.
References Barr, H., Koppel, I., Reeves, S., Hammick, M., & Freeth, D. (2005). Effective interprofessional education: Argument, assumption and evidence. Oxford: Blackwell.
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DOI: 10.3109/13561820.2014.891979
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