Delirium prevention in hospices: Opportunities and limitations - A focused ethnography.

Background: Delirium is common and distressing for hospice in-patients. Hospital-based research shows delirium may be prevented by targeting its risk factors. Many preventative strategies address patients' fundamental care needs. However, there is little research regarding how interventions need to be tailored to the in-patient hospice setting.

Aim: To explore the behaviours of hospice in-patient staff in relation to delirium prevention, and the influences that shape these behaviours.

Design: Focused ethnography supported by behaviour change theory. Observation, semi-structured interviews and document review were conducted.

Setting/participants: A total of 89 participants (multidisciplinary staff, volunteers, patients and relatives) at two UK in-patient hospice units.

Results: Hospice clinicians engaged in many behaviours associated with prevention of delirium as part of person-centred fundamental care, without delirium prevention as an explicit aim. Carrying out essential care tasks was highly valued and supported by adequate staffing levels, multidisciplinary team engagement and role clarity. Patients' reduced physical capability limited some delirium prevention behaviours, as did clinicians' behavioural norms related to prioritising patient comfort. Delirium prevention was not embedded into routine assessment and care decision-making, despite its potential to reduce patient distress.

Conclusions: The value placed on fundamental care in hospices supports delirium prevention behaviours but these require adaptation as patients become closer to death. There is a need to increase clinicians' understanding of the potential for delirium prevention to reduce patient distress during illness progression; to support inclusion of delirium prevention in making decisions about care; and to embed routine review of delirium risk factors in practice.