Alternative Strategies for Managing and Reducing Bedside Sitter Use for Delirious Patients

Description of the Capstone Project

The capstone project described here explains how a situation-specific theory applicable to the treatment of delirious patients in acute care settings.  Situation-specific theories explain how the management and reduction of bedside sitters may encourage hospital staff to delegate job-specific tasks accordingly (Im, 2005, 2014; Im & Meleis, 1999).  While volunteers have the potential to reduce workloads for nurses and clinicians working in acute care settings, the persistent use of bedside sitters may prove costly and ineffective in the long term (Jong, Kitchen, Foo, & Hill, 2018).  Similarly, the rationale for conducting this capstone project has its basis in research findings indicating that nursing assistants, nurse aides, and healthcare assistants must fulfill the responsibilities of caring for delirious patients.  

The cost-effectiveness of relying on bedside sitters presents concerns for ensuring that delirious patients receive adequate care when nurses and clinicians employ an integrative approach developed from the application of a situation-specific theory to nursing practice (Wood et al., 2018).  Moreover, the dearth of economic evidence accounting for the benefits conferred from relying on bedside sitters indicates further the need to introduce alternative strategies.  Important to this capstone project is how an integrative approach developed from a situation-specific theory may effectively manage or reduce bedside sitter use in treating delirious patients.  An integrative approach will emphasize the use of non-pharmacological interventions such as cognitive enhancement strategies to improve cognition and perceptions of safety (Brown et al., 2018; Im, 2005, 2014; Im & Meleis, 1999; Jong et al., 2016; Wood et al., 2018).   Specifically, an integrative approach has the potential to produce empirical evidence justifying the management or reduction of bedside sitter for treating delirious patients in acute care settings.  

Significance and Rationale for the Project

The significance of this capstone project has its basis in situation-specific theories applicable to explaining how managing and reducing bedside sitter use benefits hospital staff members in acute care settings when older when leaders rely on volunteers to carry out specific duties (Im, 2005, 2014; Im & Meleis, 1999).  Volunteers have the potential to enhance patient care by relieving nurses and clinicians of workloads as well as by providing a meaningful source of temporary companionship to reduce distress in delirious patients (Hall, Pendlebury, Brooke, & Jackson, 2019; Wood et al., 2018).  Secondly, volunteers may provide the assistance necessary to prevent delirious patients from incurring serious injuries from falls.  In acute settings, fall prevention programs in acute care settings involve nurses and clinicians directly supervising volunteers who may assist delirious patients with daily activities (Jong et al., 2018).  However, very little evidence to date can effectively account for how volunteers in acute care settings may enhance the health outcomes of delirious patients.  Despite this gap, the capstone project has significance for explaining why bedside sitters are equally ineffective and costly.  As suggested by Jong and colleagues (2018), the reduction of bedside sitter use in acute care settings does not increase the probability that delirious patients will have more falls.  The research findings are scant with regards to how bedside sitter use may decrease falls in delirious patients.  However, these findings conflict with assumptions that bedside sitters lack the knowledge about best practice principles for reducing fall rates among individuals in this special population group.  

The rationale for conducting this capstone project has its basis in research findings indicating that nursing assistants, nurse aides, and healthcare assistants must fulfill the responsibilities of caring for delirious patients.  Yet, Wood and colleagues (2018) noted now many earlier studies included information describing how non-nursing staff—e.g., customer support, security staff, chaplains, and receptionists—may receive some degree of clinical training to act as surrogates for bedside sitters.  In many cases, delirious patients suffer from neurological problems and may become, agitated, violent, or suicidal (Brown et al., 2018; Waszynski, Milner, Staff, & Molony, 2018; Wood et al., 2018).  Delirious patients experiencing alcohol withdrawal or mental distress may also present the risk for elopement in disrupting treatment protocols by exhibiting psychotic behaviors (Wood et al., 2018).  However, the cost-effectiveness of relying on bedside sitters also presents concerns for ensuring that delirious patients receive adequate care.  To a similar degree, the dearth of economic evidence accounting for the benefits conferred from relying on bedside sitters indicates further the need to introduce alternative strategies.  

Moreover, the research findings indicate that few nurses and clinicians in acute care settings feel unqualified to address the needs of delirious patients.  Nurse and clinicians may, thus, feel compelled to use restraints or medications as tools to increase patient safety.  For Kresevic and colleagues (2016), some nurse and clinicians may rely on personal experience to address the medical needs of delirious patients.  Yet, persistent knowledge limitations for treating members of this special population group continue to present cost-effectiveness issues (Kresevic et al., 2016; Wood et al., 2018).  Bedside sitters may also produce only secondary outcomes in relation to the effective management of delirious patients.  Brown and colleagues (2018) suggested that bedside sitters in acute care settings may produce secondary effects when delirious patients have serious neurological conditions.  However, situation-specific theories establish that delirious patients require more specialized treatments.  

Theory Guiding the Capstone Project

A situation-specific theory guides this capstone project in positing that nurses and clinicians who act as bedside sitters to delirious patients in acute care settings may draw from the assumptions of post-empiricism, critical social theory, and/or hermeneutics to improve cognition and safety.  Im and Meleis (1999, pp. 15-18) identified the key properties of situation-specific theories as presenting a low level of abstraction, a reflection of nursing phenomena, context, linkages between research and practice, the incorporation of diversities, and limits to generalization.  A situation-specific theory also provides the space for nurses and clinicians in acute care settings to rely less on bedside sitters when an integrative approach promotes dialogue.  More specifically, the integrative aspects of a situation-specific theory enrich how nurses and clinician reflect on their accumulated professional experience.  An integrative approach, therefore, provides opportunities for nurses and clinicians to reflect on personal biases that impact the improvements to cognition and safety.  

Im (2005, 2014) explained further how a situation-specific theory applies to its testability.  Situation-specific theories do not assume that nurses and clinicians who work in acute care settings should test hypothesis when electing to manage or reduce their reliance on bedside sitters when delivering treatments that improve cognitive and safety perceptions in delirious patients.  Moreover, a situation-specific theory has philosophical foundations that do not rely on positive assumptions.  A situation-specific theory may originate in phenomenological assumptions.  Yet, phenomenological assumptions encourage nurses and clinicians to unpack the meanings of living experiences.  

A situation-specific theory presents nurses and clinicians with opportunities to identify common themes that clearly explain the implications of lived experiences for nursing practice.  These themes also have significant implications for healthcare practice when nurses and clinicians identify the narrow foci specific to managing or reducing the use of bedside sitters to treat delirious patients.  Im (2014) explained how the narrow foci included in situation-specific theories enhance care quality for a special population group.  Accordingly, the lived experiences of nurses and clinicians who act as bedside sitters may inform a theory of nursing practice by providing the groundwork for articulating more realistic expectations considered pertinent to treating delirious patients.  Yet, an integrative approach requires nurses and clinicians to examine multiple assumptions suggesting bias in practice.  An integrative approach has even further significance for theory development when nurses and clinicians in acute care settings apply research evidence that has not yet received scholarly attention.  However, the findings produced therein rarely receive attention except in cases when nurses and clinicians rely on experience.  

Concerning the use of volunteers as bedside sitters, the theoretical assumptions determine whether an integrative approach will support patients whose interactions with nurses and clinicians reflect a lack of training regarding the delivery of adequate treatments to delirious patients (Hall et al., 2019; Im, 2005, 2014; Im & Meleis, 1999).  These assumptions may also have contingent impacts pertaining to whether nurses and clinicians may cultivate authentic care relationships with delirious patients (Brown et al., 2018; Wood et al., 2018).  The assumptions of a situation-specific theory may have similar impacts concerning whether bedside sitters are effective at preventing falls and mitigating elopement (Jong et al., 2018; Wood et al., 2018).  Accordingly, the gaps between Kolcaba's middle-range nursing theory and practice must receive attention with regard to the management and reduction of bedside sitters in acute care settings.  

Application of the Theory to the Capstone Project

In clinical practice, a situation-specific theory provides the basis for developing clear standards and guidelines applicable to nursing practice.  For Wood and colleagues (2018), the development of clear standards and guidelines informs decision-making processes in acute care settings insofar as bedside sitters may improve cognition in delirious patients.  However, more research on the management and reduction of bedside sitter use is necessary to identify how the articulation of standards and guidelines inform theory development in nursing practice.  While standards and guidelines in nursing practice may inform the alternative strategies for addressing the medical needs of delirious patients, a situation-specific situation theory applied to nurse practice would facilitate the recommendation of delivering nonpharmacological interventions from an integrated approach.  Waszynski and colleagues (2018) suggested here that such an approach would reduce perceptions of safety that could result from using restraints or medications.  Thus, an integrated approach would provide delirious patients with the means to articulate individual preferences concerning musical tastes and family contact.  

Similarly, Kresevic and colleagues (2016) recommended the development and application of a simulation center that relied on an interdisciplinary approach.  The simulation center would facilitate the conditions for managing and reducing bedside sitter use to treat delirious patients when nurses and clinicians in acute care settings enlist the assistance of a delirium coach.  A simulation center entails the delivery of virtual training activities for managing precarious clinical situations involving delirious patients.  Training activities may include evidence-based clinical research material for managing physical symptoms, establishing effective communication patterns, and improving decision-making processes.  Moreover, the training activities included in a simulation center may involve nurses and clinicians in acute care settings using role-play scenarios to practice assessment and communication skills.  Role-play scenarios inform theory and practice by providing opportunities for nurses and clinicians to impart experiential knowledge onto volunteers.  Likewise, role-play scenarios promote improvements to interpersonal skills when nurses and clinicians receive accurate feedback from peers or supervisors.  

Thirdly, a situation-specific theory can apply to the development of multi-component interventions for selected groups when nurses and clinicians must either manage or reduce bedside sitter use when treating delirious patients in acute care settings.  Brown and colleagues (2018) recommended the application of a multi-component intervention when treating delirious patients with severe neurological conditions.  Specifically, the multi-component intervention emphasizes risk stratification concerning delirium onset, delirium screening, and non-pharmacological interventions.  The incidence of delirium is a primary endpoint in the multi-component intervention.  The secondary endpoints include delirium days, length of stay, restraint use, readmission rates, and discharge disposition.  By accounting for both endpoints, nurses and clinicians may either manage or reduce bedside sitter use by predicting the likelihood of elopement.  Nurses and clinicians in acute care settings may also record whether delirious patients require pharmacological interventions like antipsychotics such as lithium, benzodiazepines, or sleeping aids.  However, a multi-component intervention should encourage nurses and clinicians to provide delirious patients with non-pharmacological interventions in preventing falls or reducing the risk of elopement (Brown et al., 2018; Jong et al., 2016; Wood et al., 2018).  Multi-component interventions necessarily reduce the number of incidents in delirious patients.  Yet, these interventions may inform which standards and guidelines will inform how nurses and clinicians in acute care settings may effectively manage or reduce the need for bedside sitters.  

Fourthly, a situation-specific theory may influence the use of non-pharmacological interventions like simulated family presence to not only manage or reduce bedside sitter use but also to reduce feelings of agitation in delirious patients.  For Waszynski and colleagues (2018), simulated family presence (SFP) involves the use of pre-recorded audio or video by friends and family members of delirious patients to reduce agitation among patients receiving treatment in acute care or nursing home settings.  The messages included in audio or video messages may include a personalized greeting.  However, some video images may also include audio records of falling rain.  These interventions may help delirious patients achieve a state of calm.  In return, nurses, staff members, or volunteers may use SFP to limit the administration of medications or restraints (Kresevic et al., 2016; Waszynski et al., 2018).  In most cases, the positive responses to SFP by patients are longer-lasting when compared against traditional methods for calming delirious patients in an agitated state.  When nurses and clinicians who work in acute care settings believe that restraints or medications will only reduce perceptions of safety health outcomes of delirious patients, SFP may provide relief when audio or video messages have the potential to create a sense of familiarity.  Unfortunately, more research on the long-term efficacy of SFP is necessary to determine whether this intervention will facilitate the management or reduction of bedside sitter use in all treatment cases involving delirious patients.  

Summary

This capstone project relied on an application of situation-specific theories to explain how nurses who work in acute care settings may effectively manage or reduce the use of bedside sitters when working with delirious patients.  Situation-specific theories provide nurses and clinicians with opportunities to enhance patient care through the adoption of an integrative approach.  Situation-specific theories provide the basis for developing clear standards and guidelines applicable to nursing practice.  Importantly, situation-specific theories leading to the application of an integrative approach would reduce the potential harm that could result from using restraints or medications.  Situation-specific theories may also apply to reduce the probability of delirious patients experiencing falls or eloping from a facility.  While an integrative approach may lead nurses and clinicians to use simulation tools in managing and reducing bedside sitter use, other non-pharmacological interventions have the potential to improve cognition in delirious patients.  Other than simulation, a multi-component intervention may develop from the application of situation-specific theories to treat patients with severe neurological conditions.  By applying an integrative approach developed from a situation-specific theory, the overarching goals are to improve how delirious patients, as well as their family members, understand the impacts of various interventions on cognition and safety.

References

Brown, E. G., Josephson, S. A., Anderson, N., Reid, M., Lee, M., & Douglas, V. C. (2018). Evaluation of a multicomponent pathway to address inpatient delirium on a neurosciences ward. BMC Health Services Research, 18, 106-113. doi: 10.1186/s12913-018-2906-3

Hall, C. L., Brooke, J., Pendlebury, S. T., & Jackson, D. (2019). What is the impact of volunteers providing care and support for people with dementia in acute hospitals? A systematic review. Dementia, 18(4), 1410-1426. doi: 10.1177/1471301217713325

Im, E.-O. (2005). Development of situation-specific theories: An integrative approach. Advances in Nursing Science, 28(2), 137-151. 

Im, E.-O. (2014). Situation-specific theories from the middle-range transitions theory. Advances in Nursing Science, 37(1), 19-31. 

Im, E.-O., & Meleis, A. I. (1999). Situation-specific theories: Philosophical roots, properties, and approach. Advances in Nursing Science, 22(2), 11-24. 

Jong, L. D. de, Kitchen, S., Foo, Z., & Hill, A.-H. (2018). Exploring falls prevention capabilities, barriers and training needs among patient sitters in hospital setting: A pilot survey. Geriatric Setting, 39(3), 263-270. doi: 10.1016/j.gerinurse.2017.09.006

Kresevic, D., Heath, B., Fine-Smilovich, E., Jennings, A., Carter, J., Chen, P., & Burant, C. J. (2016). Simulation training, coaching, and cue cards improve delirium care. Federal Practitioner, 33(12), 22-28. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373715/pdf/fp-33-12-22.pdf

Waszynski, C. M., Milner, K. A., Staff, I., & Molony, S. L. (2018). Using simulated family presence to decrease agitation in older hospitalized delirious patients: A randomized controlled trial. International Journal of Nursing Studies, 77, 154-161. doi: 10.1016/j.ijnurstu.2017.09.018

Wood, V. J., Vindrola-Padros, C., Swart, N., McIntosh, M., Crowe, S., Morris, S., & Fulop, N. J. (2018). One to one specialling and sitters in acute care hospitals: A scoping review. International Journal of Nursing Studies, 84, 61-77. doi: 10.1016/j.ijnurstu.2018.04.018