Year

2024

Degree Name

Doctor of Philosophy

Department

School of Nursing

Abstract

Background: Delirium is a significant and distressing illness with a high morbidity and mortality. Early detection and management of the underlying cause of delirium are vital to reduce its severity, duration, and complications. Despite the growing focus nationally and internationally to recognise delirium, it is often under-detected. To address the barriers to under-detection and translate the Delirium Clinical Care Standard into practice, education and training have been ranked as the most important intervention. Objective structured clinical examinations (OSCEs) are a potential educational intervention to enhance healthcare practitioners’ self-efficacy, knowledge, and delirium care clinical practice.

Aim: The Delirium Puzzle Project aimed to develop and evaluate delirium educational interventions, using OSCEs, to enhance the self-efficacy, knowledge, and clinical practice of undergraduate medical students and post-registration healthcare practitioners, with a focus on nurses.

Methods: Following the Medical Research Council framework for developing and evaluating complex interventions, the Delirium Puzzle Project had six discrete yet interrelated studies conducted in three phases. Stakeholder consultation and engagement activities were undertaken prior to each phase.

Phase 1 (development) involved two literature reviews to identify existing literature on the use and value of OSCEs in undergraduate geriatric medicine education (a scoping review) and postregistration nurse education (an integrative review) (Chapter 2). Phase 1 included the development of a conceptual framework to better understand how OSCEs transfer delirium knowledge and skills into clinical practice (Chapter 3). Phase 2 (pilot studies) (Chapter 4) included: (i) a pre-post survey pilot study designed to evaluate The Delirium group-OSCE Education Package on self-perceived confidence and competence in delirium assessment tools and delirium knowledge; delirium knowledge scores; planned practice change; and perceived usefulness of the education for third-year medical students during their aged care clinical placement; and (ii) a quasi-experimental study with follow-up qualitative methods to evaluate the effects of The Delirium OSCE Education Package on self-perceived confidence and competence in delirium assessment tools and delirium knowledge; delirium knowledge score; clinical practice; planned practice change; and perceived usefulness of the education for registered healthcare practitioners. Phases 1 and 2 informed Phase 3.

Phase 3 (controlled trials) included: (i) a non-randomised, clustered, controlled study to compare The Delirium group-OSCE Education Package to standard delirium education for medical students during clinical placement (Chapter 5), and (ii) a multisite randomised controlled trial (RCT) comparing The Delirium OSCE Education Package to standard professional development education for registered healthcare practitioners (specifically nurses) (Chapter 6). Results from Phases 2 and 3 were synthesised to answer the overarching research questions of the Delirium Puzzle Project (Chapter 7).

Results: Phase 1 demonstrated that OSCEs have evolved into educational interventions to improve self-efficacy and drive learning. Bandura’s Self-Efficacy Theory was explored as the conceptual framework to explain how OSCEs could lead to heightened self-efficacy that results in increased competence in delirium care. The two pilot studies in Phase 2 demonstrated significant improvements in self-efficacy and delirium knowledge scores following the educational intervention. The medical student cohort in Phase 3 demonstrated a significant difference in mock OSCE exam scores in favour of medical students who completed The Delirium group-OSCE Education Package. While there was a broad spread in the raw practice scores, Phase 3 for the post-registration nursing cohort demonstrated the intervention group were 10.1 times more likely to achieve a satisfactory score in delirium practice (p=0.009).

Conclusion: The Delirium Puzzle Project demonstrated that delirium educational OSCEs are effective in enhancing undergraduate medical students and post-registration healthcare practitioners’ self-efficacy, delirium knowledge, and delirium detection and care. However, delirium educational OSCEs, are just one piece of the delirium care puzzle. The Delirium Puzzle Project identified a range of recommendations at the micro (clinician), meso (ward), and macro (organisational) levels to ensure that the Delirium Clinical Care Standard is translated into clinical practice. Implementing the Delirium Puzzle Project recommendations will improve delirium care in Australia.

FoR codes (2020)

320210 Geriatrics and gerontology, 390305 Professional education and training, 420501 Acute care

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Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.