Knowledge and attitudes of patient safety attendants in managing hospitalized older adults with delirium and dementia.

Delirium and dementia are extremely common among hospitalized older adults and are often associated with functional and cognitive decline.1, 2 Pharmacologic treatments for preventing and managing delirium and dementia behavioral problems are limited, often ineffective, and have significant side effects.3-5 Non-pharmacological management, such as providing orientation, engaging in activities and a calming environment, is, therefore, of primary importance.6 Hospitals often use patient safety attendants (PSAs) (“sitters”) for one-to-one observations to reduce the use of physical restraints and psychotropic medications.7-9 The goal of this needs assessment was to examine the knowledge, skills, and attitude of PSAs regarding management of delirium and dementia in older hospitalized patients. This is the initial need assessment step of a quality improvement (QI) project to improve the adoption and implementation of evidence-based nonpharmacological management of delirium and dementia. The core elements are drawn from the translating research into practice (TRIP) model10 and represents the first three steps (Supplementary Table S1). We used sequential explanatory design to summarize the evidence, identified the barriers to implementation, and PSAs perception by mixed methods. This project was conducted after institutional IRB approval at a tertiary academic medical center. Performance assessment was performed in two phases. Anonymous survey in phase 1 has 6 items on confidence to manage behavioral problems, 9 items on engagement strategies, and 5 items on job satisfaction. After 6 months, focused group interviews were conducted with hospital PSAs. Descriptive statistics of survey data compared hospital PSAs with PSAs from agency (agency PSAs) using Fisher's exact test for categorical variables and Wilcoxon rank-sum test or Likert items. We used qualitative content analysis to analyze the focused group interview transcripts. Out of 85 PSAs, 45 hospital PSAs (100%), and 21 agency PSAs (52.5%) participated in the survey (Supplementary Table S2). The majority were female (88%), Black (79%), and between 25 and 44 years of age (59%). Most of the PSAs reported confidence in their skills to work as PSAs (80% hospital PSAs and 73% agency PSAs). Majority of PSAs (>90%) reported helping patients with activities of daily living followed by connecting with families as part of their job training (Figure 1). Both PSA groups ranked high job satisfaction (>85%) and many felt that the COVID-19 pandemic had affected their job performance (50% hospital PSA and 42% agency PSA). The responses regarding being a valuable member of the team were variable; less hospital PSAs agreed (55%) as compared to agency PSAs (72%). Five focused group interviews were conducted, 4 sessions were in-person (range 2–6; n = 15) and the 5th virtually on Zoom (n = 8). Audio recordings of the interviews were transcribed by an outside agency, except for the zoom recording (Table 1). Using grounded theory, PI and the research assistant parsed for new insight on the themes from the survey as well as any new themes introduced.11 “The kind of stuff I learn on the job, was not part of my training.” “I don't know what to do except for calling the nurse for help when patient is getting combative.” Our study adds to the existing literature by highlighting the specific challenge that PSAs have in differentiating delirium and dementia among older hospitalized patients to possibly deeper systemic issues impacted by COVID-19. Our study also reflects the importance of addressing communication challenges with nurses and other staff members, in addition to providing evidence-based engagement tools to PSAs. Our results are relevant for hospital and health system leadership to address role-setting for PSAs and to inform future training programs. Our work also draws attention to the importance of integrating PSAs, many of whom are minority and female workers, to be more valued and integrated as health care team members. Given the growing interest in developing Age Friendly Health Systems, PSAs can play a valuable role in the implementation of the 4 M's.12 Supporting and empowering PSAs can make them active members of the clinical team and will help reduce job-related stress and communication challenges. As one of the next steps, the QI project will include a new training program for hospital PSAs to improve communication with patients and their care partners. Single medical center study imposes some limitation since job description of PSAs may vary in hospitals. In summary, PSAs reported inadequate training before and inadequate support during their work. These gaps can negatively impact their job satisfaction and effectiveness that may negatively affect patient care. Study concept and design: Shaista U. Ahmed, Michele Bellantoni, Danelle Cayea, Nancy Schoenborn, and Esther S. Oh. Data collection and management: Shaista U. Ahmed, Sean Tackett, Jacqueline Massare, and Nancy Schoenborn. Data analysis and interpretation: Shaista U. Ahmed, Jacqueline Massare, Sean Tackett, and Nancy Schoenborn. Preparation of manuscript: Shaista U. Ahmed, Michele Bellantoni, Danelle Cayea, Sean Tackett, Jacqueline Massare, Hannah Ward, Nancy Schoenborn, and Esther S. Oh. Dr. Shaista U. Ahmed had full access to all of the data in the study and took full responsibility for the integrity of the data and accuracy of the data analysis. We thank Nursing leadership of Johns Hopkins Bayview Medical Center for their support. We would like to acknowledge the role of Jane Marks RN, Elaine Clayton RN, and Rona Corral DNP, RN, for their assistance in conceptualizing and connecting with the PSA supervisors. We thank PSA supervisor's Rochelle Mariano RN, Meg Dendy RN, and Nicci Domanski RN for their help in facilitation with the survey and focused group interviews. We also want to express our gratitude to the participants who, despite their busy schedules, agree to participate in this study. Gift cards for the PSA interviews were made possible by the Mason F Lord Family gift money given to this project by the Geriatric Division leadership at Johns Hopkins School of Medicine in 2021. Dr. Esther S. Oh was supported by NIA/NIH R01AG057725, R01AG07652, and R01AG057667. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The authors have no conflict. The funding sources had no role in the design, methods, subject recruitment, data collections, analysis, and preparation of paper. Supplementary Table S1. Action plan for translating research into practice (TRIP). This table is a Translating Research into Practice (TRIP) model. TRIP helps identify barriers and measure performance by using pre- and post- intervention assessment for knowledge retention. Supplementary Table S2. Baseline characteristics of the PSAs participated in phase one of the study. This table includes the demographic characteristics including age, gender, race, and the duration of work for PSAs who participated in the survey. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.