Reasons influencing the nurses’ prioritization process while preventing and managing delirium: findings from a qualitative study

Background Nurses play an important role in the prevention and management of delirium episodes. However, some studies have reported that not all interventions recommended are applied due to time and resource constraints, resulting in patients receiving less care than required because other patients and/or interventions are prioritised. The concept of prioritization is part of the broader concept of decision-making as the ability to choose between two or more alternatives to ensure patient safety. Understanding the reasons influencing the prioritization process in patients at risk or with delirium may inform interventions to prevent and/or minimise the unfinished nursing care. Aim The purpose of this study was to explore the reasons that inform the prioritisation process among nurses when they are challenged to make decisions for patients at risk and with delirium. Methods A descriptive qualitative study performed according to the COnsolidated criteria for Reporting guidelines, in 2021. An intentional sample of nurses working full-time with older patients in medical, geriatric, and post-acute care facilities affiliated with the National Health System was involved. Semi-structured interviews were conducted and narratives thematic analysed. Results A total of 56 nurses (55.4% in internal medicine, 26.8% in geriatrics and 17.8% in post-acute/intermediate care) participated with an average age of 31.6 years. The reasons informing the prioritisation process while providing preventive or managerial interventions towards a patient at risk of or with delirium are set at three levels: (1) unit level, as reasons belong to the inadequacy of the ‘Environment’, the ‘Human Resources’, and the ‘Organisation and Work Processes’, (2) nurse’s level, as issues in ‘Competencies’ and ‘Attitudes’ possessed, and (3) patient level, due to the ‘Multidimensional Frailty’. Conclusion Nurses caring for patients at risk of and with delirium face several challenges in providing care. To prioritise preventive and managerial interventions, it is essential to implement multilevel and multifaced organizational and educational strategies. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-024-02818-3.


Introduction
Delirium is still a priority problem [1] with a prevalence of approximately 30% in geriatric and internal medicine up to 70% among older residents living in long-term care facilities [2][3][4].Among the predisposing factors for delirium, advanced age, cognitive impairment, dementia, and frailty have been underlined; in both hospital and long-term care settings, delirium-related adverse outcomes include decreased independence in activities of daily living and an increased risk of mortality.Consequently, delirium is still a concern for its influence of patient safety, and for its impact on healthcare professionals work processes.
Nurses play an important role in preventing and managing episodes of delirium as underlined by available guidelines [5]; however, as emerged recently [6] several recommendations are not applicable due to time and resources restrains [7], thus causing the patient to receive less care than required because other patients and/or interventions are prioritised.
The concept of prioritisation is part of the broader concept of decision making, defined as the ability to choose between two or more alternatives with the aim of pursuing the goal of patient safety [8].The need to perform multiple tasks (e.g.administering medications) and the cognitive process (e.g. the knowledge and experience possessed) are combined to optimise the decision-making processes [9].However, as reported in the literature [10,11] when nurses establish a sequence of care activities they may decide to delay or omit those perceived as less important [12] generating the so-called Unfinished Nursing Care (UNC) phenomenon describing any nursing interventions needed by the patient/family which is delayed or omitted [11].The UNC conceptual model has been established as consisting in multilevel elements (i.e., macrosystem, ecosystem, mesosystem, microsystem, and nurse-related level), with antecedents in poor resources and consequences in the poor quality of care [13].
Although the concept of prioritisation is quite new, several studies have established the influencing elements as the patient needs [14]; the context of care (e.g.acute, chronic); [15]; the philosophies, models of care and its organisational aspects [16]; the resources available [16,17]; and the training; experiences; personalities; values; and beliefs of the nurses [18,19].The prioritization may also be associated with the patient's profile: in the specific context of delirium prevention and management, nurses have been reported to prioritise some interventions as 'Monitoring the vital parameters (heart rate, blood pressure, oxygen saturation)' and 'Ensuring a safe environment (e.g.reducing bed height)' [7]; on the other hand, they have been documented to rank at low priority the family and/or caregivers involvement and education (e.g., 'How to re-orient the beloved') and the presence of clocks, calendars, and specific signs in the room allowing re-orientation [7,20].However, the reasons already documented for UNC in general settings (e.g., [21,22]) have not been integrated with data regarding patients with delirium.Understanding the reasons informing the prioritization process among at-risk and/or patients with delirium can improve clinical outcomes, promote quality improvement strategies and reduce the impact on the individual, his/ her relatives, on health care professionals, and ultimately, on the entire organisation [23].Therefore, the aim of this study was to explore the reasons informing the prioritisation process among nurses while stimulated to make decisions for patients at risk of and with delirium.

Study design
A qualitative study was conducted in 2021 and here reported according to the Consolidated criteria for reporting qualitative research appropriate guidelines [24].

Setting and participants
The study involved a public research and academic hospital located in Northern Italy, characterised by 49,000 admissions per year and 1,515 beds with a staff of 6807 employees, of which 2478 were nurses.In addition, we involved three private post-acute, extensive and intensive rehabilitation hospitals, with 90 beds affiliated with the health system and equipped with 45 nurses [25].Specifically, 11 clinical wards (three post-acute and eight academic hospital) with the mission to provide diagnosis, treatment and care of acute and post-acute internal medical patients, were considered as the setting of the study.All wards participated on a voluntary basis: the process of involvement started with the presentation of the project aims to the nurse managers.After having obtained their acceptance, an intentional sample [26] of nurses with the following characteristics were deemed eligible: (a) clinical nurses working full-time in the identified units; (b) able to understand and communicate in Italian; (c) with at least 6 months of clinical experience [9]; and (d) willing to participate in the study.Nurses with organisational roles (e.g.nurse managers) were excluded [27].Potential participants were invited through a communication from the nurse managers and the researcher (LS) at the shift changes; at the end, 56 nurses provided their contact details to participate.

Data collection process
The research team (see authors) developed a scenario (Table 1) to stimulate nurses to think and define priorities regarding preventive and managerial interventions needed.The main questions to investigate the reasons influencing the prioritisation were developed according to the available evidence [28] (Table 2).The scenario was provided prior to the meeting, whereas the interview questions were not shared with participants in advance.After obtaining the consent to participate in the study, interviews were scheduled between May and June 2021.All meetings took place online, via the Zoom platform.Each meeting lasted approximately 105 min (range: 90-120 min).19 meetings were conducted by two researchers (LS, NVU), where the participants ranged from one to seven.The researchers act as observer (NVU) and interviewer (LS), respectively.Audio-visual recordings and in-the field notes were collected to capture all details [29].The participants were asked to classify the preventive (first sub-scenario) and the managerial (second sub-scenario) interventions by indicating their priorities; for each priority, the underlying reasons were asked, and the reasons freely reported were audio-recorded.A short questionnaire was administered to collect some socio-demographic and professional data.

Data analysis
Quantitative data from the socio-demographic questionnaire was summarised with frequencies, percentages, means and standard deviations/Confidence of Interval (CI; 95%) using Statistical Package for Social Science, version 25.The qualitative data were thematic analysed through the following steps [30].
Step 1: Transcription, familiarization with the data, and selection of quotations One researcher (NVU) transcribed verbatim all the interviews, and a second researcher (LS) checked the accuracy of the transcriptions.Subsequently, three researchers (SC, LS, NVU) independently familiarised themselves with the data by re-reading the transcription several times.
Step 2: Selection of keywords Three researchers (SC; LS; NVU) independently identified the keywords from the text according to their capacity to depict and encapsulate the key concepts as emerging from the transcripts.Then, they compared the key words reaching an agreement.

Step 3: Coding
The three researchers (SC; LS; NVU) already involved in the previous steps identified the codes, i.e. short phrases or words explaining the central meaning of the data around the keyword identified.
Step 4: Theme development Then, the same researchers (SC; LS; NVU) started a careful analysis of the identified codes to initiate a detailed interpretation of them and create themes, considering the aims of the study.

Step 5: Conceptualization through interpretation of keywords, codes, and themes
The researchers (SC; LS; NVU) completed the conceptualisation phase: the themes were described, and sub-themes identified by checking their consistency with the codes and the keyword selected in the previous steps.
A fourth researcher (AP) was consulted during the process when divergences emerged.With the final step, it was provided the categorization of the themes at different levels by using an inductive and a deductive approach [13].

Ethical considerations
The study was approved by the Bioethics Committee of the University of Bologna (Italy) register no.0109186 of 5 May 2021.Participation was voluntary; all nurses gave their written informed consent before being audio recorded and they were allowed to withdraw from the study at any time.In verbatim transcribing the narratives, researchers ensured anonymity by using an alphanumeric code (e.g., RN1); confidentiality was also ensured by anonymising specific details (e.g., the hospital name) encountered during the transcriptions.

Rigour and truthfulness
According to the available literature [31] to ensure credibility, participants working in the areas of interest were involved; moreover, all researchers (see authors) were experts in the methods and in the topic of investigation.Rigour and reliability were ensured through the following strategies: (a) the use of an interview guide (Table 2); (b) the adoption of a detailed research protocol describing the methodology also regarding the data analysis; (c) a careful collection of the in-the field notes regarding participants' reasoning, which was shared during data analysis (LS; NVU); (d) the prolonged involvement of several researchers both in the interviews (LS; NVU) and in the data analysis (LS; SC; NVU; AP).Furthermore, an intentional sample was used to ensure transferability, involving nurses caring for patients at risk of or with delirium in medical, geriatric and in post-acute setting.

Participants
A total of 56 nurses with a mean age of 31.6 years (CI 95% = 29.6-33.6)participated, of whom 39 (69.6%) were female.Among them, 53 (94.6%) were educated in nursing at the bachelor level, and 12 (21.4%)reported a postgraduate qualification.15 participants (26.8%) attended also a specific course on delirium.At the time of the study involvement, 31 (55.4%)nurses were working in internal medicine, 15 (26.8%) in geriatrics and 10 (17.8%) in post-acute care/intermediate care settings.They reported on an average of 4.5 years (CI 95% = 2.7-6.2) of experience and the setting in which they worked at the time of the study was the one in which they had spent most of their professional life (n = 36; 67.9%) (Supplementary Table 1).

Prioritisation reasons
The reasons informing the prioritisation process in delivering preventive and management interventions towards hospitalised older individuals were identified at three levels: unit, nurse and patient level as reported in Table 3.

Unit level: issues in the care environment, in the human resources, and in the organization and work process
This level provides the reasons for prioritisation linked to the context in which the patient at risk of and with delirium is admitted and cared for.Prioritization can be influence by the environment, the human resources, and the organization/ work processes.
Inappropriate and chaotic care units with several patients in small rooms, with the equipment and the required material to deliver nursing care stored away from the rooms affect the time and the concentration require to undertake the right priorities.Dedicated, safe environments, without architectural barriers and tools (e.g., clock and calendar or with a delirium room), are all limited or absent, thus influencing the prioritization of all space-time reorientation preventive management interventions.
Furthermore, the lack of human resources in terms of nurse-to-patients and nurse aides-to-patient's ratios forces to take care of those needs perceived as most important, urgent, or critical, leaving others unmet.Moreover, while shortages in nurses affect both preventive and managerial interventions, the shortages in nurses-aides influence only the management of the delirium but not its prevention.
A role is played also by the organisation and work processes: the geriatric mission of the unit increases the attention of nurses towards delirium prevention and management, whereas work processes based on strong routines, i.e. 'it has always been done this way', prevent the prioritization of some individual needs, given that all interventions are provided in an established order along the time and the sequence.The poor interprofessional collaboration increases the need to spend time in searching for, discussing, and in communicating with other professionals, thus further reducing the time available for patients.In this context, the lack of specific supportive tools (procedures, guidelines) in the field of delirium prevention and management threatens an effective care delivery, increasing the repetition of some wellacknowledged routinised activities (e.g., evaluating the risk factors), and implicitly delegating the interventions to other professions.In addition, the shift work, where subsequent nurses are involved in the 24/24 care of patients with no specific point of reference as a primary nurse, increases the need to collect data, searching for information regarding what has been done in the previous shifts with discontinuous care delivered to patients based on different priorities.Moreover, although at night nurses have more time to devote to the patient by autonomously organising the work processes, the lack of resources (e.g. two nurses on average for 40 patients) influences the prioritization of the interventions, providing them to urgent/clinical instable patients, leading to UNC.

Nurse level: the role of the nurses' competencies and attitudes
Identifying, recognising and managing the predisposing and precipitating factors of delirium require competencies that may influence the priorities.Possessing a specific professional experience in the context of patients with delirium supports nurses in the prioritization process as well as in the early identification of the risks.On the other hand, the lack of knowledge leads nurses to prioritise according to what they have learnt during under and post-graduate education, planning some unnecessary interventions (e.g.monitoring vital signs) and leaving those required neglected.Moreover, nurses set priorities according to their continuous awareness of the situation, and reflexivity of what is going on, where the ability to assess the risks, to perceive them and to hypothesise the patient' trajectory, anticipating the course of the events may inform the decision of priorities.Nurses' communication abilities also play a role in detecting patients' needs when not verbally communicated, which helps in prioritising those not immediate visible.
Time management skills are reported by nurses as another reason influencing the priorities: they emphasise the importance of being able to organise the shift and save time to provide individualised interventions.
Also attitudes were recognised as influencing the priority process.Making decisions may be challenging for nurses; not all could face these challenges and to identify what to put aside, when not everything can be done.Moreover, some nurses live in a 'hurry' also when there is no time pressure, as a sort of shaped attitude, reducing the time to invest in the patient care.Additionally, not all nurses are able to do several things simultaneously to optimise time, by overlapping different activities to deliver at the same time, such as communicational-relational and technical interventions, e.g.assessing the risk while taking vital signs.This further '…The effect of restraint always depends on the case, because maybe there are people who are restrained, they get more agitated and maybe by not being restrained they calm down.It has happened that agitated patients have calmed down with restraints and they don't try to climb over the rails…' (RN56) '…First of all, the safety of the person and to prevent them from wandering off or hurting themselves…' (RN46) '…So the choice also goes on whether you have more than one patient like that… Not just one patient, but also the priority of other patients…' (RN39) '…I also have to be safe while the patient is agitated…' (RN19) M '…I prefer the presence of family members when we could and when we can….It's hard, hard for patients not to see their children, people get disorientated and even more so without their loved ones..I have often found patients in a state of confusion…' (RN24) Other competitive clinical issues * * P '…I try to stabilise the patient first… there is a possibility of sudden deterioration…' (RN24) You stabilise the patient first…' (RN5) M '…More critical, that is for this type of patient, so here let's say we had little information, but I was guided by the fact that, that is, it was an acute event, so that is the lady was agitated, so she took off the CVP, tried to get out of bed, so I, that is, I left the clinical aspect alone…' (RN20) Challenges in the needs assessment due to the cognitive reduces the likelihood to prioritise patients at risk of or with delirium.
In setting priorities, nurses follow different schemes, as safety first, needs first, or prescription first, and these different tendencies shaped during education and experience may prevent a common action.The safety approach is not only focused on that of all patients but also on the health care professionals, to prevent legal implications.

Patient level: the role of the multidimensional frailty
The multidimensional frailty of the patient, characterised by the absence of the carers, the presence of several clinical issues, and the underlying cognitive impairments, has been reported as influencing the prioritization in both preventive and management interventions.The absence of caregivers, due to the restrictive policies introduced during the pandemic, require nurses to spend more time reassuring and staying close to patients, by also replacing family members in performing some tasks (e.g., watching out for falls or supervising them when they become agitated).Moreover, high priority is given to the clinical issues as the critical condition/gravity in the context of all patients, not only towards those at risk of and with delirium; the latter have been underlined as more demanding, especially those with psychomotor agitation, consequently reducing the nurses' surveillance of stable patients.Patients' cognitive impairments also influence prioritisation, as nurses find themselves spending more time to establish a trusting relationship with the patient, to understand his/her needs and to manage them.

Discussion
To the best of our knowledge, this is the first qualitative study based on scenarios involving expert nurses caring for older patients, with different professional and educational backgrounds to discover reasons informing the process of prioritization in hospitalised older patients at risk of and with delirium.The several reasons emerged, identified at three levels, unit, nurses, and patients, suggest the presence of multifaced factors, interacting each other, that should be considered in designing interventions to promote the best quality of care.
First, priorities in these patients are influenced at different levels of the system as documented in the context of UNC for general patients [21,22]; however, some reasons seem to be specific for patients at risk of or with delirium.Specifically, the inappropriate care environment has been emphasised, but its change is out of the scope of the profession, leaving nurses aware regarding the issues, but ineffective.Programmes, such as the Delirium Room model [32] involving structural, environmental (e.g.lighting) and reorientation tools (e.g.calendar, clock) reduce the duration of delirium [33] but their development is under the responsibility of the hospital.Moreover, nurses have mentioned these reasons without any connection with the scenario administered, suggesting that, also in simulated circumstances, they set priorities as they are used to in the real context, which might highlight the challenges lived by them daily, as well as the barriers that may be encountered in any attempt to change priorities when the environment remains unchanged.
On the other hand, issues in human resources of both nurses and nursing aides [34] have also been mentionedand further affect the care given to patients at risk of and with delirium who require more time to be understood [35] and managed.Patients with delirium increase the workloads of nurses, thus further limiting the time available; also in this case, reasons influencing priorities are out of the responsibility of the nurses.The additional reasons as the need of integration with other healthcare professionals to provide personalised care have been already underlined [36]: however, the lack of time available prevents multiprofessional initiatives, forcing nurses to work alone to save time.On the other hand, some reasons characterising the work and organisation processes, such as the routinised approaches, the lack of tools for delirium assessment and management and the poor continuity across shifts, which may all affect the early identification and the following consistent management of patients with delirium, are under the responsibility of nurses.During night shifts the UNC may increase also in these patients because the lack of human resources.However, nights are seen by our nurses as an occasion to spend more time outside of routine to deliver personalised care, as already documented [37].
Nurses' competences and attitudes also play an important role in the delirium prevention and management: nurses act in coherence with their experience and education [38], and their physical and psychological exhaustion [39] may increase the difficulties in making decisions, leading to routinised interventions.Except for some aspects already documented in the literature (e.g.multitasking, [38]), the different priorities are set around different patterns based upon the safety, the needs and the medical prescriptions: these different patterns of actions, when inconsistent across shifts and nurses, may increase uncertainty in the care of patients at risk of delirium.Nurses have been recognised as important in promptly identifying risks and interventions [5] and should be supported by specific tools (e.g., [40]) for identifying, recognising and managing predisposing and precipitating factors for delirium.As in other settings, awareness and reflexivity are the basis of prioritisation and is influenced by the experience acquired in the specific field [41]; however, recognising risks may be difficult when nurses are not supported with appropriate evidence [42].Therefore, reasons influencing prioritization seems to stimulate both intuitive and analytic reasons processes: the former, when nurses lack in the knowledge, in tools, and in protocols regarding how to manage delirium; the latter, when the risk is assessed according to the experience and knowledge helping in recognising and managing the factors.Therefore, a multilevel strategy, based on mentorship and educational programmes shaping attitudes are needed, for example by identifying expert nurses in delirium prevention and management at the unit level to coach the capacity to identify right priorities and to prevent UNC; undergraduate education also play an important role, as well as postgraduate courses to stimulate continuous awareness and a more consistent and updated 'delirium literacy' among nurses [43].
Finally, the multidimensional frailty of patients seems to have a catastrophic effect on prioritization.Patients with other clinical issues are prioritised, suggesting that delirium is not considered as a relevant clinical condition; moreover, the time required to understand the patients' needs, which may be difficult to identify, is not available: consequently, needs are left unmet.The absence of relatives at the bedside further increases the challenges: family members have already been reported as safe keepers as a source of additional surveillance of patients [44].Therefore, patients without relatives should be further considered at the top of priorities to prevent any form of UNC.
Overall, according to the continuum theory model [38], the time available influences priorities, both because the scarcity of time stimulates the identification of some priorities, and because the care and management of patients with delirium requires time to assess their needs and build a trusting relationship.In this context, the silent and imperceptible risk of delirium leads nurses to postpone or miss some interventions, whereas the explosion of delirium requires immediate prioritization of these patients.Moreover, some reasons affect only the prevention (e.g., living in a hurry), while others only the management phase (e.g., night shifts); however, as most reasons are common to both the prevention and the management, suggesting that a comprehensive strategy may ameliorate the whole prioritization process.

Limitations
This study has several limitations.First, it was conducted during the pandemic and this may have influenced the results given that the process of care and the settings were subjected to several changes; second, there were involved nurses working in medical, geriatric and post-acute settings suggesting that future studies are need to accumulated evidence both in the Italian context (e.g.surgical units) and at the international levels in different health care systems and cultures.Third, the scenario-based data collection process may have prevented the full identification of the reasons influencing the prioritization occurring at the patient's bedside.Fourth, the data analysis involved an interactive and reflexive process, engaging researchers for long time and involving them in all stages.However, thesubjectivity of researchers and the different familiarity with the thematic analysis adopted may have influenced the findings [29].

Conclusions
Nurses are used to prioritising interventions; however, while the reasons influencing the process among hospitalised patients has been investigated to detect why nurses unfinish some activities in favour of others, in the context of older people at risk or with delirium, no data have been collected to date.To the best of our knowledge, this is the first study attempting to identify reasons affecting the prioritization process among these patients.Findings suggest that the process is influenced by reasons set at three levels, some of which are under the nurses' control while others are not, that mainly affect both preventive and managerial interventions.
To promote the right identification of the priorities that may protect older patients from an escalation towards delirium, targeting the (a) resources available at the unit level, the (b) nurses' competence and attitudes and the (c) patient' complexity is crucial.Changes in the environment, and ensuring an effective work and organisation processes through collaboration and integration between professionals, by also providing decision-making support tools, are recommended.In addition, given that the mission of the units, as the devoted to geriatric one seems to influence the prioritization, investments towards nurses working in other settings, are important.Moreover, nurses should be educated and supported in developing competencies and attitudes not only during undergraduate but also in postgraduate and continuing education to promote and update their 'delirium literacy'.
Patients at risk of with delirium play also a role in the prioritization process: they are at risk to be neglected in the beginning because their risks are invisible; later they are still at risk to be receive unfinished care because the increased needs cannot be managed in the context of the care that all patients required.Continuing to investigate the underlying reasons of prioritization is important to accumulate evidence and inform strategies to prevent any form of unfinished care.
chose the second one taking into account the cognitive state, at risk of delirium…' (RN35) M '…Because we say that we are dealing with psychomotor agitation of the patient in progress …' (RN19) RN registered nurses, P preventive interventions, M managerial intervention, n number of interview * means the presence of preventive/management interventions Page 12 of 15

Table 1
The scenario of Mrs. M BP blood pressure, COPD chronic obstructive pulmonary disease, FIO 2 inhaled fraction of oxygen, HR heart rate, RR respiratory rate,

Table 2
Interview guide for clinical nurses: steps and processes Interview guide Presentation Aim of the study and data collection process Consent for interview and for audio-recording (1) First section Sub-scenario regarding the delirium prevention Please indicate, in order of priority, the interventions that you will implement to this scenario Questions Sub-scenario regarding the delirium management Please indicate, in order of priority, the interventions that you will implement to this scenario Questions

Table 3
Reasons informing priorities in preventive and managerial interventions in patients at risk and/or with delirium: levels, themes, subthemes, and quotations