Table 3.

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

Level	Themes	Subthemes	Interventions		Quotations P, preventive M, managerial
			Preventive	Managerial
Unit Level	Inappropriate care environment		*	*	P ‘Then we don’t have dedicated environments for these types of patients …for example a delirium room, single rooms just like a dedicated environment.… it’s very difficult to manage these patients if you don’t have dedicated environments…’(RN40) ‘…Also the lack of dedicated tools to prevent disorientation, like clocks or calendars to help people understand where they are and what time it is so they don’t get disoriented.’ (RN14)
					M ‘…important to have a dedicated room like the delirium room. To care for a much more cognitively complex patient, they need a dedicated room close to the ward room.’(RN46) ‘…there are no calendars, there are no clocks, there are no forms of entertainment…’ (RN28)
	Inadequate Human Resources	Inadequate nurse/patient ratio	*	*	P ‘…the shortage of staff, because the adequate nurse/patient ratio also allows me to give him a shave, which may be a “superficial” thing, but for an elderly person who has no one, this could make his day. It could also change his approach to therapy…’ (RN42)
					M ‘…We could act in a thousand other ways, but we lack the resources, we have very complex patients and minimal resources, such a situation is not easy to manage to guarantee a minimum level of care…’ (RN46)
		Inadequate nursing aides/patient ratio		*	M ‘the nursing aides are an integral part but there is not even one in 44 patients.’ (RN35)
	Issues in the organisation and work processes	Mission of the ward	*	*	P ‘…I instinctively came to reason as we do in the ward with patients who have problems of this kind…So I tried to focus mainly on priority interventions, those that should be done immediately to prevent or manage a delirium episode…’ (RN43)
					M ‘…I looked at the scenario in the ward where I work…. I in my ward I am really alone…’(RN4)
		Ineffective routines	*	*	P ‘…guided not only by theory, but also by what is the reality of my daily practice…’ (RN18)
					M ‘…I have always drawn on clinical practice and everyday life…’ (RN43)
		Inadequate collaboration with other professionals	*	*	P ‘…I still work in a team and there is one thing I would instinctively say…For example, I don’t do it, the doctor does it…. Or other professionals …. In terms of how I work, the line is very blurred. The aspect of working in a team is definitely a priority…’ (RN1)
					M ‘…managing the patient with delirium within the team…’(RN29)
		Lack of shared documents (tools/procedure/protocols/guidelines)	*	*	P ‘…we never make assessments through scales of risk of delirium and with the presence of delirium and we do not have the tools for assessment…we usually assess whether the person is oriented, disoriented, oriented in time and space, we make assessments but not objective ones…’ (RN2)
					M ‘…If we have a cardiac arrest, we know what to do, i.e. we rely on standardised guidelines. I know that if I do this procedure I will get this result. On the other hand, in the case of delirium or a patient at risk of delirium, I don’t have much material, I don’t have procedures, guidelines, let’s say it’s a bit of a grey area, quote unquote, where I don’t have many elements to refer to…’ (RN20)
		Lack of care continuity		*	M ‘… We pass them on, but it happens that some information is omitted, they get lost, something is neglected, we are not infallible, maybe also because I do not follow them all the time…’(RN40)
		Night shifts challenges		*	M ‘… It’s night, so it’s really a different situation and even more complicated, patients generally decompensate at night, it’s easier for them to get confused and so on and the management is more difficult…’ (RN13) ‘… Here at night you have more time for individual care. Why should I not give her an enema or change a bladder catheter or give her chamomile tea…’(RN42)
Nurses Level	Competencies	The value of the contextual professional experience	*	*	P ‘…I think it guided the experience. I had a type of patient, or more than one patient on my mind, guiding me…’ (RN5)
					M ‘…experience helps, but it’s not necessarily true that someone who’s been working for a short time is going to act wrongly compared to someone who’s been working for many years…’ (RN32)
		Issues in the knowledge about Delirium	*	*	P ‘…I honestly don’t have any knowledge about delirium…I haven’t done any courses and at university we’ve had very little to do with it… So I don’t have any theoretical knowledge about managing the patient at risk of or with delirium…’ (RN40)
					M ‘…We are professionals, so we should also be able to assess according to our experience, skills and training…’ (RN9) M ‘…the priority is also based on knowing the patient and on continuity. It’s logical that it changes, if I see him for the first time and not a colleague who is with this patient and has already known him, for example, for 3 weeks of the patient’s stay, this is very important also to build the relationship of trust that is inevitably created between patient and nurse, patient and doctor, patient and nursing aides…’ (RN40)
		The role of the constant awareness and reflexivity	*	*	P ‘…I have concentrated on the assessment of risk factors for delirium; to identify and treat the possible risk factors for delirium. The lady has various risk factors, so go and intervene on them immediately so that they do not become causes of delirium…’ (RN2) ‘…It’s very important to encourage the person to drink, because of course if the person doesn’t drink they will become dehydrated and that can lead to infection and then disorientation…’ (RN5) ‘…Pain is very important, I put it as a priority because very often people can’t express what they have…’ (RN5) ‘…encourage sleep, bad sleep is going to change the next day’s activities anyway, it worsens the cognitive state of the patients…’ (RN7) ‘…also constipation for example, very often people who have not evacuated for a long time start to become very nervous, they show confusion…’ (RN5)
					M ‘…Assess the risk factors that led to the restlessness, understand why the person had this change…’ (RN5) ‘…as it is 03:00 in the morning, I have included among the priority interventions those that assess sleep activity and promote it… elements that could disturb it…’ (RN2) ‘…I have also given importance to the evaluation of the prevention of changes in intestinal elimination…’ (RN18) ‘…I would have invited her and I would have offered her, I don’t know, some tea instead of some water and I would have made her go into the room…’ (RN26) ‘…patient is confused so she is not able to express the pain, my attention is also focused on the pain by assessing it through the scale and finally treating the pain…’ (RN16)
		Communication abilities	*	*	P ‘…We try to talk, let them express their thoughts…’ (RN52)
					M ‘… I concentrated on what to do first to calm the patient down. Right now the patient is agitated and my thought is to communicate with her, to try to calm her down, to make her understand where she is, to assess her state of agitation through communication…’ (RN2)
		Time management skills	*	*	P ‘…I have concentrated on what you should try to do in the first few hours, then the other interventions are postponed to a later time…’ (RN43) ‘…I prioritised according to a temporal moment…’ (RN25)
					M ‘…Unfortunately, sometimes you realise that there are many things that cannot be done because of lack of time. …With this type of patient…you should have a little more personal support, but you can’t because you have so many things to do during a shift…’ (RN11)
	Attitudes	Being challenged by decisions	*	*	P ‘…so setting the priority and the hardest thing to do, I felt like I was betraying my ideals by putting some things aside…maybe because in practice the distinction is not so clear…like to say maybe because now you think with a cool mind…’ (RN1)
					M ‘…I hate making these decisions. Eh, but it can still be an important one…’ (RN42)
		Living in hurry	*		P ‘…a nurse who is in a hurry and a nurse who does not give her best to the patient and to the patient…’ (RN42)
		Being able to do things simultaneously	*	*	P ‘…There are many interventions that we do in practice at the same time… For example, while I am giving the therapy, I am trying to talk to her to calm her down and give her some instructions… That’s the point of doing things at the same time. I have to rationalise every moment…’ (RN26)
					M ‘…because you can’t choose, that is, it should be one, some things overlap with others…for example, the presence of the family member overlaps with the education of the family member…In my opinion, many activities can be done in an integrated way, none of it is separate, everything can be integrated safely…’ (RN42)
		Shaping priorities around  Safety for all as first,  Basic needs as first, or  Prescriptions as first	*	*	Safety as first P ‘…to ensure the safety, especially of the person who is at risk of delirium, because they cannot see where they are hurting themselves and we have to prevent them from hurting themselves…’ (RN46)
					M ‘…That of reassuring the patient, avoiding all interventions of restraint. I look first for other ways, other solutions…’ (RN23) ‘…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)
			*	*	Basic needs as first P ‘…Having done that, I would tailor interventions according to the person’s needs…’ (RN29) M ‘…The patient has needs now, needs that are present even if they are not expressed. I focus on the needs that the patient has in this moment of delirium, for example the need to sleep…’ (RN48)
				*	Prescriptions orders as first M ‘…Autonomy and also the ability to respond promptly and correctly to what the doctor tells you and asks you. I am the one who assesses the situation and intervenes…’ (RN34)
Patient Levels	Multidimensional frailty	Unavailable caregivers/relatives	*	*	P ‘…the person’s autonomy must be maintained as much as possible to avoid decompensation again so the nutritional intake must be … assessed.’ (RN33)
					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 state	*	*	P ‘…I 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