Aim To develop an implementation plan for delirium prevention. Background The use of non‐pharmacological interventions to prevent hospital‐acquired delirium is well established but their implementation has been notoriously difficult to achieve. Systematic analysis of context as part of implementation planning is critical. Methods Ethnographic study was conducted in a 24‐bed general medical ward. Eleven patients and family members and 15 health service staff participated through observations, individual interviews and document review. Inductive analysis was used to generate themes that described enablers and barriers. Results Enablers included a ward culture that embraced safety and placing the person at the centre of care. Barriers were in tension with the enablers and included limited staff knowledge, specialist forms exclusive to the nursing discipline, inflexible ward routines and frequent disruptions. Conclusions In addition to standard implementation strategies such as individual education and leadership, implementing delirium prevention requires consideration of team practices, review of policy document design and identification of outcomes data than can support collaborative reflexive practice. Implications for Nursing Management The use of a theory‐informed ethnographic approach exposed tensions that may be otherwise invisible. Understanding the tensions increases the likelihood of implementation success. Using a systematic assessment approach can create a comprehensive implementation plan.

Objectives: to explore patients' experiences of an individualised yoga therapy intervention for rheumatoid arthritis (RA), specifically in terms of its acceptability and impact on patientreported outcomes.Design: Ten patients took part in a 16 week yoga therapy intervention in a hospital setting, consisting of 10 one-to-one consultations with a yoga therapist followed by two group review sessions. Changes in health (EQ-5D, HADS) were assessed pre-and post-intervention and at 12-month follow-up. In-depth interviews were conducted post-intervention and analysed using thematic analysis.Results: Attendance of the 1-to-1 sessions was high (98%) and all participants reported strong commitment to their personalised home practice. There were significant improvements in measures of depression, anxiety, pain, quality of life and general health at post-intervention and 12-months (p<0.05). In interviews, all but one participant reported positive changes to their symptoms and several reported reductions in their medication and broader benefits such as improved sleep, mood and energy, enabling re-engagement with life. The personally tailored nature of the practice and perceived benefits were key motivational factors. Particular value was placed on the therapeutic function of the consultation and provision of tools to manage stress and build resilience. Conclusion:This yoga therapy intervention was positively received by patients with RA, with high levels of adherence to both the treatments and tailored home practice. The findings suggest that yoga therapy has potential as an adjunct therapy to improve RA symptoms, increase self-care behaviours and manage stress and negative affect such as anxiety. A larger multi-centre study is therefore warranted.

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Objectives The aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care. Methods A prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 ‘A’s test (4AT), with a score >0 indicating cognitive impairment (1–3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire. Results In all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers. Conclusions Cognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers. What is known about the topic? Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment. What does this paper add? This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care. What are the implications for practitioners? Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.

Aims Fundamentals of care are particularly important for older people in acute inpatient settings, who are at increased risk of serious hospital‐associated complications like delirium and functional decline. These complications occur due to interactions between clinical complexity and the complex processes and context of hospital care and can be reduced by consistent attention to the fundamentals of care. This paper aims to illustrate of how multi‐level nursing leadership of fundamentals of care can be supported to emerge within complex multidisciplinary delivery systems in acute care. Design Discussion paper informed by clinical and organizational experience of a multidisciplinary leadership team and complexity leadership theory. Data sources We provide a series of vignettes as practical illustrations of a successful multidisciplinary improvement program called Eat Walk Engage which supports the delivery of better care for older inpatients, significantly reducing delirium. We argue that taking a broader complexity‐based approach including collaborative multidisciplinary engagement, iterative and integrated interventions and appropriate knowledge translation frameworks can enable emergent leadership by nurses at all levels. Implications for nursing This promising approach to improving care for older patients requires organizational support for facilitation and reflective practice, and for meaningful data to support change. Our discussion challenges nursing leaders to support the time, agency and connections their nursing staff need in order to emerge as local leaders in fundamental care. Conclusion The debate around scope and responsibilities for fundamentals of care in hospital care has important practical implications for conceptualizing leadership and accountability for improvement. Impact Our discussion illustrates how a structured multidisciplinary approach that acknowledges and navigates complexity can empower nurses to lead and improve outcomes of older patients in acute care.