Fidelity
delirium
SIL
Changes in ward ethos varied and appeared to be linked to the implementation climate, dose delivered and reach. Staff at ward C, where implementation went well, talked about changes in approach.Occupational Therapist: I think as [senior nurse] highlighted, it’s [PERFECT-ER] brought an awareness of delirium… I have had a sense of that amongst the nursing colleagues …people are a lot more sensitive and patient and maybe provide better care maybe.Senior Nurse: Yeah I agree. (Focus Group, Ward C)Some participants indicated PERFECT-ER provided a guiding philosophy for staff.PERFECT-ER is our ward philosophy do you know what I mean? … it actually is part of their [Ward staff’s] umm vision part of their thinking about their patient care (SIL, Ward A)Whereas, in Ward E which struggled to implement, there was no ethos change.Occupational Therapist: As far as the PERFECTED Ward goes I am not sure how much it has really, it has sort of changed our practice as such because we kind of work to enable people anyway…Lead Occupational Therapist: Yeah, I am still not a 100% clear about the different check lists …that makes it the PERFECTED Ward …I don’t think it is something that is obvious what we are working towards. (Focus Group, Ward E)Many aspects of PERFECT-ER were implemented as intended. However, the intervention was developed with one SIL intended as the appointed implementation leader. Whereas two wards employed three individuals to conduct the SIL role between them.I do not feel I have been very supported by the other SILs …due to workload on the project ward and lack of staff. (SIL, Ward E)…my management team, they tried to give an hour or two on occasional days …subject to how busy the ward was so found that majority of the times this ended up not being used. (SIL Report, Ward D)In these wards, readiness for implementation was limited by organisational commitment of resources. SIL time was not protected and teamwork between SILs was lacking.Two SILs from these wards (D and E) changed their own practices by ensuring PERFECT-ER documents were present in patients’ notes instead of encouraging ward practices to change in a sustainable way.…folders of these patients checked, and appropriate documentation placed in bedside folders. (SIL Report, Ward D)The PERFECT-ER checklist was designed to be completed from documentary evidence, however two SILs, again from wards D and E, described using other evidence to complete their checklist.…also standing at the end of the bed and looking …so I use quite a lot of things to get the information …you can find it in lots of different places and from obviously talking to staff as well. (SIL, Ward E)