A Delirium Screen Nobody Uses: Choosing Among Implementation Theories, Models and Frameworks for a Step-Down Unit, and Why PARIHS and CFIR Answer Different Questions
[Student Name]
University of Phoenix
DNP/705: Philosophy, Theory, and Science for Nursing Practice
Week 5 Assignment
[Instructor Name]
[Date]
The unit and scenario are composites written for a model paper.
Eighteen months ago, our 24-bed step-down unit added a validated delirium screening tool to the nursing flowsheet, to be completed every shift. An audit last month showed it was completed on 31% of shifts, and when it was completed, positive screens rarely led to any action. Delirium is common in our older patients and linked to longer stays and higher mortality. The evidence for screening is sound; implementation has failed. This paper uses implementation theory to understand why and to plan a relaunch.
Sorting the Theories
Nilsen (2015) proposes a taxonomy of theoretical approaches in implementation science with three aims: describing or guiding the process of translating research into practice, understanding or explaining what influences implementation outcomes and evaluating implementation. He identifies five categories: process models, determinant frameworks, classic theories, implementation theories and evaluation frameworks. The taxonomy helps me see that I need two kinds of guidance: a framework to explain why screening failed and a structure to evaluate a relaunch.
Why the First Rollout Failed
Our first rollout followed an informal process: education by email, a flowsheet change and a go-live date. No one assessed the unit's readiness, identified barriers or assigned anyone to support nurses. Measured against the taxonomy (Nilsen, 2015), we used neither a determinant framework to understand barriers nor an evaluation framework to track implementation.
PARIHS as a Diagnostic Lens
Kitson et al. (1998) proposed that successful implementation of research into practice is a function of the interplay of three elements: the level and nature of the evidence, the context into which it is placed and the way the process is facilitated. They argued that all three should have equal standing, contrary to the assumption that strong evidence alone ensures uptake.
The evidence was strong; the context was busy and the facilitation was an email. PARIHS predicted the result.
Evidence
The research evidence for delirium screening is strong, but nurses' experiential evidence was not considered. In interviews, several nurses said the tool felt pointless because positive screens did not lead to physician action. Patient evidence, such as family reports of confusion, was not incorporated either. By PARIHS, the evidence element was only partly strong.
Context
Our unit's context includes high turnover, a culture focused on hemodynamic monitoring, no protocol for what to do after a positive screen and leadership that did not review screening data. Kitson et al. (1998) described context as encompassing culture, leadership and evaluation. Each was weak for this change.
Facilitation
Facilitation was nearly absent: no champion, no bedside support, no feedback. Given weak context and partial evidence, PARIHS would predict that strong facilitation was needed to succeed.
CFIR for Planning and Evaluation
Damschroder et al. (2009) developed the Consolidated Framework for Implementation Research by merging overlapping constructs from earlier theories into five groups: the innovation's own features, pressures from beyond the hospital walls, the unit's internal climate and structures, the clinicians expected to adopt it and the sequence of planning, engaging, executing and reflecting. They designed CFIR to promote consistent evaluation of what works where and why across contexts.
Applying CFIR to the Relaunch
Intervention characteristics: I will reduce the screening burden by using a brief tool and pairing it with a clear response pathway so positive screens lead to action. Outer setting: our hospital's participation in a regional quality collaborative provides external incentive. Inner setting: I will ask the unit manager to review screening rates weekly at huddles, a sign of leadership engagement. Individuals: I will assess nurses' knowledge and beliefs about delirium and address the belief that screening is pointless. Process: I will recruit two nurse champions, plan a staged launch, engage physicians in the response pathway and reflect on progress every two weeks.
What Nurses Said
Focus groups with day and night nurses added detail the audit could not. Night nurses said the screen was hard to complete when patients were asleep and they were unsure whether to wake them. Day nurses said physicians dismissed positive screens as "sundowning." Several nurses were unsure how to score inattention. Each of these maps onto a CFIR domain: the intervention's design, the inner setting's physician culture and individuals' knowledge.
The Response Pathway
A screen without a response is a form without a purpose. With the hospitalist group, I drafted a pathway: a positive screen prompts the nurse to review medications, check for pain, retention and constipation, begin nonpharmacologic measures such as reorientation and sleep protection and notify the provider, who reviews the patient within the shift. Making the screen lead somewhere addresses the nurses' belief that it was pointless.
Why Two Frameworks
PARIHS gave a simple, memorable diagnosis for the failure: strong research evidence, weak context, absent facilitation. CFIR offers a more detailed checklist for planning and a common language for evaluating what changes. Nilsen (2015) notes that approaches in different categories serve different purposes, and using them together reflects that.
Readiness Before Relaunch
Before the relaunch, I will survey nurses on their readiness for the change, including whether they see delirium as a problem worth addressing and whether they believe the unit can support the screen. Low readiness in one area, such as physician engagement, will be addressed before go-live rather than discovered afterward.
Change Theory in the Background
Classic change theories, such as those describing unfreezing and refreezing, remain useful for explaining the human side of change. For this project, they inform how I prepare staff but do not replace the implementation frameworks, which address evidence, context and organizational factors more fully.
Choosing Champions
Champions will be one day and one night nurse, chosen by peers rather than appointed, since credibility with colleagues matters more than title. They will receive four hours of training, attend weekly huddles and model screening at the bedside. PARIHS emphasizes that facilitation is a role requiring skill and support, not only enthusiasm (Kitson et al., 1998).
Sustaining the Change
Implementation does not end at go-live. Screening rates and response rates will be reviewed at monthly staff meetings for a year, and new nurses will be taught the screen and pathway during orientation. If rates fall, the champions and I will return to the CFIR domains to find the cause.
Evaluation
I will measure screening completion, the proportion of positive screens followed by action within 24 hours, nurses' knowledge and beliefs before and after and delirium-related outcomes such as restraint use. CFIR constructs will guide interviews at three months to understand what helped and hindered.
Conclusion
Our delirium screening failed because strong research evidence was introduced into a weak context without facilitation, a pattern PARIHS explains well. A taxonomy of implementation approaches clarified that I need both a diagnostic lens and a planning and evaluation framework. CFIR structures a relaunch that attends to the screen's design, the unit's culture, nurses' beliefs and a staged launch, with measures to judge whether implementation succeeds.
References
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7(3), 149-158. https://doi.org/10.1136/qshc.7.3.149
Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science, 10, Article 53. https://doi.org/10.1186/s13012-015-0242-0
How this DNP 705 Week 5 example is structured
The DNP/705 Week 5 work usually examines change and implementation theories. This paper first sorts the many available approaches by purpose, then applies two complementary frameworks to one stalled practice change, showing how each shapes diagnosis and action. Students search this week as DNP 705 Week 5, DNP705 Wk 5 or DNP/705 Wk 5; all three are the same assignment.
DNP/705 Week 5 questions, answered
What does DNP/705 Week 5 usually ask for?
Many sections ask students to examine change and implementation theories and apply one or more to a practice change, explaining how the theory guides implementation.
What is the difference between a process model and a determinant framework?
Process models describe the steps of translating research into practice, while determinant frameworks identify the factors that help or hinder implementation, such as characteristics of the intervention, the setting and the people involved.
What does PARIHS stand for?
Promoting Action on Research Implementation in Health Services, a framework proposing that successful implementation depends on the nature of the evidence, the context and how the process is facilitated.
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