An exploratory study of staff nurses' knowledge of delirium in the medical ICU: an Asian perspective

Knowledge, barriers, and training needs of nurses working in delirium care

BACKGROUND

Nurses' competency in delirium care is important because delirium can extend hospitalization and increase patient mortality.

AIM

This study aimed at identifying and comparing the perceived knowledge, barriers, importance, performance, and training priorities between the intensive care unit (ICU) and ward nurses working in delirium care.

STUDY DESIGN

This cross-sectional descriptive study included 71 ICU nurses and 149 ward nurses at one university hospital. Nurses' self-reported knowledge, barriers, importance, and performance of delirium care were surveyed. Data were analysed using descriptive statistics, chi-squared test or Fisher's exact test, Wilcoxon signed-rank tests, Mann-Whitney U tests, and the importance-performance analysis matrix.

RESULTS

Compared to ward nurses, ICU nurses reported lower overall knowledge level (57.1% vs 60.7%, z = -2.005, P = .045) but higher overall gap between the importance and performance of delirium care (0.5 vs 0.2, z = -4.008, P < .001). The level of overall barriers to delirium care was similar between the two groups (3.8 vs 3.8, z = -1.190, P = .234). The highest training priority, showing high importance but low performance in the importance-performance matrix, was "family involvement and education" for ICU nurses and "non-pharmacological management" for ward nurses.

CONCLUSIONS

The highest training priority for delirium care was different between ICU and ward nurses. To enhance the delirium care competency of hospital nurses, the nurse educator should develop training programs that target knowledge deficits, perceived barriers, and training priorities.

RELEVANCE TO CLINICAL PRACTICE

Acute cognitive disturbances are common in patients hospitalized in wards and ICUs and can lead to adverse patient outcomes if not properly assessed and managed. Nurse educators need to develop and implement a training program based on the needs assessment and priorities identified in this study so that ICU and ward nurses can obtain the optimal level of delirium care competency.

Improving Nurses Knowledge and Practices of Delirium Assessment at Mbarara Regional Referral Hospital: A Quasi Experimental Study

BACKGROUND

Despite the recommendations for delirium assessment in clinical settings, it stills remain a serious clinical problem associated with prolonged mechanical ventilation, stress on the patient and family, and mortality. There is paucity of data regarding delirium assessment and prevention in developing world. The Confusion Assessment Method for Intensive Care Unit (CAM-ICU) was developed to aid in the assessment of delirium. There is no documented assessment of delirium and prevention in Uganda. This study evaluated the effect of an educational intervention on nurses' knowledge and practices of delirium assessment using the CAM-ICU tool.

METHODS

We used a quasi-experimental and recruited a convenience sample of 29 nurses from ICU and ER. The assessment before and after the interventions was conducted using a self-completed questionnaire from October 2020 to January 2021. The interventions were delivered through face-to-face presentations, demonstrations, watching videos, and hands on practice. Data were entered into excel, cleaned and exported to Stata version 14. Median and interquartile ranges were used for continuous variables, and frequencies and percentages for categorical variables. The mean knowledge score was calculated before and after the intervention. A paired t-test was used to compare Pre- and Post-test knowledge and practice scores at P <0.05.

RESULTS

Majority (62%) were female, 48% were Diploma holders, median age was 30 (IQR = 28-32) years and median years of experience 3.5 (IQR = 3-4). The Mean knowledge scores was 10.7 (SD = 2.36) pretest and 19 (0.94) posttest. The mean practice score was 2 (SD = 0.83) pretest and 6 (0.35) posttest. There were significant differences in mean knowledge and practice scores before and after intervention mean of (t (28) =17.32, p < 0.001) and (t (28) = 25.04, p<0.001), respectively.

CONCLUSION

Educational intervention Improved nurses' knowledge and practice of delirium assessment. Continuous nursing education could improve nurses' knowledge of delirium assessment and thus quality of patient care.

[Development and content validity of a questionnaire to assess knowledge about delirium]

BACKGROUND

Delirium is a neuropsychiatric syndrome that can have serious consequences and is often overlooked by healthcare professionals. The level of knowledge about delirium is often insufficient among nursing and medical staff. At the current time there is no suitable questionnaire to record the level of knowledge in German-speaking countries.

AIM

Development of a questionnaire and evaluation of content validity.

METHODS

Following a literature search to identify current best practice, several questionnaires were identified. An already published questionnaire with the dimensions of basic knowledge of delirium and risk factors has been translated, adapted and extended by the dimension of nonpharmacological delirium prevention. Delirium experts assessed the relevance of the questionnaire items in two rounds of reviews. Content validity was calculated using the Content Validity Index (CVI) at item (I-CVI) and scale (S-CVI) level. Additionally, the modified Kappa (k*) was calculated using a lower 95% confidence interval (CI).

RESULTS

The original 30-item questionnaire was expanded to include 18 delirium prevention items. After the first round of scoring 30 out of 48 items showed good to excellent I‑CVI scores. Considering the comments, 6 items were discarded and 12 were adapted in terms of language and content. In the final version of the questionnaire 41 items with excellent scores remained. The total scale score increased from 0.88 in the first version to 1.0 in the final version. Nurses were identified as the target group, potentially also therapists and medical personnel.

CONCLUSION

The delirium knowledge questionnaire is content-valid.

Self-efficacy of caring for patients in the intensive care unit with delirium: Development and validation of a scale for intensive care unit nurses

BACKGROUND

Improving the self-efficacy of intensive care unit nurses for delirium care could help them adapt to the changing situation of delirium patients. Validated measures of nurses' self-efficacy of delirium care are lacking OBJECTIVES: The objective of this study was to develop a Delirium Care Self-Efficacy Scale for assessing nurses' confidence about caring for patients in the intensive care unit and to examine the scale's psychometric properties.

METHODS

Draft scale items were generated from a review of relevant literature and face-to-face interviews with intensive care unit nurses; content validity was conducted with a panel of five experts in delirium. A group of nurses were recruited by convenience sampling from intensive care units (N = 299) for item analysis of the questionnaire, assessment of validity, and reliability of the scale. Nurse participants were recruited from nine adult critical care units affiliated with a hospital in Taiwan. Data were collected from August 2020 to July 2021.

RESULTS

Content validity index was 0.98 for the initial 26 items, indicating good validity. The critical ratio for item discrimination was 14.47-19.29, and item-to-total correlations ranged from 0.67 to 0.81. Principal component analysis reduced items to 13 and extracted two factors, confidence in delirium assessment and confidence in delirium management, which explained 66.82% of the total variance. Cronbach's alpha for internal consistency was 0.94 with good test-retest reliability (r = 0.92). High scale scores among participants were significantly associated with age (≥40 years), work experience in an intensive care unit (≥10 years), delirium education, and willingness to use delirium assessment tools.

CONCLUSIONS

The newly developed Delirium Care Self-Efficacy Scale demonstrated acceptable reliability and validity as a measure of confidence for intensive care nurses caring for and managing patients with delirium in the intensive care unit.

The training needs of Korean intensive care unit nurses regarding delirium

OBJECTIVES

The aim of this study was to investigate high-priority training needs by analysing the perceived importance and self-reported performance of nurses' delirium care competency.

DESIGN

A cross-sectional survey with a convenience sample of 255 Korean intensive care units nurses.

SETTING

Intensive care units in the Republic of Korea.

MAIN OUTCOME MEASURES

Intensive care unit nurses' delirium care competency.

RESULTS

Exploratory factor analysis of the Nurse Delirium Care Competency Scale showed a six-factor structure, which accounted for 67.51% of the variance in nurses' delirium care competency: management algorithm, prevention, communication, nursing management, assessment, and collaboration. The self-reported performance scores of all six factors were significantly lower than their perceived importance scores. The delirium assessment factor was identified as a high training priority on the importance-performance matrix for new graduate nurses.

CONCLUSION

Training programmes should be developed considering the six delirium care competency factors identified in this study. Further, nurse educators must adopt active educational modalities such as case-based small group learning and simulation-based learning to improve nurse competency in recognising and managing delirium.

Review of the Literature on the Occurrence of Delirium after Veno-Venous and Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is an extracorporeal gas exchange method which, despite a number of advantages, carries the risk of many complications. ECMO is a modern intensive care method which in many cases is the last resort for the patient. Care and supervision are provided by a multidisciplinary team of specialists: physicians, perfusionists, and nurses. The aim of this review is to analyze the occurrence of delirium in ECMO patients.

METHODS

Both authors independently extracted data from all included trials and assessed the risk of bias. A systematic review was performed using the protocol of the Cochrane Collaboration Risk of Bias tool. The search was based on PubMed, Web of Science, and Mendeley. Three articles from recent years have been analyzed in this work. Literature selection was made using the PRISMA checklist. The analyzed literature proves how important the topic of delirium is in ECMO therapy. In the case of pharmacotherapy, there are many combinations of drugs that prevent the occurrence of the delirium phenomenon.

RESULTS

This work deals with the subject of delirium after ECMO, which is not a common subject in the popular literature. Many of the elements mentioned in the articles analyzed show how important this topic is. The authors place great emphasis on the elements which are not related to pharmacotherapy and the prevention of delirium. For the prevention of delirium after ECMO, a psychological approach to the patient is important. As far as pharmacotherapy is concerned, it is the last element to be taken into account in the prevention of delirium in ECMO patients. An overview of the literature indicates that the subject of nursing care has been omitted; however, there are tools which allow nurses to assess delirium in patients.

CONCLUSION

Delirium in patients undergoing ECMO therapy is a topic that has not been fully described in the literature. This review of the literature shows how important it is to treat a patient with delirium during this therapy and how important it may be to have an early diagnosis of delirium to prevent complications.

Development of a Tool for the Assessment of Nurses' Attitudes Toward Delirium

BACKGROUND AND PURPOSE

The prevalence of delirium during hospitalization is high in older patients and there is evidence of staff regarding them as unpopular or a burden. This study aims to develop an instrument examining nurses' attitudes toward patients with delirium.

METHODS

Stages included (a) content identification, (b) content development, (c) content critique, (e) pilot study with a test-retest reliability, (f) field study consisting of psychometric testing of the internal consistency and construct validity.

RESULTS

The Cronbach's alpha was 0.89 and the stability reliability was acceptable. The factor analysis resulted in three factors explaining a total of 56.5% of the variance. hese factors are "beliefs," "behavior," and "emotions," explaining 37.025%, 12.792%, and 5.652% of variance.

CONCLUSIONS

The Attitude Tool of Delirium (ATOD) is a reliable and valid instrument for the assessment of attitudes toward delirium.

Educational intervention on delirium assessment using confusion assessment method-ICU (CAM-ICU) in a general intensive care unit

AIMS AND OBJECTIVES

To assess intensive care unit nurses' knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses' perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives.

BACKGROUND

Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools.

DESIGN

This study, performed in Malaysia, used a single-group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment.

METHODS

Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and postintervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance.

RESULTS

There were significant differences in the knowledge scores pre- and postintervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision-making" and "difficult to interpret delirium in intubated patients".

CONCLUSIONS

Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and interprofessional involvements are essential for a successful implementation of intensive care unit delirium assessment practice.

RELEVANCE TO CLINICAL PRACTICE

This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings.

Nurses' knowledge about perioperative care of patients with neurological diseases

This study investigated the level of nurses' knowledge regarding the perioperative care of neurological patients. An author-developed questionnaire of 20 items was used in a sample of 94 hospital nurses serving in the neurology, surgery and anesthesiology departments and the intensive care unit. The average percentage of participants with correct answers was 49.2%. The mean value of participants' score was 9.8 ±3.4. Preexisting experience in the care of cases with multiple sclerosis and Parkinson's disease was positively related to the level of knowledge (p = 0.001 and 0.014 respectively). The ascertained level of nurses' knowledge regarding the perioperative care of neurological patients was moderate, questioning their adequacy to handle such cases. Previous experience in the care of particular diseases had significantly positive impact on knowledge, suggesting potential improvement strategies through targeted education and specialization of nurses. In conclusion, nurse's knowledge regarding perioperative care of neurological patients was insufficient, requiring appropriate improvement interventions.

Prevention, recognition and management of delirium in patients who are critically ill

Delirium is common in patients who are critically ill, often resulting in extended hospital stays and increased mortality and morbidity. There are several subtypes of delirium, which are often undiagnosed and untreated, resulting in suboptimal patient outcomes. This article examines delirium in patients in the intensive care unit, including its signs and symptoms, incidence, causes and subtypes. It outlines the assessment of delirium and the pharmacological and non-pharmacological interventions that can be used to manage the condition, as well as describing the optimal prevention measures.

The early diagnosis and management of mixed delirium in a patient placed on ECMO and with difficult sedation: A case report

Delirium represents a serious problem that impacts the physical and cognitive prognosis of patients admitted to intensive care units and requires prompt diagnosis and management. This article describes the case and progress of a patient placed on Extracorporeal Membrane Oxygenation with difficult sedation criteria and an early diagnosis of mixed delirium. During the case report, we reflect on the pharmacological and non-pharmacological strategies employed to cope with delirium paying special attention to the non-use of physical restraint measures in order to preserve vital support devices (endotracheal tube or Extracorporeal Membrane Oxygenation cannula). The multimodal and multidisciplinary approach, focused on nursing interventions, strict Pain/Agitation/Delirium monitoring and pharmacological measures, as well as the implementation of measures according to the eCASH (early Comfort using Analgesia, minimal Sedatives and maximal Human Care) concept, were effective, resulting in a relatively short admission considering the severity of the patient's condition and the associated complications. Early independent ambulation was achieved prior to transfer to a hospitalisation unit.

Critical care nurses' knowledge and practice of delirium assessment

AIMS

The aim of this study was to examine perceived barriers to assessment of delirium for critical care nurses, and the impact of education on their knowledge and practice.

BACKGROUND

Delirium is a significant problem in critical care, leading to increased morbidity and mortality. Many authors have found variations in assessment by critical care nurses, but there has been limited analysis of the reasons for this. Education on the topic improves knowledge and practice, but the best approach has not been examined.

DESIGN

A questionnaire survey design.

METHODS

A self-reported questionnaire was distributed to critical care nurses (n=31) at a district general hospital. Data were analysed with descriptive statistics.

RESULTS

Knowledge and practice were variable, but correlation was seen between nursing band and years of experience with better scores. Any type of education led to significantly improved scores. Several barriers to assessment were found, with the most common being lack of knowledge and difficulty in assessing intubated patients.

CONCLUSION

It is essential to improve practice in delirium assessment and management. Education is vital to improve the knowledge and practice of critical care nurses regarding delirium.

Cardiovascular surgery nurses' level of knowledge regarding delirium

BACKGROUND

Studies have shown that nurses have a crucial role in the recognition of delirium; however, they have insufficient knowledge regarding the issue.

OBJECTIVE

The aim of the study is to determine the knowledge level of cardiovascular surgery nurses regarding delirium.

METHODS

A survey design was used. The population of the study consisted of 124 nurses employed at the cardiovascular surgery wards and intensive care units of universities as well as state and private hospitals located in two different cities in Turkey between May and June 2014. The sample consisted of 97 nurses employed at the aforementioned institutions and time. Data were collected using the questionnaire form depicting the demographic characteristics of the nurses and the knowledge form including the level of nurses' knowledge regarding delirium. For the evaluation of data, number, percentage, Kruskal-Wallis, Mann-Whitney U- and independent-samples t-test were used.

RESULTS

Nurses were between 18 and 47 years of age with a mean 29·8 (SD = 6·80, the youngest = 18 and the oldest = 47) years. They spent a minimum of 1, a maximum of 25 and a median value of 3 (interquartile range, IQR: 5) years working in cardiovascular surgery. As for the scores received from the knowledge form regarding delirium, the lowest was zero, the highest was 60, and the average score was 41·18 ± 12·50 (a moderate level of knowledge). It was found that the nurses working in intensive care units, those who were chief nurses and those who received in-service training scored higher than the others.

CONCLUSIONS

Cardiovascular surgery nurses had a moderate level of knowledge regarding delirium. This may result in the neglect of delirium or a misdiagnosis.

RELEVANCE TO CLINICAL PRACTICE

It is recommended that training is provided that includes recognition, assessment and application of appropriate interventions to minimise the incidence of delirium.