A qualitative study on experience of nurses caring for patients with delirium in ICUs in China: Barriers, burdens and decision making dilemmas

Nurse anesthetists' perceptions and experiences of managing emergence delirium: A qualitative study

BACKGROUND

This study employs a descriptive phenomenological approach to investigate the challenges anesthesia nurses face in managing emergence delirium (ED), a common and complex postoperative complication in the post-anesthesia care unit. The role of nurses in managing ED is critical, yet research on their understanding and management strategies for ED is lacking.

AIM

To investigate anesthetic nurses' cognition and management experiences of ED in hopes of developing a standardized management protocol.

METHODS

This study employed a descriptive phenomenological approach from qualitative research methodologies. Purposeful sampling was utilized to select 12 anesthetic nurses from a tertiary hospital in Shanghai as research subjects. Semi-structured interviews were conducted, and the data were organized and analyzed using Colaizzi's seven-step analysis method, from which the final themes were extracted.

RESULTS

After analyzing the interview content, four main themes and eight subthemes were distilled: Inefficient cognition hinders the identification of ED (conceptual ambiguity, empirical identification), managing diversity and challenges (patient-centered safe care, low level of medical-nursing collaboration), work responsibilities and pressure coexist (heavy work responsibilities, occupational risks and stress), demand for high-quality management (expecting the construction of predictive assessment tools and prevention strategies, and pursuing standardized management processes to enhance management effectiveness).

CONCLUSION

Nursing managers should prioritize the needs and suggestions of nurses in order to enhance their nursing capabilities and provide guidance for standardized management processes.

Non-pharmacological delirium prevention practices among critical care nurses: a qualitative study

Background

Delirium is common among critically ill patients, leading to increased mortality, physical dependence, and cognitive impairment. Evidence suggests non-pharmacological delirium prevention practices are effective in preventing delirium. However, only a few studies explore the actual implementation and its associated challenges among critical care nurses.

Aim

To explore critical care nurses’ perceptions of current non-pharmacological delirium prevention practices in adult intensive care settings, including delirium screening, early mobilisation, sleep promotion, family engagement, and sensory stimulation.

Methods

A qualitative design adopting a thematic analysis approach. Semi-structured interviews with 20 critical care nurses were conducted in ten acute hospitals in mainland China.

Results

Three themes emerged: (a) importance of family engagement; (b) influence of organisational factors, and (c) suggestions on implementation. The implementation of non-pharmacological delirium prevention practices was limited by a strict ICU visitation policy, lack of routine delirium screening and delirium training, light and noise disturbances during nighttime hours, frequent resuscitation and new admissions and strict visitation policy. Case-based training, adopting a sensory stimulation protocol, and family engagement may be enablers.

Conclusion

ICU care routine that lacks delirium assessment and the strict family visitation policy made it challenging to implement the complete bundle of non-pharmacological practices. Resource deficiency (understaffing, lack of training) and ICU environment (frequent resuscitation) also limited the implementation of non-pharmacological practices. Clinicians could implement case-based training and sensory-stimulation programs and improve communication with family caregivers by instructing family caregivers to recognise delirium symptoms and delirium prevention strategies.

Knowledge, attitude, and practice toward delirium and subtype assessment among Chinese clinical nurses and determinant factors: A multicentre cross-section study

BACKGROUND

Delirium, a confused transient state of consciousness, can be divided into hyperactive, hypoactive, mixed, and no motor subtypes, according to different clinical manifestations. Several studies have investigated delirium subtypes in the knowledge dimension, but few studies have investigated delirium subtype in the attitude and practice dimensions. The barriers, knowledge sources, and practice details regarding subtype assessment are unclear.

OBJECTIVES

This study had three objectives. First, we planned to investigate the KAP status regarding delirium and subtypes for nurses. Second, we wanted to identify factors affecting clinical nurses' KAP scores. Third, this study expected to explore more details regarding delirium and subtypes assessment, including assessment barriers, assessment instruments, and knowledge sources.

METHODS

This multicentre cross-section study was conducted in 10 tertiary hospitals in three provinces, China, from January to April 2022. We investigated 477 nurses from six departments with a high prevalence. The self-developed KAP questionnaire regarding delirium and subtypes assessment had four parts: knowledge, attitude, practice, and source. Its reliability and validity were verified effectively by 2-round Delphi expert consultation.

RESULTS

A total of 477 nurses from the general intensive care unit (ICU), specialty ICU, orthopedics, thoracic surgery, operating room, and geriatrics were 28.3, 22.4, 22.2, 10.5, and 5.2%, respectively. The total KAP score regarding delirium and subtypes assessment was 60.01 ± 6.98, and the scoring rate was 73.18%. The scoring rate for knowledge, attitude, and practice was 58.55, 83.94, and 51.70%, respectively. More than half (54.1%) were unaware of the delirium subtypes assessment instruments. A total of 451 (94.6%) participants recognized the importance of nursing work for delirium prevention. A total of 250 (52.4%) nurses occasionally or sometimes assessed delirium subtypes, and 143 (30.0%) never assessed for delirium subtypes. We found that age, department, technical title, familiarity with delirium, familiarity with delirium subtypes, delirium training, and subtype training affected the total KAP scores. ICU nurses achieved the highest scores.

CONCLUSION

Chinese nurses' KAP status regarding delirium and subtypes assessment were barely acceptable, and the attitude score was positive, but knowledge and practice needed improvement. Meanwhile, the department was one of the significant KAP factors, and ICU nurses did better in delirium and subtype assessment in knowledge and practice dimension than other departments. Systematic and scientific training processes including subtype content and assessment tools are required. Experience still drives nurses' assessments of delirium and subtype. Adding the delirium assessment into routine tasks should be considered.

Managing agitation secondary to hyperactive delirium in deteriorating patients

Delirium is an under-recognised condition which adversely affects deteriorating patients. Delirium can be an acute or long-term condition and is associated with increased morbidity and mortality, and extended length of hospital stay. The management of delirium is often reactive rather than proactive, which can lead to the inappropriate use of chemical and physical restraint to control agitation secondary to hyperactive delirium. Caring for patients with delirium presents physical and emotional challenges for nurses, who are sometimes inclined to use restraint, which should be a last resort. This article describes the challenges of caring for patients with delirium, presents the risk factors for and assessment of delirium, and describes the management of agitation secondary to hyperactive delirium. Support and education for nurses caring for patients with delirium is essential to ensure optimal patient care and avoid staff burnout.

Nurses’ Experience of Caring for Patients with Delirium: Systematic Review and Qualitative Evidence Synthesis

Delirium is an acute deterioration in attention, conscious state, perception, and cognition of a person. While nurses possess the theoretical understanding of the condition, they lack insight into its early recognition and management. This systematic review aims to understand what factors influence nurses as they care for patients with delirium, and to identify best practices to improve overall clinical care. The Qualitative Evidence Synthesis (QES), as a strategy process to identify gaps in research, formulate new models or strategies for care, underpinned the review. In addition to specific inclusion and exclusion criteria, a methodological assessment, data were analysed using QES, as informed by the Joanna Briggs Institute Review process. Ten studies were identified and synthesised to generate four key themes. The themes included (1) nurse’s knowledge deficit; (2) increased workload and stress; (3) safety concerns among nurse when caring for patients with delirium; and (4) strategies used when caring for patients with delirium. Overall, the review has highlighted the need for increased delirium education and coping strategies among nurses to effectively care for patients with delirium. This may be augmented through regular education sessions to provide nurses with the confidence and competence to care for the acutely confused person.

Non-pharmacologic interventions for the prevention of delirium in the intensive care unit: An integrative review

BACKGROUND

Delirium in the intensive care unit (ICU) is associated with increased mortality, longer hospital stays, and increased odds of institutionalization after discharge. Delirium is a significant complication that occurs frequently in ICU yet lacks a standardized treatment protocol. Because of the limited effective pharmacologic treatments available for the management of delirium, non-pharmacologic interventions such as early mobilization, earplugs and blinds at night, music and natural sunlight during the day, continuous reorientation, and increased visitation and family participation are essential to integrate into the treatment plan for the management of delirium in the ICU.

AIM

To summarize evidence on the use of non-pharmacologic interventions for the reduction in incidence and duration of delirium in ICU patients and to integrate qualitative studies that explore the perception of delirium in the ICU from staff and patients' families to support the use of non-pharmacologic interventions.

METHODS

For this integrative review, electronic databases PubMed, EMBASE, and Google Scholar were searched using the guidance of a librarian and second reviewer to find qualitative and quantitative studies that were published after 2005 and involved adult patients in the ICU.

CONCLUSION

Eight quantitative articles and four qualitative articles were chosen to be included in this review. All eight quantitative studies provide significant evidence (P < .05) for the efficacy of their interventions to provide benefit to at least one delirium-related outcome. The four qualitative research studies reviewed provide insight on delirium in the ICU from staff and patients' families who share a desire for the use of effective non-pharmacologic interventions.

RELEVANCE TO CLINICAL PRACTICE

Non-pharmacologic interventions used for patients in the ICU may be efficacious in reducing the incidence and duration of delirium in adults. Non-pharmacologic interventions are feasible and supported by ICU staff and patients' families and should be considered in the care of the critically ill patient.

Delirium in older hospitalized patients-signs and actions: a retrospective patient record review

Background

Delirium is common in older hospitalized patients, and is associated with negative consequences for the patients, next of kin, healthcare professionals and healthcare costs. It is important to understand its clinical features, as almost 40% of all cases in hospitals may be preventable. Yet, delirium in hospitalized patients is often unrecognized and untreated. Few studies describe thoroughly how delirium manifests itself in older hospitalized patients and what actions healthcare professionals take in relation to these signs. Therefore, the aim of this study was to describe signs of delirium in older hospitalized patients and action taken by healthcare professionals, as reported in patient records.

Methods

Patient records from patients aged ≥65 (n = 286) were retrospectively reviewed for signs of delirium, which was found in 78 patient records (27%). Additionally, these records were reviewed for action taken by healthcare professionals in relation to the patients’ signs of delirium. The identified text was analyzed with qualitative content analysis in two steps.

Results

Healthcare professionals responded only in part to older hospitalized patients’ needs of care in relation to their signs of delirium. The patients displayed various signs of delirium that led to a reduced ability to participate in their own care and to keep themselves free from harm. Healthcare professionals met these signs with a variation of actions and the care was adapted, deficient and beyond the usual care. A systematic and holistic perspective in the care of older hospitalized patients with signs of delirium was missing.

Conclusion

Improved knowledge about delirium in hospitals is needed in order to reduce human suffering, healthcare utilization and costs. It is important to enable older hospitalized patients with signs of delirium to participate in their own care and to protect them from harm. Delirium has to be seen as a preventable adverse event in all hospitals units. To improve the prevention and management of older hospitalized patients with signs of delirium, person-centered care and patient safety may be important issues.