Intensive care nurses’ experiences and perceptions of delirium and delirium care

https://doi.org/10.1016/j.iccn.2017.01.003Get rights and content

Abstract

Objective

To explore nurses’ experiences and perceptions of delirium, managing delirious patients, and screening for delirium, five years after introduction of the Confusion Assessment Method for Intensive Care into standard practice.

Research design and setting

Twelve nurses from a medical-surgical intensive care unit in a large teaching hospital attended two focus group sessions. The collected qualitative data was thematically analysed using Braun and Clarke’s framework (2006).

Findings

The analysis identified seven themes: (1) Delirium as a Secondary Matter (2) Unpleasant Nature of Delirium (3) Scepticism About Delirium Assessment (4) Distrust in Delirium Management (5) Value of Communication (6) Non-pharmacological Therapy (7) Need for Reviewed Delirium Policy.

Conclusion

Nurses described perceiving delirium as a low priority matter and linked it to work culture within the intensive care specialty. Simultaneously, they expressed their readiness to challenge this culture and to promote the notion of providing high-quality delirium care. Nurses discussed their frustrations related to lack of confidence in assessing delirium, as well as lack of effective therapies in managing this group of patients. They declared their appreciation for non-pharmacological interventions in treatment of delirium, suggested improvements to current delirium approach and proposed introducing psychological support for nurses dealing with delirious patients.

Introduction

Delirium is a reversible manifestation of acute brain dysfunction, characterised by an abrupt onset and a fluctuating course of disturbed consciousness, attention, cognition and perception (American Psychiatric Association (APA), 2013). The syndrome affects up to 80% of intensive care patients and has been associated with increased mortality, higher intubation rates, extended intensive care and hospital admissions (Ely et al., 2001, Ely et al., 2004, Page et al., 2009), and an increased risk of dementia and institutionalisation (Witlox et al., 2010, Brummel et al., 2014). It therefore presents a significant economic challenge for healthcare providers (Milbrandt et al., 2004) and can be seen as a public health threat.

It is recommended that clinicians routinely screen patients for delirium using a validated tool, such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), which gathers information from a structured observation and interview to formally measure the characteristics of delirium (Barr et al., 2013, Ely et al., 2001; National Institute for Health and Clinical Excellence (NICE), 2010). CAM-ICU is an adaptation of the Confusion Assessment Method, which was originally developed to be used by clinicians without formal psychiatric training with elderly hospitalized patients (Inouye et al., 1990). CAM-ICU is specifically designed for nonverbal patients.

Critical care nurses, who have continuous contact with patients, are in the best position to monitor fluctuations in delirium symptoms, and ensure prompt recognition and introduction of appropriate treatment. The initial measures to address delirium include identification and correction of its organic causes such as hypoxia, pain or infection, as well as rationalisation of drug regimens to avoid poly-pharmacy. It is also a good practice to implement early non-pharmacological interventions, such as patient reorientation, early mobilisation and sleep promotion, as these address other factors that may precipitate delirium. Failure to resolve the symptoms with these strategies should lead to introduction of drug therapies, i.e. neuroleptics and atypical antipsychotics into patient treatment (Borthwick et al., 2006, Fong et al., 2009).

However, the syndrome remains under-recognised (Cadogan et al., 2009, Forsgren and Eriksson, 2010, Mac Sweeney et al., 2010). A routine compliance audit in the author’s local ICU indicated that a third of delirium assessments were not attempted (Zamoscik et al., 2014). These reduced efforts in detecting delirium were identified despite delirium screening being integrated into core ICU nurse training, mandatory critical care competencies and nursing documentation, and despite the local policy on delirium management and provision of informal bedside teaching to staff.

Section snippets

Background

ICU nurses report having a good understanding of the seriousness of delirium, but simultaneously assign low priority to screening for and dealing with the syndrome (Devlin et al., 2008, Price, 2004, Scott et al., 2013). Some nurses feel uncomfortable when delirium is diagnosed, and when faced with patients’ distrusting, irritable and sometimes violent behaviours (Jung et al., 2013). They experience emotional and physical exhaustion due to high levels of stress, heavy workload and occasional

Methods

As the study sought to gain an understanding of a phenomenon from the perspective of the individuals experiencing it, a qualitative approach was utilised (Burns and Grove, 2011, Neergaart et al., 2009). The participants’ experiences and perceptions were elicited in focus group discussions which, apart from being more time-efficient and cost-effective than a series of one-to-one interviews, have the potential to generate new ideas through verbal interaction driven by group dynamics (Krueger and

Ethical considerations

This study (conducted as the first author’s Master’s project) was approved by the University of Hertfordshire Ethics Committee and by the managements of the ICU and of the local hospital. Participation was informed and consensual. All parties signed confidentiality agreements to ensure the participants’ anonymity.

Findings

The study findings are organised in seven themes, illustrated by direct quotes from participants.

Discussion

These findings present the ICU culture as one where delirium care is marginalised. While nurses’ perceptions of delirium as a low priority issue have been reported in earlier studies (Devlin et al., 2008, Price, 2004, Scott et al., 2013), such views have not been explicitly linked with the characteristic for ICU reliance on sophisticated technology in patient management, where the degree of critical illness is judged by the amount of employed equipment (Almerud et al., 2007, Walters, 1995).

Limitations

Since participants were recruited from one ICU, the findings may not be readily transferrable to other units or hospitals. The absence of male nurses in the sample could have resulted in loss of additional perspectives. The findings may be affected by sample bias, as participants could have a particular interest in delirium care. Also, due to the researcher’s inexperience in moderating focus groups, several opportunities to explore the topic further in the first discussion were only noticed

Conclusion

This study has revealed the influence of ICU culture on perceiving delirium as a low priority matter, and replication of some misconceptions about delirium and CAM-ICU. It has also suggested that nurses’ longer exposure to established delirium practices has not resulted in their increased confidence in assessing or managing delirium. The study has furthermore demonstrated that the current approach to delirium care is seen as unsatisfactory, and that nurses ought to receive support in caring for

Funding source information

The authors have no sources of funding to declare.

Conflicts of interest

None.

Acknowledgements

The authors would like to thank the participants in the focus group discussions for devoting their time to share their professional experiences and reflections. We also thank the ICU managers and the research assistants for facilitating the realisation of this research project.

References (66)

  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (2013)
  • J. Barr et al.

    American College of Critical Care Medicine: clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

    Crit. Care Med.

    (2013)
  • J.S. Benbenishty et al.

    Non-verbal communication to restore patient- provider trust

    Intens. Care Med.

    (2015)
  • S. Bihari et al.

    Factors affecting sleep quality of patients in intensive care unit

    J. Clin. Sleep Med.

    (2012)
  • P. Black et al.

    The effect of nurse-facilitated family participation in the psychological care of the critically ill patient

    J. Adv. Nurs.

    (2011)
  • M. Borthwick et al.

    Detection, Prevention and Treatment of Delirium in Critically Ill Patients

    (2006)
  • J. Bradt et al.

    Music interventions for mechanically ventilated patients

    Cochrane Database Syst. Rev.

    (2014)
  • V. Braun et al.

    Using thematic analysis in psychology

    Qual. Res. Psychol.

    (2006)
  • S. Brajtman et al.

    Caring for patients with terminal delirium: palliative care unit and home care nurses’ experiences

    Int. J. Palliat. Nurs.

    (2006)
  • E. Bruera et al.

    Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers

    Cancer

    (2009)
  • N.E. Brummel et al.

    Delirium in the ICU and subsequent long-term disability among survivors of mechanical ventilation

    Crit. Care Med.

    (2014)
  • N. Burns et al.

    Understanding nursing research

    Building an Evidence-Based Practice

    (2011)
  • F.L. Cadogan et al.

    Current awareness of delirium in the intensive care unit: a postal survey in the Netherlands

    Netherlands J. Med.

    (2009)
  • R. Cavallazzi et al.

    Delirium in the ICU: an overview

    Ann. Intens. Care

    (2012)
  • R. Colombo et al.

    A reorientation strategy for reducing delirium in the critically ill: results of an interventional study

    Minerva Anestesiol.

    (2012)
  • S. Dahlke et al.

    Caring for hospitalized older adults at risk for delirium: the silent, unspoken piece of nursing practice

    J. Gerontol. Nurs.

    (2008)
  • J.W. Devlin et al.

    Assessment of delirium in the intensive care unit: nursing practices and perceptions

    Am. J. Crit. Care

    (2008)
  • W.E. Ely et al.

    Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for Intensive Care Unit (CAM-ICU)

    Crit. Care Med.

    (2001)
  • E.W. Ely et al.

    Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

    JAMA

    (2004)
  • K. Epp

    Burnout in critical care nurses: a literature review

    Dynamics

    (2012)
  • T.G. Fong et al.

    Delirium in elderly adults: diagnosis, prevention and treatment

    Nat. Rev. Neurol.

    (2009)
  • U. Guenther et al.

    Implications of objective vs subjective delirium assessment in surgical intensive care patients

    Am. J. Crit. Care

    (2012)
  • D. Gusmao-Flores et al.

    The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies

    Crit. Care

    (2012)
  • Cited by (0)

    View full text