- Email: [email protected]
An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
Intensive and Critical Care Nursing (2013) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective Martin Christensen ∗ School of Health and Human Sciences, Southern Cross University, New South Wales 2480, Australia Accepted 14 August 2013
KEYWORDS Delirium; ICU psychosis; ICU syndrome
∗
Summary Aim: The aim of this study was to establish intensive care unit nurses’ knowledge of delirium within an acute tertiary hospital within South East Asia. Background: Delirium is a common, life threatening and often preventable cause of morbidity and mortality among older patients. Undetected and untreated delirium is a catalyst to increased mortality, morbidity, functional decline and results in increased requirement for nursing care, healthcare expense and hospital length of stay. However, despite effective assessment tools to identify delirium in the acute setting, there still remains an inability of ICU nurses’ to accurately identify delirium in the critically ill patient especially that of hypoactive delirium. Method: A purposive sample of 53 staff nurses from a 13-bedded medical intensive care unit within an acute tertiary teaching hospital in South East Asia were asked to participate. A 40 item 5-point Likert scale questionnaire was employed to determine the participants’ knowledge of the signs and symptoms; the risk factors and negative outcomes of delirium. Results: The overall positively answered mean score was 27 (67.3%) out of a possible 40 questions. Mean scores for knowledge of signs and symptoms, risk factors and negative outcomes were 9.52 (63.5%, n = 15), 11.43 (63.5%, n = 17) and 6.0 (75%, n = 8), respectively. Conclusion: Whilst the results of this study are similar to others taken from a western perspective, it appeared that the ICU nurses in this study demonstrated limited knowledge of the signs and symptoms, risk factors and negative outcomes of delirium in the critically patient. The implications for practice of this are important given the outcomes of untreated delirium. © 2013 Elsevier Ltd. All rights reserved.
Tel.: +61 (02) 6620 3992. E-mail address: [email protected]
0964-3397/$ — see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.iccn.2013.08.004
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
2
M. Christensen
Implications for clinical practice The implications for practice are such that any further reiteration around knowledge acquisition, formally or informally is probably not warranted simply because there is enough available literature for individuals to make informed choices around delirium management. Instead, practice could: • Develop alternative methods of theory integration that supersede competence and promote performance such as case vignettes’, simulation using standardised patient scenarios and the development of key performance indicators specifically developed to measure competence and performance in detecting, assessing and managing delirium in the ICU. • Promote delirium awareness days or weeks where heightened knowledge and understanding of delirium is at the forefront of practice based on those principles mentioned above. • That a comprehensive delirium incidence and management database be developed or included in the APACHE scoring system so that individual units can monitor its incidence and develop and promote an evidence base of practice to aid in care-delivery and future research.
Introduction Delirium can be a common, life threatening and often preventable cause of morbidity and mortality among individuals of all ages but especially the elderly (Han et al., 2010). This clinical diagnosis is derived from the presence of the four cardinal signs: disturbance of consciousness; a change in cognition, short time frame and evidence of nosocomial/medication causation (American Psychiatric Association’s Diagnostic and Statistical Manual, 2000). It has been universally agreed that the behaviours commonly associated with delirium and encountered in the Intensive Care Unit (ICU) are either hypoalert, hyperalert or a mixture of both (Arend and Christensen, 2009) with a small number of patients being deemed unclassifiable. In the past the use of various descriptive and diagnostic terminologies for acute cognitive impairments has compounded the difficulty in deriving a diagnosis and instituting routine assessment of delirium in ICU (Inouye, 1994; Wells, 2012). Despite the current consensus on the definition of delirium and the availability of extensively validated screening tools such as the Confusion Assessment Method for ICU (CAM-ICU) (Devlin et al., 2007; Ely et al., 2001), routine assessment of delirium appears not to constitute standard practice in most healthcare settings (HamdanMansour et al., 2010; Wells, 2012). Evidence by both direct and indirect measurements suggests that one-to two-thirds of patients with delirium are undiagnosed by the attending physicians and nurses (Fick et al., 2007; Flagg et al., 2010; Hare et al., 2008a; Lemiengre et al., 2006; Voyer et al., 2008). For nurses this is centred on inadequate nursing assessment and knowledge (Boot, 2012). It is concerning that despite the large number of studies and discursive work around delirium, its detection and management (Arend and Christensen, 2009) there continues to be under-recognition of delirium in the critical care environment by nurses. Perhaps the difference is not about having a theoretical/competency based understanding of delirium but more attuned to a performance issue, given that competency is concerned with perceived skills and is outcome focused, whereas performance is actual situated behaviour and is process driven (While, 1994). This could lead the casual observer to conclude that whilst nurses may
recognise that patients are distressed, confused and require assistance, their perceived lack of performance knowledge may hinder their ability to recognise and diagnose delirium effectively (Steis and Fick, 2008).
Methodology Aims The aim of this study was to assess Registered Nurses’ level of knowledge in detecting and managing delirium in the medical intensive care unit from within an Asian context and whether participant demographics had an impact on their knowledge of the signs and symptoms, risk factors and negative outcomes associated with delirium.
Design A descriptive, survey design was adopted for this study.
Setting The setting was a 13 bedded medical ICU (MICU) in an acute tertiary teaching hospital in South East Asia over a onemonth period from December 2011 to January 2012.
Ethical considerations Ethical approval for this study was granted by the hospital research ethics committee. Permission was also sought from the Director of Nursing and the Medical Director of the MICU to conduct the study within the MICU. Initial invitation to participate in the study was announced via emails to the MICU Nurse Manager with assistance from the hospitals Evidenced Based Nursing (EBN) unit. Written consent for the study was waived because return of a completed questionnaire as stated in the participant information sheet was considered an indicator of the participant’s interest and consent to the study.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
Intensive care unit nurses’ knowledge of delirium
3
Participants
Results
This study used purposive sampling, whereby 52 Registered Nurses from the MICU were included in the study. To reduce the risk of bias from purposive sampling, available hospital data from the period of January 2010 to June 2011 was assessed for the incidence of delirium in this setting to ensure participants chosen were representative of the intended population. The results showed a high incidence (>50%) of delirium in patients within this clinical setting.
Demographics
Data collection A self-administered close-ended Likert scale questionnaire was developed from the literature with necessary modification to fit within an Asian context. The instrument consisted of two sections: Section ‘‘Introduction’’ comprised of demographic data (n = 13) in particular generic personal details such as age, citizenship and gender as well as knowledge of delirium training and current hospital policy. Section ‘‘Methodology’’ included questions pertaining to knowledge of the signs and symptoms (n = 14), risk factors (n = 17) and negative outcomes of delirium (n = 8). All registered nurses from the MICU were briefed on the purpose of the study with details pertaining to the research aims, procedures, possible outcomes and researcher contacts. Participants were reminded that they had the right to withdraw from the study at any time and for any reason. The completed questionnaires were sealed in individual envelopes to ensure anonymity and were collected from a sealed letterbox placed in the staff room at a later date.
Content validity Expert opinion was sought to ensure that content validity of the instrument was suitable for this clinical setting. A panel of five medical practitioners (2 geriatricians, 1 intensivist, 1 neurologist and 1 psychiatrist) who were considered to be clinical experts in the management of delirium and a panel of non-experts, comprising 3 registered nurses from the cardiac ICU were invited to review the questionnaire for readability, relevance and accuracy. As a result of this review minimal changes to wording were made on 6 of the questions to make these particular questions more easily understood.
Statistical analysis The SPSS software for Windows, version 19 (SPSS, 2010) was used to perform the data analysis. Cronbach’s ˛ was used to examine the internal consistency of the items within each subscale (Munro, 2005) and descriptive statistics were used to describe the nursing teams demographic variables. To offset potential skewness power transformation (Xn , n = 1.3, 1.4, 1.5) was used to normalise the variable data to nearnormal distributions before non-parametric statistical test analysis using Kruskal—Wallis and Mann—Whitney U were performed. All of the statistical tests were set at 5% alpha level of significance. p-Values less than 0.05 (p < 0.05) were deemed to be statistically significant.
The overall mean score of allocated marks for positively answered questions was 26.1 (63.6%) (SD 2.8). The majority of participants were young females (90.6%), (Table 1). The highest qualification obtained was a bachelor’s degree with the majority of those nurses originally from the Philippines (44%) where there is a preponderance of nurses trained at baccalaureate level few participants had honours degrees; none had higher degrees.
Signs and symptoms Most of the participants (96%, n = 50) were able to identify the signs and symptoms of delirium albeit hyperactive delirium, only 12% (n = 6) of participants recognised some clinical features of hypoactive delirium. When additional analysis of signs and symptoms subsets (hyperactive versus hypoactive) was undertaken there was some disparity between what participants understood these two facets of delirium to be. A significant number of participants (71%, n = 37) were unable to definitively identify the core features of hypoactive delirium yet there was no significant statistical differences between nursing demographic data and the nursing team’s ability to detect or manage delirium in the ICU (Table 1). However descriptively, the nurses from India performed poorly in recognising the majority of signs and symptoms associated with both forms of delirium.
Risk factors The mean score for identifying risk factors associated with developing delirium was 63.8% (n = 35). No statistical difference was found between a majority of the demographic subsets. There was a significant statistical difference between educational qualifications and the risk factors associated with delirium (p < 0.040) in favour of the degree educated participants (Table 1). Whilst this simply could be the result of a type 1 error given the disparity between the group sizes, closer analysis of the group means suggests only a slight variation between the two groups in terms of risk factor knowledge. Therefore any inferences proposing degree students are better educated in terms of delirium recognition cannot be substantiated from this data.
Negative outcomes Overall 75% (n = 39) participants were able to correctly predict outcomes or potential complications for patients who had experienced an episode of delirium during their hospitalisation. When Kruskal—Wallis was used to find differences in demographic data, it found a significant difference between citizenship and negative outcomes overall (p < 0.028) (Table 1). When each country was tested against each individual question no statistical difference was found. Descriptively, participants from China were better at
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model
ARTICLE IN PRESS
YICCN-2298; No. of Pages 7
4
M. Christensen Table 1 Comparison of MICU staff nurses knowledge of the signs and symptoms, risk factors, negative outcomes of delirium by demographics. Demographic
Total (n = 53), n%
Age (years) 20—30 31 (58) 31—40 18 (33) 41—50 3 (5) p˝ Gender Male 5 (9.4) Female 48 (90.6) p¥ Country China 3 (5.7) Philippines 24 (45.3) Myanmar 2 (3.8) Singapore 11 (20.8) India 5 (9.4) Malaysia 6 (11.3) Others 2 (3.8) p˝ Designation Staff nurse 38 (71.7) Senior staff nurse 14 (26.4) p¥ Duration in area (months) <6 12 (22.6) 6—12 8(15.1) >12 33 (62.3) p˝ Work experience <5 28 (52.8) 6—12 21 (39.6) 13—20 3 (5.7) p˝ Highest qualification Diploma in nursing 8 (15.1) Bachelor’s degree 44 (83) p¥
Positive S & S, mean (SD)
Positive RF, mean (SD)
Positive NO, mean (SD)
10.32 (2.98) 9.72 (2.58) 12.33 (2.88) 0.710
11.65 (3.78) 11 (3.55) 12.67 (3.51) 0.880
5.10 (1.88) 5.00 (1.95) 4.33(2.08) 0.481
9.4 (4.09) 10.31 (2.70) 0.880
11.20 (5.31) 11.54 (3.44) 0.928
5.40 (1.81) 4.94 (1.91) 0.695
12.00 (2.00) 10.71 (2.27) 10.50 (0.71) 10.63 (3.80) 7.60 (1.14) 8.50 (3.61) 11.00 (1.41) 0.185
12.67 (4.04) 12.58 (2.37) 12.00 (1.41) 10.73 (5.04) 7.60 (2.51) 11.00 (3.89) 12.00 (1.41) 0.228
6.67 (0.58) 5.29 (1.68) 5.00 (2.82) 5.64 (1.93) 2.40 (1.14) 4.00 (1.67) 4.50 (0.71) 0.028*
9.42 (2.90) 14.00 (2.47) 0.126
10.86 (3.47) 13.00 (3.48) 0.419
5.16 (1.76) 4.43 (2.21) 0.264
8.12 (3.66) 10.69 (2.17) 10.22 (2.82) 0.056
9.87 (3.99) 11.70 (2.95) 11.51 (3.57) 0.213
5.25 (1.66) 3.88 (1.55) 5.15 (1.99) 0.187
10.33 (3.09) 8.33 (2.47) 14.00 (2.08) 0.383
12.00 (3.85) 8.67 (3.13) 13.00 (4.50) 0.433
5.07 (1.94) 5.19 (1.72) 2.33 (0.58) 0.060
7.00 (2.99) 10.22 (2.57) 0.352
9.00 (4.06) 11.51 (3.23) 0.040*
4.88 (1.73) 5.09 (1.85) 0.217
S & S, signs & symptoms; RF, risk factors; NO, negative outcomes. Kruskal—Wallis. ¥ Mann—Whitney U. * p < 0.05.
answering these questions (mean rank, 40.67, SD 0.577) than all others, with participants from India performing poorly (mean rank 7.70, SD 1.14).
Hospital policy Only 39% of registered nurses were aware that a hospital policy existed and 69% of participants had received no formal training on delirium. Interestingly, whilst 56% of nurses were aware of routine screening 46% did not undertake any sort of screening of their patients to assess for the presence of delirium. However, in contrast 52% of nurses did use the internationally recognised CAM-ICU when they undertook an assessment for suspected delirium.
Discussion Much of the work focusing on delirium has taken place from a western perspective and there appears to be very little work from an Asian viewpoint. Whilst it could be agreed that delirium is delirium regardless of the global context there is a difference in the way health care in this clinical environment is delivered. The healthcare management structure in this area is very much based around the premise of filial piety, is hierarchical in nature and is medically dominated. Therefore the role of the nurse could be considered to be one of compliancy and where clinical decision making is undertaken at the sole discretion of the medical team. Moreover there is an over emphasis on education whether it is formal or informal the unwritten rule it appears, is that
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
Intensive care unit nurses’ knowledge of delirium educational qualifications whatever they may be determines competency. Therefore, as a means to assessing and managing delirium in this cultural context it was important to be able to distinguish between what is known and learnt and what is practiced given the above observations. Therefore the overall aim of this exploratory study was to assess whether nurses from a tertiary hospital MICU in South East Asia had sufficient knowledge to assess and manage delirium in this clinical setting. The results were what would have been expected given the plethora of literature related to delirium in the ICU (Arend and Christensen, 2009). Whilst this cohort fared better than some western studies (Flagg et al., 2010; Hare et al., 2008b) still only 63% of nurses in this study knew what the signs and symptoms, the risk factors and the negative outcomes associated with delirium were as it related to their clinical area. It is alarming that a large group of nurses (37%) had poor knowledge. The reason for this is perhaps due to the fluctuating nature of delirium and its myriad of presentations — hypo, hyper, mixed and unexplained. Whilst evidence suggests that nurses often have great difficulty in identifying the fluctuating core features of delirium such as acute onset and disorganised thinking (Arend and Christensen, 2009; Lemiengre et al., 2006; Morency, 1990; Voyer et al., 2008), findings from this study demonstrated that at least 50% of nurses were able to identify some of those core features of delirium alone. However this tended to be those behaviours commonly associated with hyper-active delirium. When it came to identifying hypoactive delirium, like other studies (Flagg et al., 2010; Wang and Mentes, 2009), this cohort was only able to detect its presence in 41% of cases. This suggests nurses tend to focus on the behaviours of delirium that had the potential to increase their workload for example, preventing patient harm and/or protecting invasive lines such as endotracheal tubes or indwelling catheters. Why this is the case may be multi-factorial although evidence suggests two things. First a lack of knowledge in identifying the clinical features of delirium results in under-recognition and misdiagnosis of delirium by medical and nursing staff (Boot, 2012; Devlin et al., 2012; Steis and Fick, 2008). Second, the complexity of screening tools in the past have been less able to detect which delirium feature is present (Spronk et al., 2009; Wells, 2012) and as a result detection is reliant on clinical experience and not always at the behest of nursing. With the introduction of CAM-ICU as a formative assessment tool for delirium in the ICU, there has been a significant increase in the way that delirium is now being assessed in this clinical area (Ely et al., 2001). Although some ICU nurses still feel that the CAM-ICU is difficult to use and does not necessarily warrant the time it takes to complete the assessment (Eastwood et al., 2012), on the whole its effectiveness together with the Intensive Care Delirium Screening Checklist is well supported within the literature (Devlin et al., 2012). Unfortunately that cannot be said of this study. A small number of respondents (34.5%) despite receiving some form of delirium training albeit limited as well as having an awareness of current hospital policy failed to either undertake a formalised assessment or tended to use their own clinical judgement. Like Eastwood et al. (2012) who found that their ICU nurses did recognise the importance of delirium assessment; the participants in this study tended to rely on direction from medical staff and therefore it would
5 Table 2 Staff nurses knowledge of current hospital/ department policy and training on delirium. Delirium policy and training Knowledge of hospital policy Yes No Knowledge of routine screening Yes No Delirium training Yes No Type of delirium training Nil In-service E-learning Conference Type of assessment used Nil CAM CAM-ICU
Total (n = 52), n% 20 (38.5) 32 (61.5) 29 (55.8) 23 (44.2) 17 (32.7) 36 (69.3) 34(65.5) 15 (28.8) 2 (3.8) 1 (1.9) 24 (46.2) 1 (1.9) 27 (51.8)
appear placed little importance on undertaking a delirium assessment or alternatively saw the assessment as a task to be performed. This is consistent with findings by Devlin et al. (2008), who found that only 3% of nurses ranked delirium as the most important condition to evaluate. However, there is the cultural element that must be taken into account here: it would be wrong to suggest that the nurses in this ICU would not consciously provide support for a patient experiencing a delirious episode. Instead it is important to remember that the cultural nature of decision-making in this MICU is based loosely around the Confucius edit of filial piety where from an early age individuals are taught humility towards those in power and authority as well as care being policy driven. Therefore, whilst the results of this study articulate that nurses are indeed knowledgeable with regard to most aspects of delirium, cultural propriety may well also explain the reasons why some participants did not perform a delirium assessment on their patients (Table 2). However, this still raises the question as to whether theoretical knowledge alone is enough to detect, manage and prevent delirium in this setting. The results of this study certainly give some credence to this notion and as mentioned previously it is believed qualifications often equals competency. Although it is easy to suggest that nurses are the ideal frontline person to assess and identify those patients at risk for delirium, establishing a patient’s baseline vulnerability status and applying effective targeted interventions is not always met with success. In other words having substantive theoretical knowledge does not always mean it is reproducible in a performance context. Therefore caution must be warranted where the perception is that improved ‘‘knowledge’’ would lead to better prevention, detection and even management of delirium (Tabet et al., 2005). Of course increased knowledge would inevitably heighten nurses’ awareness and whilst some nurses in this study identified correctly those aspects of delirium detection and management it would appear that little is done in a practical sense to limit if not prevent those attributable outcomes.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
6
M. Christensen
Creating a sense of urgency to perform prompt screening assessment and early implementation measures to prevent or manage delirium is potentially the way forward (Tabet et al., 2005). Preventing delirium however, is an onerous task given the complexity of its presentation, underlying causative factors and that nurses may not conduct timely routine screening assessment and implement effective preventive measures due to misperception of low threats (Flagg et al., 2010).
Limitations Several limitations affected the outcomes of this study. First, due to purposive sampling, the small sample size and the sampling frame restricted to one hospital, generalisation of findings to the entire population of interest is expected to be limited and should be made with caution. Whilst it is conceded that the sample was taken from one of the seven ICU’s present in this hospital, it was felt the MICU was better suited because of the patient group that was often admitted to the ward. Unlike the other ICU’s the patient group admitted to the MICU often stayed longer, had substantive comorbidities and the acuteness of their admission meant they were more prone to developing delirium quicker. Second, the newly developed instrument was not statistically validated to support construct validity however we felt that content validity was such that the results from the study would at the very least provide enough information to make it statistically viable and significant. It is accepted that establishing adequate psychometric measurement following a comprehensive literature review and content validity was appropriate; construct validity through formal statistical analysis, such as exploratory factor analysis, would be recommended in future studies to identify any deficits and refine the instrument prior to further use. Third, data obtained from a self-reported questionnaire may cause possible response bias from each responder (Beck and Polit, 2006), which is based on respondent honesty and is entirely reliant on the subjective views of the participants and therefore may be a source of error in a self-reported questionnaire (Siegel et al., 1998).
Conclusion Delirium is a commonly encountered condition within the ICU. Its effects on the patient can be debilitating and in some cases promote early death. Whilst there is a plethora of literature in both the medical and nursing press addressing the problem and management of delirium, there has however, been a number of studies which have demonstrated that health care professionals are poor at recognising and treating delirium effectively this study was no exception. There have been many suggestions that continued education be at the forefront of reducing the incidence of delirium. Although this is a sensible approach, one only has to review the number of articles that promote, identify, discuss and acknowledge the presence of ICU delirium to recognise its importance. Perhaps what is needed is a fresh approach to improve compliance and more effective management streams. The introduction of CAM-ICU has helped and supported this development, however there still
appears to be the problem that nurses view the assessment tool as a task to be done (tick-box nursing care) or its too complicated or difficult to undertake given perceived time constraints around workload. Performing the assessment itself is straight forward and therefore perhaps the problem is around the decision-making process that accompanies this where differing opinions about observed delirious behaviour are open to scrutiny.
References American Psychiatric Association: Diagnostic and Statistical Manual of mental Disorders. Delirium, dementia, and amnestic and other cognitive disorders. 4th ed. Washington DC: American Psychiatric Association Press; 2000. p. 135—80. Arend E, Christensen M. Delirium in the intensive care unit: a review. Nurs Crit Care 2009;14(3):145—54. Beck CT, Polit DF. Essentials of nursing research: methods, appraisal and utilization. United States: Lippincott Williams & Wilkins; 2006. Boot R. Delirium: a review of the nurses role in the intensive care unit. Intensive Crit Care Nurs 2012;28:185—9. Devlin JW, Fong JJ, Fraser GL, Riker RR. Delirium assessment in the critically ill. Intensive Care Med 2007;33:929—40. Devlin JW, Fong JJ, Howard EP, Skrobik Y, McCoy N, Yasuda C, et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. Am J Crit Care 2008;17(6):555—67. Devlin JW, Brummel NE, Al-Qadheeb NS. Optimising the recognition of delirium in the intensive care unit. Best Pract Res Clin Anaesthesiol 2012;26:385—93. Eastwood GM, Peck L, Bellomo R, Baldwin I, Reade MC. A questionnaire survey of critical care nurses’ attitudes to the delirium assessment before and after introduction of the CAM-ICU. Aust Crit Care 2012;25:162—9. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;2997:1370—9. Fick DM, Hodo DM, Lawrence F, Inouye SK. Recognizing delirium superimposed on dementia: assessing nurses knowledge using case vignettes. J Gerontol Nurs 2007;33(2):40—7. Flagg B, Cox L, McDowell S, Mwose JM, Buelow JM. Nursing identification of delirium. Clin Nurse Spec 2010;24(5):261—6. Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, et al. Delirium in the emergency department: An independent predictor of death within 6 months. Ann Emerg Med 2010;56(3):244—52. Hamdan-Mansour AM, Farhan NA, Othman EH, Yacoub MI. Knowledge and nursing practice of critical care nurses caring for patients with delirium in intensive care units in Jordan. J Contin Educ Nurs 2010;41(12):571—6. Hare M, McGowan S, Wynaden D, Speed G, Landsborough I. Nurses’ descriptions of changes in cognitive function in the acute care setting. Aust J Adv Nurs 2008a;26(1):21—5. Hare M, Wynaden D, McGowan S. A questionnaire to determine nurses’ knowledge of delirium and its risk factors. Clin Nurs 2008b;29(1):23—31. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalised elderly medical patients. Am J Med 1994;97:278—88. Lemiengre J, Nelis T, Joosten E, Braes T, Foreman M, Gastmans C, et al. Detection of delirium by bedside nurses using the confusion assessment methods. J Am Geriatr Soc 2006;54(4):685—9. Morency CR. Mental status change in the elderly: recognising and treating delirium. Clin Updates 1990;6(6):357—63.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
Intensive care unit nurses’ knowledge of delirium Munro BH. Statistical methods for health care research. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. Siegel DM, Aten MJ, Roghmann KJ. Self-reported honesty among middle and high school students responding to a sexual behaviour questionnaire. J Adolesc Health 1998;23:20—8. Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009;35:1276—80. Steis MR, Fick DM. Are nurses recognising delirium? A systematic review. J Gerontol Nurs 2008;34(9):40—8. Tabet N, Hudson S, Sweeney V, Saucer J, Bryant C, Macdonald A, et al. An educational intervention can prevent
7 delirium on acute medical wards. Age Ageing 2005;34: 152—6. Voyer P, Richard S, Doucet L, Danjou C, Carmichael PH. Detection of delirium by nurses among long-term care residents with dementia. BioMed Central Nurs 2008;7(4):1—14. Wang J, Mentes JC. Factors determining nurses clinical judgments about hospitalized elderly patients with acute confusion. Issues Ment Health Nurs 2009;30:399—405. Wells LG. Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature. Aust Crit Care 2012;25:157—61. While AE. Competence versus performance: which is more important. J Adv Nurs 1994;20:525—31.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
ARTICLE IN PRESS
Intensive and Critical Care Nursing (2013) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective Martin Christensen ∗ School of Health and Human Sciences, Southern Cross University, New South Wales 2480, Australia Accepted 14 August 2013
KEYWORDS Delirium; ICU psychosis; ICU syndrome
∗
Summary Aim: The aim of this study was to establish intensive care unit nurses’ knowledge of delirium within an acute tertiary hospital within South East Asia. Background: Delirium is a common, life threatening and often preventable cause of morbidity and mortality among older patients. Undetected and untreated delirium is a catalyst to increased mortality, morbidity, functional decline and results in increased requirement for nursing care, healthcare expense and hospital length of stay. However, despite effective assessment tools to identify delirium in the acute setting, there still remains an inability of ICU nurses’ to accurately identify delirium in the critically ill patient especially that of hypoactive delirium. Method: A purposive sample of 53 staff nurses from a 13-bedded medical intensive care unit within an acute tertiary teaching hospital in South East Asia were asked to participate. A 40 item 5-point Likert scale questionnaire was employed to determine the participants’ knowledge of the signs and symptoms; the risk factors and negative outcomes of delirium. Results: The overall positively answered mean score was 27 (67.3%) out of a possible 40 questions. Mean scores for knowledge of signs and symptoms, risk factors and negative outcomes were 9.52 (63.5%, n = 15), 11.43 (63.5%, n = 17) and 6.0 (75%, n = 8), respectively. Conclusion: Whilst the results of this study are similar to others taken from a western perspective, it appeared that the ICU nurses in this study demonstrated limited knowledge of the signs and symptoms, risk factors and negative outcomes of delirium in the critically patient. The implications for practice of this are important given the outcomes of untreated delirium. © 2013 Elsevier Ltd. All rights reserved.
Tel.: +61 (02) 6620 3992. E-mail address: [email protected]
0964-3397/$ — see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.iccn.2013.08.004
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
2
M. Christensen
Implications for clinical practice The implications for practice are such that any further reiteration around knowledge acquisition, formally or informally is probably not warranted simply because there is enough available literature for individuals to make informed choices around delirium management. Instead, practice could: • Develop alternative methods of theory integration that supersede competence and promote performance such as case vignettes’, simulation using standardised patient scenarios and the development of key performance indicators specifically developed to measure competence and performance in detecting, assessing and managing delirium in the ICU. • Promote delirium awareness days or weeks where heightened knowledge and understanding of delirium is at the forefront of practice based on those principles mentioned above. • That a comprehensive delirium incidence and management database be developed or included in the APACHE scoring system so that individual units can monitor its incidence and develop and promote an evidence base of practice to aid in care-delivery and future research.
Introduction Delirium can be a common, life threatening and often preventable cause of morbidity and mortality among individuals of all ages but especially the elderly (Han et al., 2010). This clinical diagnosis is derived from the presence of the four cardinal signs: disturbance of consciousness; a change in cognition, short time frame and evidence of nosocomial/medication causation (American Psychiatric Association’s Diagnostic and Statistical Manual, 2000). It has been universally agreed that the behaviours commonly associated with delirium and encountered in the Intensive Care Unit (ICU) are either hypoalert, hyperalert or a mixture of both (Arend and Christensen, 2009) with a small number of patients being deemed unclassifiable. In the past the use of various descriptive and diagnostic terminologies for acute cognitive impairments has compounded the difficulty in deriving a diagnosis and instituting routine assessment of delirium in ICU (Inouye, 1994; Wells, 2012). Despite the current consensus on the definition of delirium and the availability of extensively validated screening tools such as the Confusion Assessment Method for ICU (CAM-ICU) (Devlin et al., 2007; Ely et al., 2001), routine assessment of delirium appears not to constitute standard practice in most healthcare settings (HamdanMansour et al., 2010; Wells, 2012). Evidence by both direct and indirect measurements suggests that one-to two-thirds of patients with delirium are undiagnosed by the attending physicians and nurses (Fick et al., 2007; Flagg et al., 2010; Hare et al., 2008a; Lemiengre et al., 2006; Voyer et al., 2008). For nurses this is centred on inadequate nursing assessment and knowledge (Boot, 2012). It is concerning that despite the large number of studies and discursive work around delirium, its detection and management (Arend and Christensen, 2009) there continues to be under-recognition of delirium in the critical care environment by nurses. Perhaps the difference is not about having a theoretical/competency based understanding of delirium but more attuned to a performance issue, given that competency is concerned with perceived skills and is outcome focused, whereas performance is actual situated behaviour and is process driven (While, 1994). This could lead the casual observer to conclude that whilst nurses may
recognise that patients are distressed, confused and require assistance, their perceived lack of performance knowledge may hinder their ability to recognise and diagnose delirium effectively (Steis and Fick, 2008).
Methodology Aims The aim of this study was to assess Registered Nurses’ level of knowledge in detecting and managing delirium in the medical intensive care unit from within an Asian context and whether participant demographics had an impact on their knowledge of the signs and symptoms, risk factors and negative outcomes associated with delirium.
Design A descriptive, survey design was adopted for this study.
Setting The setting was a 13 bedded medical ICU (MICU) in an acute tertiary teaching hospital in South East Asia over a onemonth period from December 2011 to January 2012.
Ethical considerations Ethical approval for this study was granted by the hospital research ethics committee. Permission was also sought from the Director of Nursing and the Medical Director of the MICU to conduct the study within the MICU. Initial invitation to participate in the study was announced via emails to the MICU Nurse Manager with assistance from the hospitals Evidenced Based Nursing (EBN) unit. Written consent for the study was waived because return of a completed questionnaire as stated in the participant information sheet was considered an indicator of the participant’s interest and consent to the study.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
Intensive care unit nurses’ knowledge of delirium
3
Participants
Results
This study used purposive sampling, whereby 52 Registered Nurses from the MICU were included in the study. To reduce the risk of bias from purposive sampling, available hospital data from the period of January 2010 to June 2011 was assessed for the incidence of delirium in this setting to ensure participants chosen were representative of the intended population. The results showed a high incidence (>50%) of delirium in patients within this clinical setting.
Demographics
Data collection A self-administered close-ended Likert scale questionnaire was developed from the literature with necessary modification to fit within an Asian context. The instrument consisted of two sections: Section ‘‘Introduction’’ comprised of demographic data (n = 13) in particular generic personal details such as age, citizenship and gender as well as knowledge of delirium training and current hospital policy. Section ‘‘Methodology’’ included questions pertaining to knowledge of the signs and symptoms (n = 14), risk factors (n = 17) and negative outcomes of delirium (n = 8). All registered nurses from the MICU were briefed on the purpose of the study with details pertaining to the research aims, procedures, possible outcomes and researcher contacts. Participants were reminded that they had the right to withdraw from the study at any time and for any reason. The completed questionnaires were sealed in individual envelopes to ensure anonymity and were collected from a sealed letterbox placed in the staff room at a later date.
Content validity Expert opinion was sought to ensure that content validity of the instrument was suitable for this clinical setting. A panel of five medical practitioners (2 geriatricians, 1 intensivist, 1 neurologist and 1 psychiatrist) who were considered to be clinical experts in the management of delirium and a panel of non-experts, comprising 3 registered nurses from the cardiac ICU were invited to review the questionnaire for readability, relevance and accuracy. As a result of this review minimal changes to wording were made on 6 of the questions to make these particular questions more easily understood.
Statistical analysis The SPSS software for Windows, version 19 (SPSS, 2010) was used to perform the data analysis. Cronbach’s ˛ was used to examine the internal consistency of the items within each subscale (Munro, 2005) and descriptive statistics were used to describe the nursing teams demographic variables. To offset potential skewness power transformation (Xn , n = 1.3, 1.4, 1.5) was used to normalise the variable data to nearnormal distributions before non-parametric statistical test analysis using Kruskal—Wallis and Mann—Whitney U were performed. All of the statistical tests were set at 5% alpha level of significance. p-Values less than 0.05 (p < 0.05) were deemed to be statistically significant.
The overall mean score of allocated marks for positively answered questions was 26.1 (63.6%) (SD 2.8). The majority of participants were young females (90.6%), (Table 1). The highest qualification obtained was a bachelor’s degree with the majority of those nurses originally from the Philippines (44%) where there is a preponderance of nurses trained at baccalaureate level few participants had honours degrees; none had higher degrees.
Signs and symptoms Most of the participants (96%, n = 50) were able to identify the signs and symptoms of delirium albeit hyperactive delirium, only 12% (n = 6) of participants recognised some clinical features of hypoactive delirium. When additional analysis of signs and symptoms subsets (hyperactive versus hypoactive) was undertaken there was some disparity between what participants understood these two facets of delirium to be. A significant number of participants (71%, n = 37) were unable to definitively identify the core features of hypoactive delirium yet there was no significant statistical differences between nursing demographic data and the nursing team’s ability to detect or manage delirium in the ICU (Table 1). However descriptively, the nurses from India performed poorly in recognising the majority of signs and symptoms associated with both forms of delirium.
Risk factors The mean score for identifying risk factors associated with developing delirium was 63.8% (n = 35). No statistical difference was found between a majority of the demographic subsets. There was a significant statistical difference between educational qualifications and the risk factors associated with delirium (p < 0.040) in favour of the degree educated participants (Table 1). Whilst this simply could be the result of a type 1 error given the disparity between the group sizes, closer analysis of the group means suggests only a slight variation between the two groups in terms of risk factor knowledge. Therefore any inferences proposing degree students are better educated in terms of delirium recognition cannot be substantiated from this data.
Negative outcomes Overall 75% (n = 39) participants were able to correctly predict outcomes or potential complications for patients who had experienced an episode of delirium during their hospitalisation. When Kruskal—Wallis was used to find differences in demographic data, it found a significant difference between citizenship and negative outcomes overall (p < 0.028) (Table 1). When each country was tested against each individual question no statistical difference was found. Descriptively, participants from China were better at
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model
ARTICLE IN PRESS
YICCN-2298; No. of Pages 7
4
M. Christensen Table 1 Comparison of MICU staff nurses knowledge of the signs and symptoms, risk factors, negative outcomes of delirium by demographics. Demographic
Total (n = 53), n%
Age (years) 20—30 31 (58) 31—40 18 (33) 41—50 3 (5) p˝ Gender Male 5 (9.4) Female 48 (90.6) p¥ Country China 3 (5.7) Philippines 24 (45.3) Myanmar 2 (3.8) Singapore 11 (20.8) India 5 (9.4) Malaysia 6 (11.3) Others 2 (3.8) p˝ Designation Staff nurse 38 (71.7) Senior staff nurse 14 (26.4) p¥ Duration in area (months) <6 12 (22.6) 6—12 8(15.1) >12 33 (62.3) p˝ Work experience <5 28 (52.8) 6—12 21 (39.6) 13—20 3 (5.7) p˝ Highest qualification Diploma in nursing 8 (15.1) Bachelor’s degree 44 (83) p¥
Positive S & S, mean (SD)
Positive RF, mean (SD)
Positive NO, mean (SD)
10.32 (2.98) 9.72 (2.58) 12.33 (2.88) 0.710
11.65 (3.78) 11 (3.55) 12.67 (3.51) 0.880
5.10 (1.88) 5.00 (1.95) 4.33(2.08) 0.481
9.4 (4.09) 10.31 (2.70) 0.880
11.20 (5.31) 11.54 (3.44) 0.928
5.40 (1.81) 4.94 (1.91) 0.695
12.00 (2.00) 10.71 (2.27) 10.50 (0.71) 10.63 (3.80) 7.60 (1.14) 8.50 (3.61) 11.00 (1.41) 0.185
12.67 (4.04) 12.58 (2.37) 12.00 (1.41) 10.73 (5.04) 7.60 (2.51) 11.00 (3.89) 12.00 (1.41) 0.228
6.67 (0.58) 5.29 (1.68) 5.00 (2.82) 5.64 (1.93) 2.40 (1.14) 4.00 (1.67) 4.50 (0.71) 0.028*
9.42 (2.90) 14.00 (2.47) 0.126
10.86 (3.47) 13.00 (3.48) 0.419
5.16 (1.76) 4.43 (2.21) 0.264
8.12 (3.66) 10.69 (2.17) 10.22 (2.82) 0.056
9.87 (3.99) 11.70 (2.95) 11.51 (3.57) 0.213
5.25 (1.66) 3.88 (1.55) 5.15 (1.99) 0.187
10.33 (3.09) 8.33 (2.47) 14.00 (2.08) 0.383
12.00 (3.85) 8.67 (3.13) 13.00 (4.50) 0.433
5.07 (1.94) 5.19 (1.72) 2.33 (0.58) 0.060
7.00 (2.99) 10.22 (2.57) 0.352
9.00 (4.06) 11.51 (3.23) 0.040*
4.88 (1.73) 5.09 (1.85) 0.217
S & S, signs & symptoms; RF, risk factors; NO, negative outcomes. Kruskal—Wallis. ¥ Mann—Whitney U. * p < 0.05.
answering these questions (mean rank, 40.67, SD 0.577) than all others, with participants from India performing poorly (mean rank 7.70, SD 1.14).
Hospital policy Only 39% of registered nurses were aware that a hospital policy existed and 69% of participants had received no formal training on delirium. Interestingly, whilst 56% of nurses were aware of routine screening 46% did not undertake any sort of screening of their patients to assess for the presence of delirium. However, in contrast 52% of nurses did use the internationally recognised CAM-ICU when they undertook an assessment for suspected delirium.
Discussion Much of the work focusing on delirium has taken place from a western perspective and there appears to be very little work from an Asian viewpoint. Whilst it could be agreed that delirium is delirium regardless of the global context there is a difference in the way health care in this clinical environment is delivered. The healthcare management structure in this area is very much based around the premise of filial piety, is hierarchical in nature and is medically dominated. Therefore the role of the nurse could be considered to be one of compliancy and where clinical decision making is undertaken at the sole discretion of the medical team. Moreover there is an over emphasis on education whether it is formal or informal the unwritten rule it appears, is that
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
Intensive care unit nurses’ knowledge of delirium educational qualifications whatever they may be determines competency. Therefore, as a means to assessing and managing delirium in this cultural context it was important to be able to distinguish between what is known and learnt and what is practiced given the above observations. Therefore the overall aim of this exploratory study was to assess whether nurses from a tertiary hospital MICU in South East Asia had sufficient knowledge to assess and manage delirium in this clinical setting. The results were what would have been expected given the plethora of literature related to delirium in the ICU (Arend and Christensen, 2009). Whilst this cohort fared better than some western studies (Flagg et al., 2010; Hare et al., 2008b) still only 63% of nurses in this study knew what the signs and symptoms, the risk factors and the negative outcomes associated with delirium were as it related to their clinical area. It is alarming that a large group of nurses (37%) had poor knowledge. The reason for this is perhaps due to the fluctuating nature of delirium and its myriad of presentations — hypo, hyper, mixed and unexplained. Whilst evidence suggests that nurses often have great difficulty in identifying the fluctuating core features of delirium such as acute onset and disorganised thinking (Arend and Christensen, 2009; Lemiengre et al., 2006; Morency, 1990; Voyer et al., 2008), findings from this study demonstrated that at least 50% of nurses were able to identify some of those core features of delirium alone. However this tended to be those behaviours commonly associated with hyper-active delirium. When it came to identifying hypoactive delirium, like other studies (Flagg et al., 2010; Wang and Mentes, 2009), this cohort was only able to detect its presence in 41% of cases. This suggests nurses tend to focus on the behaviours of delirium that had the potential to increase their workload for example, preventing patient harm and/or protecting invasive lines such as endotracheal tubes or indwelling catheters. Why this is the case may be multi-factorial although evidence suggests two things. First a lack of knowledge in identifying the clinical features of delirium results in under-recognition and misdiagnosis of delirium by medical and nursing staff (Boot, 2012; Devlin et al., 2012; Steis and Fick, 2008). Second, the complexity of screening tools in the past have been less able to detect which delirium feature is present (Spronk et al., 2009; Wells, 2012) and as a result detection is reliant on clinical experience and not always at the behest of nursing. With the introduction of CAM-ICU as a formative assessment tool for delirium in the ICU, there has been a significant increase in the way that delirium is now being assessed in this clinical area (Ely et al., 2001). Although some ICU nurses still feel that the CAM-ICU is difficult to use and does not necessarily warrant the time it takes to complete the assessment (Eastwood et al., 2012), on the whole its effectiveness together with the Intensive Care Delirium Screening Checklist is well supported within the literature (Devlin et al., 2012). Unfortunately that cannot be said of this study. A small number of respondents (34.5%) despite receiving some form of delirium training albeit limited as well as having an awareness of current hospital policy failed to either undertake a formalised assessment or tended to use their own clinical judgement. Like Eastwood et al. (2012) who found that their ICU nurses did recognise the importance of delirium assessment; the participants in this study tended to rely on direction from medical staff and therefore it would
5 Table 2 Staff nurses knowledge of current hospital/ department policy and training on delirium. Delirium policy and training Knowledge of hospital policy Yes No Knowledge of routine screening Yes No Delirium training Yes No Type of delirium training Nil In-service E-learning Conference Type of assessment used Nil CAM CAM-ICU
Total (n = 52), n% 20 (38.5) 32 (61.5) 29 (55.8) 23 (44.2) 17 (32.7) 36 (69.3) 34(65.5) 15 (28.8) 2 (3.8) 1 (1.9) 24 (46.2) 1 (1.9) 27 (51.8)
appear placed little importance on undertaking a delirium assessment or alternatively saw the assessment as a task to be performed. This is consistent with findings by Devlin et al. (2008), who found that only 3% of nurses ranked delirium as the most important condition to evaluate. However, there is the cultural element that must be taken into account here: it would be wrong to suggest that the nurses in this ICU would not consciously provide support for a patient experiencing a delirious episode. Instead it is important to remember that the cultural nature of decision-making in this MICU is based loosely around the Confucius edit of filial piety where from an early age individuals are taught humility towards those in power and authority as well as care being policy driven. Therefore, whilst the results of this study articulate that nurses are indeed knowledgeable with regard to most aspects of delirium, cultural propriety may well also explain the reasons why some participants did not perform a delirium assessment on their patients (Table 2). However, this still raises the question as to whether theoretical knowledge alone is enough to detect, manage and prevent delirium in this setting. The results of this study certainly give some credence to this notion and as mentioned previously it is believed qualifications often equals competency. Although it is easy to suggest that nurses are the ideal frontline person to assess and identify those patients at risk for delirium, establishing a patient’s baseline vulnerability status and applying effective targeted interventions is not always met with success. In other words having substantive theoretical knowledge does not always mean it is reproducible in a performance context. Therefore caution must be warranted where the perception is that improved ‘‘knowledge’’ would lead to better prevention, detection and even management of delirium (Tabet et al., 2005). Of course increased knowledge would inevitably heighten nurses’ awareness and whilst some nurses in this study identified correctly those aspects of delirium detection and management it would appear that little is done in a practical sense to limit if not prevent those attributable outcomes.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
6
M. Christensen
Creating a sense of urgency to perform prompt screening assessment and early implementation measures to prevent or manage delirium is potentially the way forward (Tabet et al., 2005). Preventing delirium however, is an onerous task given the complexity of its presentation, underlying causative factors and that nurses may not conduct timely routine screening assessment and implement effective preventive measures due to misperception of low threats (Flagg et al., 2010).
Limitations Several limitations affected the outcomes of this study. First, due to purposive sampling, the small sample size and the sampling frame restricted to one hospital, generalisation of findings to the entire population of interest is expected to be limited and should be made with caution. Whilst it is conceded that the sample was taken from one of the seven ICU’s present in this hospital, it was felt the MICU was better suited because of the patient group that was often admitted to the ward. Unlike the other ICU’s the patient group admitted to the MICU often stayed longer, had substantive comorbidities and the acuteness of their admission meant they were more prone to developing delirium quicker. Second, the newly developed instrument was not statistically validated to support construct validity however we felt that content validity was such that the results from the study would at the very least provide enough information to make it statistically viable and significant. It is accepted that establishing adequate psychometric measurement following a comprehensive literature review and content validity was appropriate; construct validity through formal statistical analysis, such as exploratory factor analysis, would be recommended in future studies to identify any deficits and refine the instrument prior to further use. Third, data obtained from a self-reported questionnaire may cause possible response bias from each responder (Beck and Polit, 2006), which is based on respondent honesty and is entirely reliant on the subjective views of the participants and therefore may be a source of error in a self-reported questionnaire (Siegel et al., 1998).
Conclusion Delirium is a commonly encountered condition within the ICU. Its effects on the patient can be debilitating and in some cases promote early death. Whilst there is a plethora of literature in both the medical and nursing press addressing the problem and management of delirium, there has however, been a number of studies which have demonstrated that health care professionals are poor at recognising and treating delirium effectively this study was no exception. There have been many suggestions that continued education be at the forefront of reducing the incidence of delirium. Although this is a sensible approach, one only has to review the number of articles that promote, identify, discuss and acknowledge the presence of ICU delirium to recognise its importance. Perhaps what is needed is a fresh approach to improve compliance and more effective management streams. The introduction of CAM-ICU has helped and supported this development, however there still
appears to be the problem that nurses view the assessment tool as a task to be done (tick-box nursing care) or its too complicated or difficult to undertake given perceived time constraints around workload. Performing the assessment itself is straight forward and therefore perhaps the problem is around the decision-making process that accompanies this where differing opinions about observed delirious behaviour are open to scrutiny.
References American Psychiatric Association: Diagnostic and Statistical Manual of mental Disorders. Delirium, dementia, and amnestic and other cognitive disorders. 4th ed. Washington DC: American Psychiatric Association Press; 2000. p. 135—80. Arend E, Christensen M. Delirium in the intensive care unit: a review. Nurs Crit Care 2009;14(3):145—54. Beck CT, Polit DF. Essentials of nursing research: methods, appraisal and utilization. United States: Lippincott Williams & Wilkins; 2006. Boot R. Delirium: a review of the nurses role in the intensive care unit. Intensive Crit Care Nurs 2012;28:185—9. Devlin JW, Fong JJ, Fraser GL, Riker RR. Delirium assessment in the critically ill. Intensive Care Med 2007;33:929—40. Devlin JW, Fong JJ, Howard EP, Skrobik Y, McCoy N, Yasuda C, et al. Assessment of delirium in the intensive care unit: nursing practices and perceptions. Am J Crit Care 2008;17(6):555—67. Devlin JW, Brummel NE, Al-Qadheeb NS. Optimising the recognition of delirium in the intensive care unit. Best Pract Res Clin Anaesthesiol 2012;26:385—93. Eastwood GM, Peck L, Bellomo R, Baldwin I, Reade MC. A questionnaire survey of critical care nurses’ attitudes to the delirium assessment before and after introduction of the CAM-ICU. Aust Crit Care 2012;25:162—9. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;2997:1370—9. Fick DM, Hodo DM, Lawrence F, Inouye SK. Recognizing delirium superimposed on dementia: assessing nurses knowledge using case vignettes. J Gerontol Nurs 2007;33(2):40—7. Flagg B, Cox L, McDowell S, Mwose JM, Buelow JM. Nursing identification of delirium. Clin Nurse Spec 2010;24(5):261—6. Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, et al. Delirium in the emergency department: An independent predictor of death within 6 months. Ann Emerg Med 2010;56(3):244—52. Hamdan-Mansour AM, Farhan NA, Othman EH, Yacoub MI. Knowledge and nursing practice of critical care nurses caring for patients with delirium in intensive care units in Jordan. J Contin Educ Nurs 2010;41(12):571—6. Hare M, McGowan S, Wynaden D, Speed G, Landsborough I. Nurses’ descriptions of changes in cognitive function in the acute care setting. Aust J Adv Nurs 2008a;26(1):21—5. Hare M, Wynaden D, McGowan S. A questionnaire to determine nurses’ knowledge of delirium and its risk factors. Clin Nurs 2008b;29(1):23—31. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalised elderly medical patients. Am J Med 1994;97:278—88. Lemiengre J, Nelis T, Joosten E, Braes T, Foreman M, Gastmans C, et al. Detection of delirium by bedside nurses using the confusion assessment methods. J Am Geriatr Soc 2006;54(4):685—9. Morency CR. Mental status change in the elderly: recognising and treating delirium. Clin Updates 1990;6(6):357—63.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004
+Model YICCN-2298; No. of Pages 7
ARTICLE IN PRESS
Intensive care unit nurses’ knowledge of delirium Munro BH. Statistical methods for health care research. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. Siegel DM, Aten MJ, Roghmann KJ. Self-reported honesty among middle and high school students responding to a sexual behaviour questionnaire. J Adolesc Health 1998;23:20—8. Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009;35:1276—80. Steis MR, Fick DM. Are nurses recognising delirium? A systematic review. J Gerontol Nurs 2008;34(9):40—8. Tabet N, Hudson S, Sweeney V, Saucer J, Bryant C, Macdonald A, et al. An educational intervention can prevent
7 delirium on acute medical wards. Age Ageing 2005;34: 152—6. Voyer P, Richard S, Doucet L, Danjou C, Carmichael PH. Detection of delirium by nurses among long-term care residents with dementia. BioMed Central Nurs 2008;7(4):1—14. Wang J, Mentes JC. Factors determining nurses clinical judgments about hospitalized elderly patients with acute confusion. Issues Ment Health Nurs 2009;30:399—405. Wells LG. Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature. Aust Crit Care 2012;25:157—61. While AE. Competence versus performance: which is more important. J Adv Nurs 1994;20:525—31.
Please cite this article in press as: Christensen M. An exploratory study of staff nurses’ knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs (2013), http://dx.doi.org/10.1016/j.iccn.2013.08.004