RESEARCH doi: 10.1111/nicc.12127
Delirium assessment in intensive care units: practices and perceptions of Turkish nurses Aysel Özsaban and Rengin Acaroglu ABSTRACT Aim: The aim of this study was to identify current practices and perceptions of intensive care nurses regarding delirium assessment and to examine the factors that affect these practices and perceptions. Background: As delirium in intensive care unit (ICU) patients is a serious problem that can result in increased mortality and morbidity, routine delirium assessment of all ICU patients is recommended. The severity, duration and outcome of the syndrome are directly related to nurses’ continuous assessment of patients for signs and symptoms of delirium. However, studies indicate that very few nurses monitor for delirium as a part of their daily practices. Design: A descriptive, correlational study design was used. Methods: Data were collected from five Turkish public hospitals using a structured survey questionnaire. The study sample comprised 301 nurses who agreed to participate. Data were analysed using descriptive statistics. Results: More than half of the nurses performed delirium assessments. However, the proportion of nurses who use delirium assessment tools was quite low. Almost all of the nurses perceived delirium as a problem and serious problem for ICU patients. The patient group least monitored for delirium was that of unconscious patients. Statistically significant differences were found in the proportion of nurses who assessed delirium symptoms and whose care delivery system was patient-centred and perceived delirium as a serious problem. Conclusion: While a majority of ICU nurses perceived delirium as a problem and serious problem, the proportion of those who perform routine delirium assessments was less. It was found that delirium assessment practices of nurses were affected from their perceptions of delirium and the implementation of patient-centred care delivery. Relevance to clinical practice: It is essential to develop strategies to encourage ICU nurses to perform delirium assessments through the use of delirium assessment tools. Key words: Delirium • Delirium assessment tools • Intensive care • Nursing assessments
INTRODUCTION Delirium is a serious problem among patients hospitalized in intensive care units (ICUs) and is a transient organic mental syndrome generally characterized by sudden onset of cognitive disturbances, altered level of consciousness, impaired attention, increased or decreased psychomotor activity and irregular Authors: A. Özsaban, PhD, Research Assistance, Istanbul University Florence Nightingale Nursing Faculty, Department of Fundamentals of Nursing, Istanbul, Turkey; R. Acaroglu, PhD, Associate Professor, Istanbul University Florence Nightingale Nursing Faculty, Department of Fundamentals of Nursing, Istanbul, Turkey Address for correspondence: R Acaroglu, Associate Professor, Istanbul University Florence Nightingale Nursing Faculty, Department of Fundamentals of Nursing, Abide-I Hürriyet Cad. 34381 Si¸ ¸ sli/I˙stanbul, Turkey E-mail: [email protected]
© 2015 British Association of Critical Care Nurses
sleep-wake cycles (Krahne et al., 2006). Delirium is caused by an underlying organic process, and there is growing recognition that it represents acute brain dysfunction or failure. The three motoric subtypes of delirium are hyperactive, hypoactive and mixed. Patients who experience hyperactive delirium exhibit increased psychomotor activity, restlessness, agitation, hyper-alertness and rage. Patients with hypoactive delirium present with symptoms such as psychomotor retardation, lethargy, decreased responsiveness, apathy and withdrawal. In cases of mixed delirium, patients fluctuate between hyperactive and hypoactive symptoms (Bruno and Warren, 2010; Wells, 2012). Delirium is a serious issue threatening patient safety with higher mortality, prolonged ICU stay and greater health care costs (Arend and Christensen, 2009; Shaughnessy, 2012). 1
Delirium assessment in ICU: practices and perceptions of Turkish nurses
BACKGROUND The detection of delirium is crucial for the improvement of patient safety in ICUs. Although delirium is clearly defined as a medical diagnosis, it is frequently either completely missed or misinterpreted as dementia or depression by nurses as well as physicians (Milisen et al., 2006; Voyer et al., 2008). It is therefore often overlooked by health care professionals during its early stages (Schuurmans et al., 2001; Ely et al., 2004b). A diagnosis of delirium in the ICU, the implementation of treatment and preventive interventions for patients at risk require collaboration among health care professionals. However, according to Devlin et al. (2008), near-constant contact of intensive care nurses with their patients places them in the best position to perform routine delirium assessment. It is recommended that all patients be assessed for delirium on admission to ICU. As delirium is a sudden-onset syndrome with a fluctuating course, routine assessment by nurses performed at least once per shift is considered to be ideal (Boot, 2012; Eastwood et al., 2012). Most importantly, patients who are at risk of developing delirium should be identified. The risk factors include advanced age, underlying primary cerebral illnesses, chronic illnesses, pharmacological agents and environmental factors (Roberts, 2004; Bruno and Warren, 2010; Wells, 2012). Certain patient groups require particular attention in screening for delirium. These groups involve mechanically ventilated patients, patients who are under sedation and those who are unconscious (Ely et al., 2001; Akıncı et al., 2005; Thomason et al., 2005; Devlin et al., 2007, 2008). Delirium screening and assessment could be considered as a subsection of neurological assessment. All critically ill patients should be neurologically assessed by initially using the Glasgow Coma Scoring System; however, it is only relevant to screen/assess for delirium in those patients who are appropriately responsive. This is because delirium assessment requires interactive communication between the nurse and the patient. Those patients who are unconscious or unresponsive as identified from the initial Glasgow Coma Scale neurological assessment will be classified as ‘unable to assess’. Once the patient has been identified to be responsive, the nurse can commence the screening/assessment of delirium. This stage involves mental status examination using assessment tools, such as those proposed by Page and Ely (2011). It is recommended that an assessment tool is routinely used in such patients at risk. Yet the use of systematic, valid and reliable tools in the assessment of delirium by nurses facilitates the application of necessary interventions by ensuring access to fast and objective patient information (Gaudreau et al., 2
2005). This approach allows for early detection and timely implementation of management strategies that may reduce its severity and/or duration (Voyer et al., 2008; Shaughnessy, 2012). In addition, these tools can aid in making accurate and easy assessment even in situations where it could be difficult, such as intubation, sedation and stupor (Bergeron et al., 2001; Devlin et al., 2008). The Neelon and Champagne Confusion Scale (NEECHAM), the Confusion Assessment Method for the ICU (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC) and the Organic Brain Syndrome Scale were also commonly used assessment tools for delirium in the ICU (Adamis et al., 2009). The baseline for using these scales is the consciousness level of the patient. In patients with a low level of consciousness from whom we can get verbal response can be an assessment for delirium. For this reason, it is especially significant to observe unconscious and sedated patients for the changes in their consciousness levels (Fan et al., 2012).
Literature review Studies indicate that although nurses are in a unique position to recognize delirium, they do not make adequate assessment in their daily practice. According to the studies, the possible barriers to delirium assessment are (1) assessment tools not being used, (2) lack of knowledge about delirium, (3) the misconception that the tools are complicated, (4) the difficulty of assessing intubated and sedated patients and (5) time constraints (Devlin et al., 2008; Wells, 2012). However, making use of related guidelines in diagnosis, prevention and management of delirium helps nurses. In this sense, the most remarkable guideline is the NICE Clinical Guideline developed in the UK. In particular, the guideline focuses on preventing delirium in people identified to be at risk, using a targeted, multicomponent, non-pharmacological intervention that addresses a number of modifiable risk factors (National Institute for Health and Clinical Excellence, 2010). Ely et al. (2004b) reported that 16% of the nurses who participated in a study conducted in the USA used delirium diagnosis instruments, whereas Scelsi et al. (2011) reported that 12% of the nurses in their Italian research did so. Van Eijk et al. (2008) reported that 7% of the nurses who participated in their study used these tools. Another study conducted in Holland indicates that cases of delirium are predominantly (68%) diagnosed during consultation with geriatric or psychiatric doctors, and that assessment tools are applied infrequently (25%). Such consultations take place only in the cases of hyperactivity, thereby increasing the risk of hypoactive delirium incidences remaining unrecognized (Cadogan et al., 2009). © 2015 British Association of Critical Care Nurses
Delirium assessment in ICU: practices and perceptions of Turkish nurses
Studies indicate that 16–89% of ICU patients develop delirium (Peterson et al., 2006; Pandharipande et al., 2007; Bruno and Warren, 2010; Robinson et al., 2011). ICU delirium is associated with prolonged hospital stays, increased morbidity and mortality, increased health care costs and poor clinical outcomes (Schuurmans et al., 2001; Ely et al., 2004a; Akıncı et al., 2005; Mistarz et al., 2011; Sharma et al., 2012). This study was performed because there are no Turkish studies on delirium diagnosis or on the use of delirium assessment tools by ICU nurses.
Aim The aim of this study was to identify current perceptions and practices of intensive care nurses regarding delirium assessment and to examine the factors that affect these perceptions and practices. The study questions were as follows: Do nurses in ICUs: • • • •
make the routine delirium assessments? use any assessment tools to assess delirium? perceive delirium as a problem for patients? have any factors that may affect their practices to delirium assessment?
METHODS Design A descriptive, correlational study design was used.
Setting and participants The study was conducted between 4 March 2011 and 4 June 2011 in five public hospitals in Istanbul, Turkey. These hospitals which are affiliated with the Turkish Ministry of Health were the largest public hospitals in Istanbul at the time of the study with an average of 21 beds in each ICU. There were a total of 427 nurses in these ICUs. A total of 314 critical care nurses caring for adult patients in cardiac and vascular surgery critical care units, coronary care units, multidisciplinary ICUs and mixed ICUs were contacted and asked to fill out a survey questionnaire. A total of 13 questionnaires had incomplete responses and were excluded from the study. As a result, the study sample consisted of 301 nurses.
Data collection Data were collected using a structured questionnaire form developed by the researchers in accordance with the literature. An investigator met with the intensive care nurses and explained the aim and scope of the study, its duration and what was expected of the participants. Self-reported paper and pencil questionnaire © 2015 British Association of Critical Care Nurses
was given to the nurses who agreed to participate in the study and took approximately 15 min to complete the form. The questionnaire forms were not left in the clinics so that nurses did not bias each other. While the forms were being completed, the researcher waited in the clinic and took the completed forms back from the nurses.
Survey questionnaire The survey instrument was developed by the researchers after reviewing the relevant literature as below. The questionnaire form of this study was prepared by considering the questions in the data collection tools of the studies examining the practices and perceptions of nurses about delirium in the online databases. The questionnaire was pilot-tested for face validity and clarity by a random sample of 10 critical care nurses who had 5 years of intensive care experience. The questionnaire form consisted of 15 items, 8 of which concerned the nurses’ demographic details such as gender, age, education levels, professional experience, experience working in ICUs, tasks undertaken within the ICUs and the care delivery system they used. The remaining seven items consisted of questions designed to identify the opinions, thoughts and work practices of nurses in relation to delirium. These were questions concerning nurses’ perceptions of delirium as a problem (Ely et al., 2004b), barriers to the assessment of delirium (Devlin et al., 2008), nurses’ abilities to perform routine assessments (Forsgren and Eriksson, 2010), and delirium assessment tools that were used (Bergeron et al., 2001; Devlin et al., 2007). The others were questions concerning patient groups assessed by nurses for delirium (Devlin et al., 2007, 2008), nurses’ abilities to identify delirium symptoms (Devlin et al., 2008; Flagg et al., 2010; Silva et al., 2011), and frequency of recognizing delirium symptoms (Cadogan et al., 2009; Forsgren and Eriksson, 2010).
Ethical considerations Ethical approval for this study was obtained from the Ethics Committee of Istanbul University Cerrahpasa School of Medicine before beginning the study. Written permission was also obtained from the Istanbul Provincial Directorate of the Ministry of Health of the Republic of Turkey. All the nurses in each hospital’s ICUs were informed about the study verbally and invited to participate. They were informed that involvement was completely voluntary and withdrawal from the study could take place at any time. Anonymity and 3
Delirium assessment in ICU: practices and perceptions of Turkish nurses
confidentiality were also assured. In addition, when entering the ICUs, the investigator complied with safety protocol designed to protect patients from infections. In order to avoid disruptions to patient care, data were collected during hours suitable for the nurses.
Data analysis Data were analysed using the Statistical Package for Social Sciences 15.0 (SPSS 15.0). Numbers, percentages, arithmetic means and standard deviations were used for descriptive statistics. Chi-square analysis was used to test for the existence of relationships between independent variables. Statistical significance was set at p < 0⋅005.
RESULTS The mean age of the participants was 28⋅84 ± 4⋅44 years and 79⋅1% were female. Of all participants, 48⋅2% had a bachelor’s degree, 41⋅5% had between 2 and 5 years of professional experience, and 48⋅2% had been employed in an ICU for between 2 and 5 years (Table 1). It was determined that while 87⋅4% of the nurses were using a task-based system to deliver nursing care, 12⋅1% were delivering patient-centred care (Table 1). It was found that more than half of the nurses who participated in the study (67⋅8%) performed routine Table 1 Demographic characteristics of the nurses (N = 301) Characteristics Mean age Gender Female Male Education levels Vocational school of health Diploma/associate degree Bachelor’s degree Master’s degree Professional experience (years) 0–1 2–5 6–10 ≥11 Experience in an intensive care unit (years) 0–1 2–5 6–10 ≥11 Care delivery system Patient-centred Task-based
4
n
%
(X ± SD) 28⋅84 ± 4⋅44 238 63
79⋅1 20⋅9
84 52 145 20
27⋅9 17⋅3 48⋅2 6⋅6
25 125 90 61
8⋅3 41⋅5 29⋅9 20⋅3
66 145 73 17
21⋅9 48⋅2 24⋅3 5⋅7
38 263
12⋅6 87⋅4
Table 2 Distribution of delirium assessment methods used by nurses (N = 301) Variables
n
Routine delirium assessment Performs Does not perform Delirium assessment tools (N = 204)∗ Uses Does not use Patient groups assessed∗ Patients on mechanical ventilation Conscious patients Patients on sedatives Unconscious patients Frequently identified delirium symptoms∗ Increase/decrease in psychomotor activity Disorientation as to time, place or persons Emotional fluctuations Distractibility, difficulty in concentrating Decomposition of thought content Impairment of immediate, short-term or long-term memory Deterioration of the thought process Disruption of the sleep-wake cycle Frequency of assessing delirium symptoms Hourly Each shift Every 24 h Weekly There is no set frequency
%
204 97
67⋅8 32⋅2
30 182
14⋅7 89⋅3
231 216 201 108
76⋅7 71⋅8 66⋅8 35⋅9
269 254 209 183 173 171 170 164
89⋅4 84⋅4 69⋅4 60⋅8 57⋅5 56⋅8 56⋅5 54⋅5
114 26 148 5 8
37⋅9 8⋅6 49⋅2 1⋅7 2⋅7
∗ Multiple options were marked.
delirium assessments, that 89⋅3% of these nurses requested psychiatric consultation for the diagnosis of delirium and that very few (Table 2) use delirium assessment tools. Of the tools used, the Nursing Delirium Screening Scale was used by 6⋅3% of the nurses (n = 13), the CAM-ICU was used by 4⋅4% (n = 9) and the ICDSC by 4% (n = 8). The majority of the nurses (76⋅7%) identified delirium in patients on mechanical ventilation whereas only 35⋅9% performed an assessment on patients who were unconscious. Increased/decreased psychomotor activity (89⋅4%) and disorientation as to time, place or persons (84⋅4%) were the symptoms of delirium that were most frequently identified by the nurses. It was found that nurses placed less importance (Table 2) on symptoms such as emotional fluctuations (69⋅4%), distractibility and difficulty concentrating (60⋅8%), decomposition of thought content (57⋅5%), impairment of immediate, short-term or long-term memory (56⋅8%), deterioration of the thought process (54⋅5%) and disruption of the sleep-wake cycle (54⋅5%). It was determined that while almost half of the nurses (49⋅2%) monitored delirium symptoms once © 2015 British Association of Critical Care Nurses
Delirium assessment in ICU: practices and perceptions of Turkish nurses
Table 3 Distribution of nurses’ perceptions of delirium syndrome (N = 301) Variables
n
Delirium from the perspective of patient safety Is not a problem Is a problem Is a serious problem Obstacles to diagnosing delirium∗ Patient being under sedation Patient being intubated The complexity of the diagnostic tools The time it takes to perform the assessment
%
14 130 157
4⋅6 43⋅2 52⋅2
222 199 198 36
73⋅8 66⋅1 65⋅8 12⋅0
∗ Multiple options were marked.
Table 4 Factors affecting nurses’ assessment of delirium Performing assessment Characteristics Gender Age Educational status Professional experience ICU experience Care delivery system Perception of delirium
𝜒2
p
1⋅701 0⋅215 5⋅106 8⋅971 4⋅344 11⋅788 8⋅610
>0⋅005 >0⋅005 >0⋅005 >0⋅005 >0⋅005 0⋅001 0⋅013
every 24 h, 37⋅9% performed hourly assessments (Table 2). It was determined that 52⋅2% of nurses considered delirium to be a serious problem (Table 3). While 73⋅8% reported that patients being under sedation hindered the assessment of delirium, 12% reported the excessive time taken in completing their observations to constitute an obstacle (Table 3). No statistically significant differences in nurses’ assessment of delirium in relation to their characteristics such as age, gender, educational status, professional experience and ICU experience was found (p > 0⋅005). However, statistically significant differences were found in the majority who assessed delirium symptoms and those whose care delivery system were patient-centred (p < 0⋅001) and who perceived delirium as a serious problem (p < 0⋅005) (Table 4).
DISCUSSION The aim of this study was to identify the current practices and perceptions of nurses in Turkey with regards to assessing delirium in ICUs. Almost three-quarters of nurses had two or more years of ICU experience. Only 12⋅6% of nurses worked with patient-based system that involved planning, © 2015 British Association of Critical Care Nurses
applying and evaluating the care of same patients from admission to discharge in a limited number. Patient-based system strengthens the nurse-patient relationship and enables the nurse to get acquainted with her patient better, follow and realize him continuously and faster, and take necessary precautions (National Institute for Health and Clinical Excellence, 2010). However, the fact that the majority of nurses worked with the task-based system in which their responsibilities were distributed according to the skill level and performance in each shift was a negative situation for the early assessment of delirium (Table 1). In this study, the percentage of nurses who performed routine delirium assessments was low (67⋅8%). This is consistent with the findings of Forsgren and Eriksson (2010) (59%) and Patel et al. (2009) (59%). It was found that very few nurses (14⋅7%) participating in this study used screening tools for the assessment of delirium (Table 2). This indicates that these tools are not widely used in the Turkish ICUs despite the fact that instruments such as CAM-ICU and ICDSC have been found to be valid and reliable for use in Turkey. It was reported by Ely et al. (2004b) that 16% of nurses use formal assessment tools, and Scelsi et al. (2011) determined that 12% nurses do so. Van Eijk (2008) found that 7% of nurses used them. This study is consistent with the literature in that the proportion of nurses who use delirium assessment tools was found to be low. It was found in this study that most nurses reported monitoring for delirium (Table 2), and they utilized psychiatric consultations to make the assessment (89⋅3%). However, psychiatric consultation is a procedure applied after a significant number of delirium symptoms are observed (Cadogan et al., 2009). It is crucial to take preventive measures following accurate diagnostic evaluation of patients’ risk of developing delirium. Studies have revealed a lack of awareness about delirium in health care professionals who work in the ICUs (Bruno and Warren, 2010). In fact, Cadogan et al. (2009) reported that in 90% of cases, psychiatric consultation is sought for the assessment of delirium, whereas in a study by Forsgren and Eriksson (2010) psychiatric consultation was sought in 52% of the cases. Such findings are associated with underusage of delirium screening tools. More than half of the nurses who participated in this study were conducting delirium assessment in mechanically ventilated patients (76⋅7%) and sedated patients (66⋅8%). The fact that the number of nurses observing unconscious patients for delirium assessment was quite low (35⋅9%) pointed out that their level of awareness regarding routine patient evaluation for delirium was insufficient. However, in the literature it 5
Delirium assessment in ICU: practices and perceptions of Turkish nurses
is stated that delirium as an acute situation develops in a rather short time and delirium progresses before the mental states of the comatose patients recover (Kitchener et al., 2012). In this study, the majority of nurses assessed symptoms that are observable without in-depth diagnostics (Table 2) such as measuring increase/decrease in psychomotor activity (89⋅4%) and disorientation as to time, place or persons (88⋅4%). This is consistent with other studies which indicate that nurses usually take into account hyperactive symptoms. In a study by Flagg et al. (2010), it was determined that 90% of nurses identify symptoms of hyperactive delirium whereas 77% identify symptoms of hypoactive delirium. Silva et al. (2011) reported that nurses identify delirium symptoms such as confusion, attempts to exteriorize catheters, agitation, changes in the level of consciousness, disorientation and inappropriate or meaningless speech. Conversely, Devlin et al. (2008) reported that the symptom identified most frequently is changes in levels of consciousness. In this study, the symptoms least noted by nurses were decomposition of thought content (57⋅5%), impairment of immediate, short-term or long-term memory (56⋅8%), deterioration of the thought process (54⋅5%) and disruption of the sleep-wake cycle (54⋅5%). This is consistent with the findings in a study by Cadogan et al. (2009) where very little attention was paid to symptoms such as disruption of the sleep-wake cycle and cognitive changes. In this study, almost half of the nurses (49%) were performing delirium assessments once every 24 h (Table 2). This is consistent with the findings of Ely et al. (2004b) who reported that 67% of nurses monitored their patients for delirium once every 24 h. Cadogan et al. (2009) found that 32% of nurses participating in their study performed delirium assessments thrice a day, and Forsgren and Eriksson (2010) reported that 45% did so 2–4 times per day while 24% performed hourly assessments. Delirium is a very serious problem which prolongs hospital stays, increases morbidity and threatens patient safety (Ely et al., 2004a; Ouimet et al., 2007; Arend and Christensen, 2009). Ely et al. (2004b) reported that 92% of the participants in their study perceived delirium as a serious problem. In another study by Eastwood et al. (2012), it was found that 73% considered it to be serious. Similarly, it was found that 52⋅2% of the participants in this study perceived delirium as a serious problem (Table 3). According to the literature, obstacles to assessing delirium risk are attributable partly to patient-related factors and partly to nurse-related factors (Bergeron et al., 2001; Devlin et al., 2008). This study is consistent with the literature in that a large majority of 6
the nursing staff reported that patients being sedated (73⋅8%) or intubated (66⋅1%) as well as the complexity of the screening tools (65⋅8%) hinder the assessment process (Table 3). Devlin et al. (2008) found that the most widely reported barriers were intubation (38%), the complexity of delirium assessment tools (34%) and the inability to complete the screening for delirium in sedated patients (13%). Identifying the factors that hinder delirium assessment can be considered to be an important step in resolving these problems. The fact that assessment of delirium did not differ according to nurses’ characteristics such as age, gender, education levels and professional experience or ICU experience (p > 0⋅005) may be attributable to the fact that the mean age and average ICU experience of the participants were low. It was found, however, that care delivery systems and perceptions of delirium were associated with the prevalence of delirium assessments (p < 0⋅005). Nurses who worked under patient-centred care-delivery systems tended to perform more assessments. In fact, National Institute for Health and Clinical Excellence, (2010) emphasizes the need for continual monitoring of patients and the importance of patient-centred care in assessing delirium. In this study, a statistically significant difference was found that the nurses who perceived delirium as a syndrome that embodies serious problems had higher delirium assessment rates (p < 0⋅005). This finding supports the idea that thoughts and emotions that are believed in and valued are reflected in the behaviour. It also highlights the importance of developing strategies that will increase awareness among ICU nurses of situations where patient safety is at risk due to delirium (Table 4).
Limitations In data collection, a survey form that was pilot tested and developed by the researchers was used because there was not a suitable measurement tool of which reliability and validity studies were performed and which was adapted to the Turkish society. It was applied only to nurses working in the adult ICUs. Despite these limitations, the results of this study provide the first view of current practices and perceptions of Turkish ICU nurses with regards to assessment of delirium.
CONCLUSION The purpose of this study which was the first on this topic to be conducted in Turkey was to identify current perceptions and practices of intensive care nurses regarding delirium assessment as well as the factors that affect these perceptions and practices. It was found that while a majority of ICU nurses perceive delirium © 2015 British Association of Critical Care Nurses
Delirium assessment in ICU: practices and perceptions of Turkish nurses
as a problem for patient safety, not as many perform routine delirium assessments. They were not using any reliable delirium assessment instruments to monitor for or identify delirium symptoms. Consistent with the literature, the three major barriers to assessment reported by the nurses were patients being sedated or intubated and the complexity of the assessment tools. It was found that nurses who implement patient-centred care delivery tend to perform delirium assessments more frequently.
raised. Some strategies increasing the use of delirium assessment tools and protocols that enable the assessment of delirium routinely may be developed. Moreover, national guidelines regarding the diagnosis, prevention, care and treatment of delirium may be developed and used to help nurses in ICUs. In addition, encouraging the provision of patient-centred care rather than task-based patient care could contribute to improving quality of the care provided.
ACKNOWLEDGEMENTS RECOMMENDATIONS FOR FUTURE PRACTICE By developing and applying training programmes related to delirium management, awareness can be
The authors would like to thank the nursing staff who contributed to this project during the data collection phase.
WHAT IS KNOWN ABOUT THIS TOPIC • •
Nursing staff have key roles within ICU health care teams in the identification of delirium risk factors and the early detection of delirium symptoms. The use of systematic, valid and reliable assessment tools by nursing staff facilitates the timely collection of objective patient information.
WHAT THIS PAPER ADDS • •
Nursing staff do not adequately assess the risk of delirium. Nurses underuse delirium assessment tools to screen for delirium risk factors.
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Roberts B. (2004). Screening for delirium in an adult intensive care unit. Intensive and Critical Care Nursing; 20: 206–213. Robinson TN, Raeburn CD, Tran ZV, Brenner LA, Moss M. (2011). Motor subtypes of postoperative delirium in older adults. Archives of Surgery; 146: 295–300. Scelsi S, Giusti GD, Federica P, Sandra S. (2011). Italian nurses’ perception of delirium in ICU: a survey. 4th EfCCNa Congress and FSAIO Spring Congress, Denmark. Schuurmans MJ, Duursma SA, Shortridge-Baggett LM. (2001). Early recognition of delirium: review of the literature. Journal of Clinical Nursing; 10: 721–729. Sharma A, Malhotra S, Grover S, Jindal SK. (2012). Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: a study from India. General Hospital Pschiatry; 34: 639–646. Shaughnessy L. (2012). Introducing delirium screening in a cardiothoracic critical care unit. Nursing in Critical Care; 18: 8–13. Silva RCG, Silva AAP, Marques PAO. (2011). Analysis of a health team’s records and nurses’ perceptions concerning signs and symptoms of delirium. Revista Latino-Americana de Enfermagem; 19: 81–89. Thomason JWW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW. (2005). Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Critical Care; 9: 375–381. ˘ J, Slooter AJC. (2008). Intensive care Van Eijk MMJ, Kesecioglu delirium monitoring and standardised treatment: a complete survey of Dutch intensive care units. Intensive and Critical Care Nursing; 24: 218–221. Voyer P, Richard S, Doucet L, Danjou C, Carmichael P. (2008). Detection of delirium by nurses among long-term care residents with dementia. BMC Nursing; 7: 1–14. Wells LG. (2012). Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature. Australian Critical Care; 25: 157–161.
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Delirium assessment in intensive care units: practices and perceptions of Turkish nurses Aysel Özsaban and Rengin Acaroglu ABSTRACT Aim: The aim of this study was to identify current practices and perceptions of intensive care nurses regarding delirium assessment and to examine the factors that affect these practices and perceptions. Background: As delirium in intensive care unit (ICU) patients is a serious problem that can result in increased mortality and morbidity, routine delirium assessment of all ICU patients is recommended. The severity, duration and outcome of the syndrome are directly related to nurses’ continuous assessment of patients for signs and symptoms of delirium. However, studies indicate that very few nurses monitor for delirium as a part of their daily practices. Design: A descriptive, correlational study design was used. Methods: Data were collected from five Turkish public hospitals using a structured survey questionnaire. The study sample comprised 301 nurses who agreed to participate. Data were analysed using descriptive statistics. Results: More than half of the nurses performed delirium assessments. However, the proportion of nurses who use delirium assessment tools was quite low. Almost all of the nurses perceived delirium as a problem and serious problem for ICU patients. The patient group least monitored for delirium was that of unconscious patients. Statistically significant differences were found in the proportion of nurses who assessed delirium symptoms and whose care delivery system was patient-centred and perceived delirium as a serious problem. Conclusion: While a majority of ICU nurses perceived delirium as a problem and serious problem, the proportion of those who perform routine delirium assessments was less. It was found that delirium assessment practices of nurses were affected from their perceptions of delirium and the implementation of patient-centred care delivery. Relevance to clinical practice: It is essential to develop strategies to encourage ICU nurses to perform delirium assessments through the use of delirium assessment tools. Key words: Delirium • Delirium assessment tools • Intensive care • Nursing assessments
INTRODUCTION Delirium is a serious problem among patients hospitalized in intensive care units (ICUs) and is a transient organic mental syndrome generally characterized by sudden onset of cognitive disturbances, altered level of consciousness, impaired attention, increased or decreased psychomotor activity and irregular Authors: A. Özsaban, PhD, Research Assistance, Istanbul University Florence Nightingale Nursing Faculty, Department of Fundamentals of Nursing, Istanbul, Turkey; R. Acaroglu, PhD, Associate Professor, Istanbul University Florence Nightingale Nursing Faculty, Department of Fundamentals of Nursing, Istanbul, Turkey Address for correspondence: R Acaroglu, Associate Professor, Istanbul University Florence Nightingale Nursing Faculty, Department of Fundamentals of Nursing, Abide-I Hürriyet Cad. 34381 Si¸ ¸ sli/I˙stanbul, Turkey E-mail: [email protected]
© 2015 British Association of Critical Care Nurses
sleep-wake cycles (Krahne et al., 2006). Delirium is caused by an underlying organic process, and there is growing recognition that it represents acute brain dysfunction or failure. The three motoric subtypes of delirium are hyperactive, hypoactive and mixed. Patients who experience hyperactive delirium exhibit increased psychomotor activity, restlessness, agitation, hyper-alertness and rage. Patients with hypoactive delirium present with symptoms such as psychomotor retardation, lethargy, decreased responsiveness, apathy and withdrawal. In cases of mixed delirium, patients fluctuate between hyperactive and hypoactive symptoms (Bruno and Warren, 2010; Wells, 2012). Delirium is a serious issue threatening patient safety with higher mortality, prolonged ICU stay and greater health care costs (Arend and Christensen, 2009; Shaughnessy, 2012). 1
Delirium assessment in ICU: practices and perceptions of Turkish nurses
BACKGROUND The detection of delirium is crucial for the improvement of patient safety in ICUs. Although delirium is clearly defined as a medical diagnosis, it is frequently either completely missed or misinterpreted as dementia or depression by nurses as well as physicians (Milisen et al., 2006; Voyer et al., 2008). It is therefore often overlooked by health care professionals during its early stages (Schuurmans et al., 2001; Ely et al., 2004b). A diagnosis of delirium in the ICU, the implementation of treatment and preventive interventions for patients at risk require collaboration among health care professionals. However, according to Devlin et al. (2008), near-constant contact of intensive care nurses with their patients places them in the best position to perform routine delirium assessment. It is recommended that all patients be assessed for delirium on admission to ICU. As delirium is a sudden-onset syndrome with a fluctuating course, routine assessment by nurses performed at least once per shift is considered to be ideal (Boot, 2012; Eastwood et al., 2012). Most importantly, patients who are at risk of developing delirium should be identified. The risk factors include advanced age, underlying primary cerebral illnesses, chronic illnesses, pharmacological agents and environmental factors (Roberts, 2004; Bruno and Warren, 2010; Wells, 2012). Certain patient groups require particular attention in screening for delirium. These groups involve mechanically ventilated patients, patients who are under sedation and those who are unconscious (Ely et al., 2001; Akıncı et al., 2005; Thomason et al., 2005; Devlin et al., 2007, 2008). Delirium screening and assessment could be considered as a subsection of neurological assessment. All critically ill patients should be neurologically assessed by initially using the Glasgow Coma Scoring System; however, it is only relevant to screen/assess for delirium in those patients who are appropriately responsive. This is because delirium assessment requires interactive communication between the nurse and the patient. Those patients who are unconscious or unresponsive as identified from the initial Glasgow Coma Scale neurological assessment will be classified as ‘unable to assess’. Once the patient has been identified to be responsive, the nurse can commence the screening/assessment of delirium. This stage involves mental status examination using assessment tools, such as those proposed by Page and Ely (2011). It is recommended that an assessment tool is routinely used in such patients at risk. Yet the use of systematic, valid and reliable tools in the assessment of delirium by nurses facilitates the application of necessary interventions by ensuring access to fast and objective patient information (Gaudreau et al., 2
2005). This approach allows for early detection and timely implementation of management strategies that may reduce its severity and/or duration (Voyer et al., 2008; Shaughnessy, 2012). In addition, these tools can aid in making accurate and easy assessment even in situations where it could be difficult, such as intubation, sedation and stupor (Bergeron et al., 2001; Devlin et al., 2008). The Neelon and Champagne Confusion Scale (NEECHAM), the Confusion Assessment Method for the ICU (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC) and the Organic Brain Syndrome Scale were also commonly used assessment tools for delirium in the ICU (Adamis et al., 2009). The baseline for using these scales is the consciousness level of the patient. In patients with a low level of consciousness from whom we can get verbal response can be an assessment for delirium. For this reason, it is especially significant to observe unconscious and sedated patients for the changes in their consciousness levels (Fan et al., 2012).
Literature review Studies indicate that although nurses are in a unique position to recognize delirium, they do not make adequate assessment in their daily practice. According to the studies, the possible barriers to delirium assessment are (1) assessment tools not being used, (2) lack of knowledge about delirium, (3) the misconception that the tools are complicated, (4) the difficulty of assessing intubated and sedated patients and (5) time constraints (Devlin et al., 2008; Wells, 2012). However, making use of related guidelines in diagnosis, prevention and management of delirium helps nurses. In this sense, the most remarkable guideline is the NICE Clinical Guideline developed in the UK. In particular, the guideline focuses on preventing delirium in people identified to be at risk, using a targeted, multicomponent, non-pharmacological intervention that addresses a number of modifiable risk factors (National Institute for Health and Clinical Excellence, 2010). Ely et al. (2004b) reported that 16% of the nurses who participated in a study conducted in the USA used delirium diagnosis instruments, whereas Scelsi et al. (2011) reported that 12% of the nurses in their Italian research did so. Van Eijk et al. (2008) reported that 7% of the nurses who participated in their study used these tools. Another study conducted in Holland indicates that cases of delirium are predominantly (68%) diagnosed during consultation with geriatric or psychiatric doctors, and that assessment tools are applied infrequently (25%). Such consultations take place only in the cases of hyperactivity, thereby increasing the risk of hypoactive delirium incidences remaining unrecognized (Cadogan et al., 2009). © 2015 British Association of Critical Care Nurses
Delirium assessment in ICU: practices and perceptions of Turkish nurses
Studies indicate that 16–89% of ICU patients develop delirium (Peterson et al., 2006; Pandharipande et al., 2007; Bruno and Warren, 2010; Robinson et al., 2011). ICU delirium is associated with prolonged hospital stays, increased morbidity and mortality, increased health care costs and poor clinical outcomes (Schuurmans et al., 2001; Ely et al., 2004a; Akıncı et al., 2005; Mistarz et al., 2011; Sharma et al., 2012). This study was performed because there are no Turkish studies on delirium diagnosis or on the use of delirium assessment tools by ICU nurses.
Aim The aim of this study was to identify current perceptions and practices of intensive care nurses regarding delirium assessment and to examine the factors that affect these perceptions and practices. The study questions were as follows: Do nurses in ICUs: • • • •
make the routine delirium assessments? use any assessment tools to assess delirium? perceive delirium as a problem for patients? have any factors that may affect their practices to delirium assessment?
METHODS Design A descriptive, correlational study design was used.
Setting and participants The study was conducted between 4 March 2011 and 4 June 2011 in five public hospitals in Istanbul, Turkey. These hospitals which are affiliated with the Turkish Ministry of Health were the largest public hospitals in Istanbul at the time of the study with an average of 21 beds in each ICU. There were a total of 427 nurses in these ICUs. A total of 314 critical care nurses caring for adult patients in cardiac and vascular surgery critical care units, coronary care units, multidisciplinary ICUs and mixed ICUs were contacted and asked to fill out a survey questionnaire. A total of 13 questionnaires had incomplete responses and were excluded from the study. As a result, the study sample consisted of 301 nurses.
Data collection Data were collected using a structured questionnaire form developed by the researchers in accordance with the literature. An investigator met with the intensive care nurses and explained the aim and scope of the study, its duration and what was expected of the participants. Self-reported paper and pencil questionnaire © 2015 British Association of Critical Care Nurses
was given to the nurses who agreed to participate in the study and took approximately 15 min to complete the form. The questionnaire forms were not left in the clinics so that nurses did not bias each other. While the forms were being completed, the researcher waited in the clinic and took the completed forms back from the nurses.
Survey questionnaire The survey instrument was developed by the researchers after reviewing the relevant literature as below. The questionnaire form of this study was prepared by considering the questions in the data collection tools of the studies examining the practices and perceptions of nurses about delirium in the online databases. The questionnaire was pilot-tested for face validity and clarity by a random sample of 10 critical care nurses who had 5 years of intensive care experience. The questionnaire form consisted of 15 items, 8 of which concerned the nurses’ demographic details such as gender, age, education levels, professional experience, experience working in ICUs, tasks undertaken within the ICUs and the care delivery system they used. The remaining seven items consisted of questions designed to identify the opinions, thoughts and work practices of nurses in relation to delirium. These were questions concerning nurses’ perceptions of delirium as a problem (Ely et al., 2004b), barriers to the assessment of delirium (Devlin et al., 2008), nurses’ abilities to perform routine assessments (Forsgren and Eriksson, 2010), and delirium assessment tools that were used (Bergeron et al., 2001; Devlin et al., 2007). The others were questions concerning patient groups assessed by nurses for delirium (Devlin et al., 2007, 2008), nurses’ abilities to identify delirium symptoms (Devlin et al., 2008; Flagg et al., 2010; Silva et al., 2011), and frequency of recognizing delirium symptoms (Cadogan et al., 2009; Forsgren and Eriksson, 2010).
Ethical considerations Ethical approval for this study was obtained from the Ethics Committee of Istanbul University Cerrahpasa School of Medicine before beginning the study. Written permission was also obtained from the Istanbul Provincial Directorate of the Ministry of Health of the Republic of Turkey. All the nurses in each hospital’s ICUs were informed about the study verbally and invited to participate. They were informed that involvement was completely voluntary and withdrawal from the study could take place at any time. Anonymity and 3
Delirium assessment in ICU: practices and perceptions of Turkish nurses
confidentiality were also assured. In addition, when entering the ICUs, the investigator complied with safety protocol designed to protect patients from infections. In order to avoid disruptions to patient care, data were collected during hours suitable for the nurses.
Data analysis Data were analysed using the Statistical Package for Social Sciences 15.0 (SPSS 15.0). Numbers, percentages, arithmetic means and standard deviations were used for descriptive statistics. Chi-square analysis was used to test for the existence of relationships between independent variables. Statistical significance was set at p < 0⋅005.
RESULTS The mean age of the participants was 28⋅84 ± 4⋅44 years and 79⋅1% were female. Of all participants, 48⋅2% had a bachelor’s degree, 41⋅5% had between 2 and 5 years of professional experience, and 48⋅2% had been employed in an ICU for between 2 and 5 years (Table 1). It was determined that while 87⋅4% of the nurses were using a task-based system to deliver nursing care, 12⋅1% were delivering patient-centred care (Table 1). It was found that more than half of the nurses who participated in the study (67⋅8%) performed routine Table 1 Demographic characteristics of the nurses (N = 301) Characteristics Mean age Gender Female Male Education levels Vocational school of health Diploma/associate degree Bachelor’s degree Master’s degree Professional experience (years) 0–1 2–5 6–10 ≥11 Experience in an intensive care unit (years) 0–1 2–5 6–10 ≥11 Care delivery system Patient-centred Task-based
4
n
%
(X ± SD) 28⋅84 ± 4⋅44 238 63
79⋅1 20⋅9
84 52 145 20
27⋅9 17⋅3 48⋅2 6⋅6
25 125 90 61
8⋅3 41⋅5 29⋅9 20⋅3
66 145 73 17
21⋅9 48⋅2 24⋅3 5⋅7
38 263
12⋅6 87⋅4
Table 2 Distribution of delirium assessment methods used by nurses (N = 301) Variables
n
Routine delirium assessment Performs Does not perform Delirium assessment tools (N = 204)∗ Uses Does not use Patient groups assessed∗ Patients on mechanical ventilation Conscious patients Patients on sedatives Unconscious patients Frequently identified delirium symptoms∗ Increase/decrease in psychomotor activity Disorientation as to time, place or persons Emotional fluctuations Distractibility, difficulty in concentrating Decomposition of thought content Impairment of immediate, short-term or long-term memory Deterioration of the thought process Disruption of the sleep-wake cycle Frequency of assessing delirium symptoms Hourly Each shift Every 24 h Weekly There is no set frequency
%
204 97
67⋅8 32⋅2
30 182
14⋅7 89⋅3
231 216 201 108
76⋅7 71⋅8 66⋅8 35⋅9
269 254 209 183 173 171 170 164
89⋅4 84⋅4 69⋅4 60⋅8 57⋅5 56⋅8 56⋅5 54⋅5
114 26 148 5 8
37⋅9 8⋅6 49⋅2 1⋅7 2⋅7
∗ Multiple options were marked.
delirium assessments, that 89⋅3% of these nurses requested psychiatric consultation for the diagnosis of delirium and that very few (Table 2) use delirium assessment tools. Of the tools used, the Nursing Delirium Screening Scale was used by 6⋅3% of the nurses (n = 13), the CAM-ICU was used by 4⋅4% (n = 9) and the ICDSC by 4% (n = 8). The majority of the nurses (76⋅7%) identified delirium in patients on mechanical ventilation whereas only 35⋅9% performed an assessment on patients who were unconscious. Increased/decreased psychomotor activity (89⋅4%) and disorientation as to time, place or persons (84⋅4%) were the symptoms of delirium that were most frequently identified by the nurses. It was found that nurses placed less importance (Table 2) on symptoms such as emotional fluctuations (69⋅4%), distractibility and difficulty concentrating (60⋅8%), decomposition of thought content (57⋅5%), impairment of immediate, short-term or long-term memory (56⋅8%), deterioration of the thought process (54⋅5%) and disruption of the sleep-wake cycle (54⋅5%). It was determined that while almost half of the nurses (49⋅2%) monitored delirium symptoms once © 2015 British Association of Critical Care Nurses
Delirium assessment in ICU: practices and perceptions of Turkish nurses
Table 3 Distribution of nurses’ perceptions of delirium syndrome (N = 301) Variables
n
Delirium from the perspective of patient safety Is not a problem Is a problem Is a serious problem Obstacles to diagnosing delirium∗ Patient being under sedation Patient being intubated The complexity of the diagnostic tools The time it takes to perform the assessment
%
14 130 157
4⋅6 43⋅2 52⋅2
222 199 198 36
73⋅8 66⋅1 65⋅8 12⋅0
∗ Multiple options were marked.
Table 4 Factors affecting nurses’ assessment of delirium Performing assessment Characteristics Gender Age Educational status Professional experience ICU experience Care delivery system Perception of delirium
𝜒2
p
1⋅701 0⋅215 5⋅106 8⋅971 4⋅344 11⋅788 8⋅610
>0⋅005 >0⋅005 >0⋅005 >0⋅005 >0⋅005 0⋅001 0⋅013
every 24 h, 37⋅9% performed hourly assessments (Table 2). It was determined that 52⋅2% of nurses considered delirium to be a serious problem (Table 3). While 73⋅8% reported that patients being under sedation hindered the assessment of delirium, 12% reported the excessive time taken in completing their observations to constitute an obstacle (Table 3). No statistically significant differences in nurses’ assessment of delirium in relation to their characteristics such as age, gender, educational status, professional experience and ICU experience was found (p > 0⋅005). However, statistically significant differences were found in the majority who assessed delirium symptoms and those whose care delivery system were patient-centred (p < 0⋅001) and who perceived delirium as a serious problem (p < 0⋅005) (Table 4).
DISCUSSION The aim of this study was to identify the current practices and perceptions of nurses in Turkey with regards to assessing delirium in ICUs. Almost three-quarters of nurses had two or more years of ICU experience. Only 12⋅6% of nurses worked with patient-based system that involved planning, © 2015 British Association of Critical Care Nurses
applying and evaluating the care of same patients from admission to discharge in a limited number. Patient-based system strengthens the nurse-patient relationship and enables the nurse to get acquainted with her patient better, follow and realize him continuously and faster, and take necessary precautions (National Institute for Health and Clinical Excellence, 2010). However, the fact that the majority of nurses worked with the task-based system in which their responsibilities were distributed according to the skill level and performance in each shift was a negative situation for the early assessment of delirium (Table 1). In this study, the percentage of nurses who performed routine delirium assessments was low (67⋅8%). This is consistent with the findings of Forsgren and Eriksson (2010) (59%) and Patel et al. (2009) (59%). It was found that very few nurses (14⋅7%) participating in this study used screening tools for the assessment of delirium (Table 2). This indicates that these tools are not widely used in the Turkish ICUs despite the fact that instruments such as CAM-ICU and ICDSC have been found to be valid and reliable for use in Turkey. It was reported by Ely et al. (2004b) that 16% of nurses use formal assessment tools, and Scelsi et al. (2011) determined that 12% nurses do so. Van Eijk (2008) found that 7% of nurses used them. This study is consistent with the literature in that the proportion of nurses who use delirium assessment tools was found to be low. It was found in this study that most nurses reported monitoring for delirium (Table 2), and they utilized psychiatric consultations to make the assessment (89⋅3%). However, psychiatric consultation is a procedure applied after a significant number of delirium symptoms are observed (Cadogan et al., 2009). It is crucial to take preventive measures following accurate diagnostic evaluation of patients’ risk of developing delirium. Studies have revealed a lack of awareness about delirium in health care professionals who work in the ICUs (Bruno and Warren, 2010). In fact, Cadogan et al. (2009) reported that in 90% of cases, psychiatric consultation is sought for the assessment of delirium, whereas in a study by Forsgren and Eriksson (2010) psychiatric consultation was sought in 52% of the cases. Such findings are associated with underusage of delirium screening tools. More than half of the nurses who participated in this study were conducting delirium assessment in mechanically ventilated patients (76⋅7%) and sedated patients (66⋅8%). The fact that the number of nurses observing unconscious patients for delirium assessment was quite low (35⋅9%) pointed out that their level of awareness regarding routine patient evaluation for delirium was insufficient. However, in the literature it 5
Delirium assessment in ICU: practices and perceptions of Turkish nurses
is stated that delirium as an acute situation develops in a rather short time and delirium progresses before the mental states of the comatose patients recover (Kitchener et al., 2012). In this study, the majority of nurses assessed symptoms that are observable without in-depth diagnostics (Table 2) such as measuring increase/decrease in psychomotor activity (89⋅4%) and disorientation as to time, place or persons (88⋅4%). This is consistent with other studies which indicate that nurses usually take into account hyperactive symptoms. In a study by Flagg et al. (2010), it was determined that 90% of nurses identify symptoms of hyperactive delirium whereas 77% identify symptoms of hypoactive delirium. Silva et al. (2011) reported that nurses identify delirium symptoms such as confusion, attempts to exteriorize catheters, agitation, changes in the level of consciousness, disorientation and inappropriate or meaningless speech. Conversely, Devlin et al. (2008) reported that the symptom identified most frequently is changes in levels of consciousness. In this study, the symptoms least noted by nurses were decomposition of thought content (57⋅5%), impairment of immediate, short-term or long-term memory (56⋅8%), deterioration of the thought process (54⋅5%) and disruption of the sleep-wake cycle (54⋅5%). This is consistent with the findings in a study by Cadogan et al. (2009) where very little attention was paid to symptoms such as disruption of the sleep-wake cycle and cognitive changes. In this study, almost half of the nurses (49%) were performing delirium assessments once every 24 h (Table 2). This is consistent with the findings of Ely et al. (2004b) who reported that 67% of nurses monitored their patients for delirium once every 24 h. Cadogan et al. (2009) found that 32% of nurses participating in their study performed delirium assessments thrice a day, and Forsgren and Eriksson (2010) reported that 45% did so 2–4 times per day while 24% performed hourly assessments. Delirium is a very serious problem which prolongs hospital stays, increases morbidity and threatens patient safety (Ely et al., 2004a; Ouimet et al., 2007; Arend and Christensen, 2009). Ely et al. (2004b) reported that 92% of the participants in their study perceived delirium as a serious problem. In another study by Eastwood et al. (2012), it was found that 73% considered it to be serious. Similarly, it was found that 52⋅2% of the participants in this study perceived delirium as a serious problem (Table 3). According to the literature, obstacles to assessing delirium risk are attributable partly to patient-related factors and partly to nurse-related factors (Bergeron et al., 2001; Devlin et al., 2008). This study is consistent with the literature in that a large majority of 6
the nursing staff reported that patients being sedated (73⋅8%) or intubated (66⋅1%) as well as the complexity of the screening tools (65⋅8%) hinder the assessment process (Table 3). Devlin et al. (2008) found that the most widely reported barriers were intubation (38%), the complexity of delirium assessment tools (34%) and the inability to complete the screening for delirium in sedated patients (13%). Identifying the factors that hinder delirium assessment can be considered to be an important step in resolving these problems. The fact that assessment of delirium did not differ according to nurses’ characteristics such as age, gender, education levels and professional experience or ICU experience (p > 0⋅005) may be attributable to the fact that the mean age and average ICU experience of the participants were low. It was found, however, that care delivery systems and perceptions of delirium were associated with the prevalence of delirium assessments (p < 0⋅005). Nurses who worked under patient-centred care-delivery systems tended to perform more assessments. In fact, National Institute for Health and Clinical Excellence, (2010) emphasizes the need for continual monitoring of patients and the importance of patient-centred care in assessing delirium. In this study, a statistically significant difference was found that the nurses who perceived delirium as a syndrome that embodies serious problems had higher delirium assessment rates (p < 0⋅005). This finding supports the idea that thoughts and emotions that are believed in and valued are reflected in the behaviour. It also highlights the importance of developing strategies that will increase awareness among ICU nurses of situations where patient safety is at risk due to delirium (Table 4).
Limitations In data collection, a survey form that was pilot tested and developed by the researchers was used because there was not a suitable measurement tool of which reliability and validity studies were performed and which was adapted to the Turkish society. It was applied only to nurses working in the adult ICUs. Despite these limitations, the results of this study provide the first view of current practices and perceptions of Turkish ICU nurses with regards to assessment of delirium.
CONCLUSION The purpose of this study which was the first on this topic to be conducted in Turkey was to identify current perceptions and practices of intensive care nurses regarding delirium assessment as well as the factors that affect these perceptions and practices. It was found that while a majority of ICU nurses perceive delirium © 2015 British Association of Critical Care Nurses
Delirium assessment in ICU: practices and perceptions of Turkish nurses
as a problem for patient safety, not as many perform routine delirium assessments. They were not using any reliable delirium assessment instruments to monitor for or identify delirium symptoms. Consistent with the literature, the three major barriers to assessment reported by the nurses were patients being sedated or intubated and the complexity of the assessment tools. It was found that nurses who implement patient-centred care delivery tend to perform delirium assessments more frequently.
raised. Some strategies increasing the use of delirium assessment tools and protocols that enable the assessment of delirium routinely may be developed. Moreover, national guidelines regarding the diagnosis, prevention, care and treatment of delirium may be developed and used to help nurses in ICUs. In addition, encouraging the provision of patient-centred care rather than task-based patient care could contribute to improving quality of the care provided.
ACKNOWLEDGEMENTS RECOMMENDATIONS FOR FUTURE PRACTICE By developing and applying training programmes related to delirium management, awareness can be
The authors would like to thank the nursing staff who contributed to this project during the data collection phase.
WHAT IS KNOWN ABOUT THIS TOPIC • •
Nursing staff have key roles within ICU health care teams in the identification of delirium risk factors and the early detection of delirium symptoms. The use of systematic, valid and reliable assessment tools by nursing staff facilitates the timely collection of objective patient information.
WHAT THIS PAPER ADDS • •
Nursing staff do not adequately assess the risk of delirium. Nurses underuse delirium assessment tools to screen for delirium risk factors.
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