Barriers to delirium assessment in the intensive care unit: A literature review

doi:10.1016/j.iccn.2017.09.001

Intensive and Critical Care Nursing

Volume 44, February 2018, Pages 99-104

https://doi.org/10.1016/j.iccn.2017.09.001 Get rights and content

Abstract

Background

Delirium is a common syndrome that has both short and long-term negative outcomes for critically ill patients. Many studies over several years have found a knowledge gap and lack of evidence-based practice from critical care personnel, but there has been little exploration of the reasons for this.

Aim

To identify the perceived barriers to delirium assessment and management among critical care nurses.

Method

A literature review of published studies to examine barriers to effective delirium assessment using a comprehensive search strategy. Five relevant studies identified for review.

Results

Few studies have investigated barriers to delirium assessment and management, but several themes reoccur throughout the literature. The perceived time consuming nature of the assessment tools is cited by many, as is the lack of medical prioritisation of results. Lack of education on delirium appears to be a significant factor and reinforces some of the stated misconceptions.

Conclusion

Many barriers exist to prevent effective assessment and management of delirium, but several of these are due to a lack of understanding or unfamiliarity with the condition and the assessment tools as well as lack of medical prioritisation of the results. Further research is needed on this topic.

Introduction

Intensive care unit (ICU) delirium is defined as an altered state of consciousness featuring disordered attention, impaired cognition, altered psychomotor activity (increased or decreased) and disorder of the sleep-wake cycle (Borthwick et al., 2006, Tait, 2016). It has an acute onset and is thought to be reversible (Borthwick et al., 2006), although Morandi et al. (2012) state that long-term cognitive impairment is common after diagnosis of ICU delirium. Delirium is associated with poorer outcomes, higher costs and increased mortality (Chevrolet and Jolliet, 2007, National Institute for Health and Care Excellence, 2010). Incidence varies widely but it is thought to affect from 18% to 82% of critically ill patients (Ely et al., 2004, Morandi et al., 2012). There are three subtypes: hyperactive, characterised by hallucinations and agitation; hypoactive, where the patient is withdrawn and inattentive; and mixed delirium, which fluctuates between the two (Page and Ely, 2015). Assessment is crucial for effective management, and many studies have identified a deficit in assessment practice such as using clinical observation rather than validated tools (MacSweeney et al., 2010) or lack of routine assessment for all ICU patients (Patel et al., 2009). However, there have been no previous reviews of the barriers to delirium assessment in critical care nurses, and this review aims to explore and establish the reported barriers to recommended practice.

Section snippets

Aim

To identify the perceived barriers to Intensive Care Unit (ICU) delirium assessment and management among critical care nurses.

Search strategy

A literature search was conducted by the author to obtain relevant material pertaining to the topic. All search words were set to be recognised within the article title, abstract and/or keywords, and combined using Boolean operators [OR] or [AND] (see Table 1). CINAHL headings were also searched in the CINAHL database, with MESH headings searched in the Pubmed and Cochrane databases. ‘Backward chaining’ of reference lists of the included studies was done to ensure no pertinent or seminal data

Results

From a total of 136 articles, five were found to meet the aims of the review (see Fig. 1).

Discussion

Although the studies provided varied methodologies and results, it is possible to use thematic analysis to categorise the identified barriers to delirium assessment into three broad themes: individual barriers; patient-related barriers; and working environment barriers.

Limitations

Limitations of this review include the small number of studies looking at barriers to delirium assessment in critical care. The included studies used variable items and the questionnaires were constructed differently and thus, although thematic analysis is possible and shows similar findings across the studies, comparison is difficult. Several of the studies used a small sample size, or had low response rates, which affects the generalisability of the findings.

Conclusion

There are very few studies that investigate the barriers to delirium assessment, and future research could address this issue on a larger scale to clarify the reasons for this. The results of this review give some insight into the reasons why nurses do not perform delirium assessment, and the barriers they perceive. It is clear that effective leadership and organisational support would remove some of the described barriers, and many of the rest could be addressed by ensuring more comprehensive

Conflicts of interest

As this study was a systematic review, no ethical approval was required.

Ethical approval

As this study was a systematic review, no ethical approval was required.

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Cited by (38)

Effects of simulation-based education module on delirium care in undergraduate nursing students: A quasi-experimental study
2024, Nurse Education in Practice
To examine the effects of a delirium education module on undergraduate nursing students’ knowledge of and perceived confidence and competence in delirium care.
Delirium is common in intensive care units (ICUs) and leads to poor clinical outcomes. The under recognition of delirium is a major problem in ICU medicine. Nurses, as first-line health care providers, can address this by recognizing patients who are experiencing delirium. Since undergraduate nursing students will be the future ICU nurses, it is important to deliver the knowledge regarding delirium care. However, education about assessing delirium in ICUs among undergraduate nursing students is lacking.
Quasi-experimental study.
A total of 74 undergraduate students were divided into an intervention group (n=34) and a comparison group (n=40). A 2-hour simulation-based delirium education module integrated into a critical care curriculum was delivered to the intervention group only. The classroom-based intervention was administered at a medical university in northern Taiwan. Study outcomes were measured using a structured survey including (1) a 16-item delirium care knowledge quiz, (2) confidence in delirium care scale and (3) competence in delirium care scale. The survey was distributed to students before and after the module in December 2020. The Mann–Whitney U test, chi-square test and Fisher’s exact test were adopted to test the differences of all variables between groups. A generalized estimating equation model was used to investigate the adjusted treatment effects.
The participants had a median age of 22 years and 81% were female. The delirium education module yielded greater knowledge (B = 3.04, 95% confidence interval = 2.20–3.88), confidence (B = 4.20, 95% confidence interval = 2.67–5.73) and competence (B = 4.82, 95% confidence interval = 3.33–6.30) in delirium care when the treatment and control groups were compared.
For undergraduate nursing students, simulation-based education module is effective in improving the knowledge of and confidence and competence in delirium care. It is recommended that this be included in critical care nursing curricula.
Self-efficacy of caring for patients in the intensive care unit with delirium: Development and validation of a scale for intensive care unit nurses
2023, Australian Critical Care
Citation Excerpt :
However, delirium is often misdiagnosed or not detected9,10 due to the characteristic rapid onset of delirium symptoms and a nurse's inability to perform delirium assessments. This stems from a lack of knowledge about delirium, inability to identify risk factors, and the high intensity of clinical work in the ICU.11 Yaghmour and Gholizadeh12 found ICU nurses were willing to accept the challenges of caring for delirium patients but lacked confidence in what was appropriate because they believed they had insufficient knowledge of delirium, which can influence decision-making skills.13
Improving the self-efficacy of intensive care unit nurses for delirium care could help them adapt to the changing situation of delirium patients. Validated measures of nurses' self-efficacy of delirium care are lacking
The objective of this study was to develop a Delirium Care Self-Efficacy Scale for assessing nurses' confidence about caring for patients in the intensive care unit and to examine the scale's psychometric properties.
Draft scale items were generated from a review of relevant literature and face-to-face interviews with intensive care unit nurses; content validity was conducted with a panel of five experts in delirium. A group of nurses were recruited by convenience sampling from intensive care units (N = 299) for item analysis of the questionnaire, assessment of validity, and reliability of the scale. Nurse participants were recruited from nine adult critical care units affiliated with a hospital in Taiwan. Data were collected from August 2020 to July 2021.
Content validity index was 0.98 for the initial 26 items, indicating good validity. The critical ratio for item discrimination was 14.47–19.29, and item-to-total correlations ranged from 0.67 to 0.81. Principal component analysis reduced items to 13 and extracted two factors, confidence in delirium assessment and confidence in delirium management, which explained 66.82% of the total variance. Cronbach's alpha for internal consistency was 0.94 with good test–retest reliability (r = 0.92). High scale scores among participants were significantly associated with age (≥40 years), work experience in an intensive care unit (≥10 years), delirium education, and willingness to use delirium assessment tools.
The newly developed Delirium Care Self-Efficacy Scale demonstrated acceptable reliability and validity as a measure of confidence for intensive care nurses caring for and managing patients with delirium in the intensive care unit.
Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units
2023, Australian Critical Care
Citation Excerpt :
The SCDI measures the difficulty level associated with management of each delirium subtype. However, it omits information such as previously reported challenges in assessing delirium,33 barriers to using assessment tools,34 lack of cooperation between professionals in managing delirium,35 patient and staff safety concerns,36 difficulty in achieving family understanding and cooperation,37 difficulty in deciding to use medications,38 and lack of feedback on nurses' practice39 and support.40 The development of an instrument that comprehensively addresses challenges in caring for patients with delirium in the ICU will help reduce the nursing burden, as it will prove useful for evaluation or development of educational interventions.
Delirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention.
The aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity.
We based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test–retest reliability.
Exploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68–.87) and test–retest reliability (intraclass correlation coefficients = .46–.62) were confirmed.
We developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.
Delirium assessment – Often ignored, always important
2021, Intensive and Critical Care Nursing
The training needs of Korean intensive care unit nurses regarding delirium
2021, Intensive and Critical Care Nursing
Citation Excerpt :
In particular, in some studies, ICU nurses reported that delirium-related care was not a top priority of care because of other more important tasks (Palacios-Ceña et al., 2016; Zamoscik et al., 2017). However, while nurses have previously reported various stresses and burdens due to the behaviour and symptoms of patients with delirium (LeBlanc et al., 2018; Yue et al., 2015), the lack of related training programmes was the root cause of suboptimal competency (Elliott, 2014; Rowley-Conwy, 2018; Selim and Ely, 2017). Therefore, it is necessary to develop and implement a training programme focused on equipping ICU nurses with the optimal delirium care competency.
The aim of this study was to investigate high-priority training needs by analysing the perceived importance and self-reported performance of nurses’ delirium care competency.
A cross-sectional survey with a convenience sample of 255 Korean intensive care units nurses.
Intensive care units in the Republic of Korea.
Intensive care unit nurses’ delirium care competency.
Exploratory factor analysis of the Nurse Delirium Care Competency Scale showed a six-factor structure, which accounted for 67.51% of the variance in nurses’ delirium care competency: management algorithm, prevention, communication, nursing management, assessment, and collaboration. The self-reported performance scores of all six factors were significantly lower than their perceived importance scores. The delirium assessment factor was identified as a high training priority on the importance-performance matrix for new graduate nurses.
Training programmes should be developed considering the six delirium care competency factors identified in this study. Further, nurse educators must adopt active educational modalities such as case-based small group learning and simulation-based learning to improve nurse competency in recognising and managing delirium.
Development and validation of a delirium care critical-thinking scale for intensive care unit nurses: A mixed-method study
2024, Journal of Clinical Nursing

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ReviewBarriers to delirium assessment in the intensive care unit: A literature review

Abstract

Background

Aim

Method

Results

Conclusion

Introduction

Section snippets

Aim

Search strategy

Results

Discussion

Limitations

Conclusion

Conflicts of interest

Ethical approval

Aust. Crit. Care

Intensive Crit. Care Nurs.

Delirium monitoring and patient outcomes in a general intensive care unit

Am. J. Crit. Care

Intensive Care Delirium Screening Checklist: evaluation of a new screening tool

Intensive Care Med.

Detection, Prevention and Treatment of Delirium in Critically Ill Patients

A hands-on guide to questionnaire research: selecting, designing and developing your questionnaire

Br. Med. J.

Standards for Nurse Staffing in Critical Care

Clinical review: agitation and delirium in the critically ill- significance and management

Crit. Care

CASP Checklist: Cohort Study

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

Am. J. Crit. Care

Developing my search strategy and applying inclusion criteria

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

Crit. Care Med.

Current opinions regarding the importance, diagnosis and management of delirium in the intensive care unit: a survey of 912 healthcare professionals

Crit. Care Med.

Response rates and responsiveness for surveys

Am. J. Pharm. Educ.

A survey of nurses’ perceptions of the intensive care delirium screening checklist

Dynamics

Review
Barriers to delirium assessment in the intensive care unit: A literature review