ORIGINAL ARTICLE
Year : 2022 | Volume
: 6 | Issue : 1 | Page : 73--81
Knowledge and attitude of nurses toward delirium
Sandeep Grover, Aseem Mehra, Neha Sharma, Swapnajeet Sahoo, Devakshi Dua
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
Abstract
Aim: This cross-sectional study aimed to evaluate the attitude, practice, and knowledge among the nurses about the delirium in a tertiary care hospital. Materials and Methods: The study included 138 nurses working in a tertiary care multispecialty hospital in North India. The knowledge and attitude toward delirium were assessed by using a self-designed questionnaire (33 questions), of which 26 items specifically evaluated the knowledge and attitude toward various aspects of delirium. Results: The majority of the participants were females (83.3%), had done graduation (92.8%) in nursing, were junior nursing staff, and were directly in contact with the patient's care. The study shows that the majority of the nurses have poor knowledge about the etiology, prevalence, symptoms, and not aware of the screen procedure and instruments for delirium. Further, they lacked knowledge about the pharmacological and nonpharmacological management of delirium. A majority (83.3%) of the nurses opined that the psychiatry ward is the best place to manage patients with delirium. The majority of the nurses routinely did not screen their patients with delirium and did not know the screening instruments (84.4%) available for delirium. A majority (92.8%) of the nurses opined that they were never trained specifically to assess and manage delirium, and 98.6% expressed willingness for training. Conclusion: This study suggests that nurses working in intensive care unit and emergency settings in a tertiary care hospital in India have poor knowledge, negative attitudes, and poor practices about delirium.
How to cite this article:
Grover S, Mehra A, Sharma N, Sahoo S, Dua D. Knowledge and attitude of nurses toward delirium.Ann Indian Psychiatry 2022;6:73-81
|
How to cite this URL:
Grover S, Mehra A, Sharma N, Sahoo S, Dua D. Knowledge and attitude of nurses toward delirium. Ann Indian Psychiatry [serial online] 2022 [cited 2023 Mar 25 ];6:73-81
Available from: https://www.anip.co.in/text.asp?2022/6/1/73/337021 |
Full Text
Introduction
Delirium is a reversible neuropsychiatric syndrome, seen quite frequently in medically ill patients. Because the clinical syndrome is seen in different medical-surgical settings, it is referred to with different names by the physicians from different disciplines. It is characterized by acute onset of symptoms, with a fluctuating course with clinical characteristics in the form of altered level of consciousness, disturbance in attention and other cognitive functions (i.e., disorientation, disturbance in memory, visuospatial abilities, etc.), thought disturbances, perceptual abnormalities, and behavioral problems. The alteration in the mental status in delirium is considered to be on a continuum between normal wakefulness and alertness at one end and coma and stupor at the other end.[1]
Delirium is associated with a high mortality rate, cognitive decline and development of dementia, prolonged hospital stay, need for institutional care, poor functionality, increased cost of treatment, and significant distress to the patient and family.[2] Hence, it is important to detect and manage delirium to reduce the emergent morbidity, mortality, and associated distress among patients and caregivers.[2]
The prevalence and incidence of delirium among the various studies are influenced by the study setting (intensive care unit [ICU] settings, medical/surgical wards, postoperative patients, and consultation-liaison psychiatry services), population assessed, and method used for identification (screening instruments and diagnostic instruments). In general, it is seen that delirium is more often encountered in elderly subjects, those with cognitive impairment/dementia, with comorbid certain medical or surgical problems (infections, renal impairment, fractured neck of femur, etc.), and admission to the ICUs.[2] Available data also suggest that delirium is often missed, and it is either underdiagnosed or misdiagnosed.[2]
Because delirium occurs in medical-surgical settings, it is essential to understand delirium among professionals working in these areas. This is important as it can determine the referral patterns of delirium to the psychiatrists and can also influence the outcome of the patients. Understanding the knowledge and attitude of doctors and nurses in medical-surgical wards can help identify the deficits in this area and develop educational programs for timely identification and management of delirium. This may help in improving the overall outcome of patients with various medical-surgical illnesses who develop delirium.
Nurses form major manpower in ICUs and medical-surgical wards and are quite efficient in screening and carrying out various interventions for patients with delirium.[3] However, the available data suggest that knowledge about delirium among the nurses is inadequate,[4],[5],[6],[7],[8] they often miss the diagnosis of delirium,[9],[10] are not comfortable or are extremely uncomfortable identifying delirious patients,[11] and a majority of the nurses are not confident of caring for patients with delirium.[12] Nurses themselves feel the need to improve their knowledge and skills to evaluate and manage delirium more effectively.[13] It is well known that educational programs for nurses can enhance their knowledge about delirium[4],[6],[14],[15],[16],[17],[18],[19],[20],[21] and patient-related outcomes.[22],[23] Some of the studies also suggest that delirium is a low priority for nursing care and is linked to the work culture with intensive care.[24]
There are limited data from India on the knowledge and attitude of nurses toward delirium. One study evaluated the knowledge of the nurses before an education program for delirium. It showed that providing knowledge about delirium to the nurses was associated with significant improvement in the knowledge and practice of nurses toward delirium.[25] However, there is a need to identify and understand the lacunae in the nursing staff's knowledge about delirium. Accordingly, this study aimed to assess the knowledge, practices, and attitude of nurses toward delirium.
Materials and Methods
It was a cross-sectional study carried out in a tertiary care hospital in North India. The Ethics Committee of the institute approved the study, and the participants were recruited after obtaining written informed consent. The participants were nursing staff working in the emergency and various ICUs by convenience sampling. Those who provided informed consent and agreed to participate were included in the study.
The knowledge and attitude toward delirium were assessed by using a self-designed questionnaire developed specifically for the study. The questionnaire comprised 33 questions. Initial few questions evaluated the basic demographic information, place of work, designation, and duration of the participants. Twenty-six questions specifically assessed the knowledge and attitude toward various aspects of delirium. The questionnaire was designed based on the review of literature in terms of knowledge of nurses about delirium, symptoms of delirium, management of delirium, and the outcome of delirium.
Additionally, mental health professionals with experience of managing patients with delirium were also consulted to give their inputs. The knowledge section assessed the basic knowledge, which any medical professional working in the areas with a high prevalence of delirium is expected to possess in terms of terminology and epidemiology of delirium. Additional knowledge was assessed in terms of risk factors, symptoms of delirium, management of delirium, the outcome of delirium, and the impact of delirium on the outcome of other illnesses. In terms of practice, the questionnaire aimed to evaluate the knowledge and use of screening instruments, frequency of screening for delirium, and the use of nonpharmacological and pharmacological treatments. Attitudes toward delirium were assessed by evaluating the place/setting best suited for the management of delirium and their interest in learning about delirium. Response to each of the item/subitems was given a score of “0” or “1” to indicate correct knowledge, practice, or attitude. Correct responses were given a score of 1, and incorrect answers were scored as “0.” Based on this, the score a participant could score ranged from 0 to 128.
For this study, one of the researchers (N) personally contacted the nurses and explained the aims and objectives of the study. Those who agreed to participate and provided written informed consent were given the questionnaire to complete, and the same was collected back from the participants. On average, the questionnaire took about 8–10 min for the participants to complete.
Results
The study included 138 nurses working in various ICUs of the tertiary care hospital. The majority of the participants were females (83.3%) and had done a graduation course (92.8%) in nursing [Table 1]. On average, the participants were on the job for 5.2 (±2.7) years and in the ICUs/emergency posting for 4.1 (±2.2) years. A majority (97.8%) of the participants were junior nursing officers actively involved in patient care [Table 1].{Table 1}
Knowledge about basic aspects of delirium
As is evident from [Table 2], although all the nurses had heard about delirium, only slightly more than half (56.5%) of the nurse's considered acute brain failure to be part of multi-organ failure. In terms of the prevalence of delirium, nurses believed that only one-sixth (18.1% ± 18.0%) of the patients develop delirium in medical-surgical wards and about one-fifth (22.8% ± 19.0%) of the patients admitted to ICUs develop delirium. Further, the percentage reported was lower than their knowledge from the literature on the prevalence of delirium in these setups. Participants reported that in only one-sixth (17.8%) of the cases diagnosed as delirium, psychiatric consultation is sought.{Table 2}
Only about half (55.8%) of the nurses knew that delirium could be prevented, and about one-fourth (23.2%) of them believed that it could not be prevented. In terms of risk factors, 90% of the participants mentioned dementia, about 80% reported a longer duration of ICU to stay, 70% reported blood loss during surgery, 60% of the participants were able to recognize infection as the cause of delirium, and more than three-fifths reported stroke, head trauma, and use of antiparkinsonian medications to cause delirium. Other common risk factors for delirium, as reported by the participants, were hepatic derangement, use of benzodiazepines, severe physical illness, and presence of metabolic disturbances. However, old age, poor pain control, duration of surgery, use of opioids, use of psychotropics, history of psychiatric illness, use of physical restraints, and sensory deprivation were considered as risk factors by a small proportion of the participants [Table 2].
In terms of various alternative terminologies used for diagnosis of delirium, less than one-third of the participants were aware of the alternative terms, and in fact, 44.9% considered psychosis to be an alternative name for delirium.
When asked about their clinical practice, more than one-third (38.4%) of the participants reported never screening their patients for delirium in the non-ICU setting, and slightly more than one-fourth (27.5%) of the participants reported never screening their patients for delirium in the ICU setting. Less than one-fourth of the participants practiced screening their patients for delirium at least once or twice a day.
In terms of symptoms of delirium, the symptoms which most commonly made the participants to consider delirium include agitation (76.1%), poor attention and concentration (75.4%), uncooperative behavior (75.4%), a sudden change in behavior (65.2%), pulling out tubings (62.3%), and un-understandable language (61.6%).
In terms of symptoms, awareness about the symptoms of hyperactive delirium was better than the features more akin to hypoactive delirium [Table 3].{Table 3}
In terms of knowledge about the assessment of delirium, only a small minuscule of participants was aware of screening instruments (15.2%) and was able to name one of the instruments (15.2%). However, a negligible proportion (3.6%) of the participants reported having ever used screening instruments for delirium. In terms of treatment setting, a majority (83.3%) of the participants believed that the psychiatry ward is the best place to manage patients with delirium [Table 4]. In terms of the impact of delirium on the outcome, 77.5% of the participants reported that it was associated with increased duration of hospital stay and 62.3% believed that it was associated with increased risk of dementia. Awareness about impact of delirium on other outcome measures was lower [Table 4].{Table 4}
In terms of nonpharmacological management, awareness was fair [Table 4]. In terms of pharmacological management, awareness was relatively poor [Table 4]. Most of the participants (97.8%) agreed that if they detected delirium, then they would seek a psychiatric opinion.{Table 4}
Only a small proportion (7.2%) of participants admitted that they were ever trained to assess and manage delirium, and almost all (98.6%) expressed their wish to know more about delirium.
Based on the responses to various questions, we devised a scoring system, in which all the correct responses were given a score of “1,” and incorrect responses were given a score of “0.”. Negatively worded items were reversed coded. Based on this, we calculated that the maximum score a participant could have scored was 128. A majority (61.6%) of the participants scored <60, indicating less than average knowledge, and only 6.5% of the nurses score 90 or more, which can be considered as a possession of reasonable knowledge about delirium [Table 5].{Table 5}
Discussion
The present study aimed to evaluate the knowledge, attitude, and practice of nurses for delirium. The present study suggests that nurses lack knowledge about the alternative terminologies of delirium, the prevalence of delirium, delirium being a preventable condition, some of the risk factors, and symptoms of delirium, especially for hypoactive delirium. In terms of practice, only a small number of nurses screen their patients routinely for delirium, are aware of screening instruments for delirium, and use one of the screening instruments to assess delirium. In terms of knowledge about the impact of delirium on the patient-related outcome, only half of the nurses were aware of increased treatment costs, mortality, distress among the patients and their caregivers, and development of posttraumatic stress disorder after recovering from a delirium. In terms of nonpharmacological measures, although a significant proportion of the participants were aware of the most commonly recognized strategies such as providing familiar things, not restraining the patient, avoiding a frequent change of bed, not isolating the patient, removing the indwelling catheter, ensuring adequate sleep, keeping the patient in a noisy environment, not keeping the patient sedated for long, proper pain control, and having clocks and calendars, a large proportion of the participants were not aware of strategies such as early mobilization, allowing the patient to use spectacles and hearing aids, keeping the patient in a silent zone, keeping the environment cool, and scheduling intravenous fluids during the waking hours. In terms of pharmacological treatment, a significantly high proportion of the participants believed that benzodiazepines, sleep-inducing agents, antidepressants, and mood stabilizers might be beneficial for the management of delirium. Almost all believed that patients with delirium should be managed in the psychiatry ward. In terms of the need for further knowledge about delirium, almost all the participants expressed the need to gain more knowledge about delirium. It can be said that the nurses have poor knowledge about risk factors, prevalence, and symptoms of delirium. Additionally, nurses too have a negative attitude toward patients with delirium (in terms of them being managed in psychiatry ward) and poor practice in terms of assessment of delirium. In terms of management of delirium, although the nurses are aware of commonly suggested nonpharmacological measures, the knowledge was still deficient. In terms of pharmacological measures too, nurses have a poor understanding of the beneficial effect of certain psychotropic medications. In the present study, the majority were considered to possess less than average knowledge, and a small proportion of the nurses score 90 or more, which can be considered as a possession of reasonable knowledge about delirium. The findings of the present study provide support to the studies from different parts of the world, which have suggested a poor understanding of delirium among the nurses.[4],[5],[6],[7],[8] In terms of specific aspects, available data also suggest poor knowledge about the risk factors,[4],[5],[8] signs and symptoms, and negative outcomes,[5] medications that can contribute to delirium,[6] and treatment of delirium.[8]
What do these findings suggest?
From the findings of the present study, it can be concluded that nurses have inadequate knowledge about delirium, which possibly leads to a negative attitude and poor clinical practices. Although we did not accurately assess the impact on the patient and caregiver outcome, it can be concluded that the poor knowledge and practices possibly contribute to the poor outcome of the patients and the caregivers. India is a resource-poor country, with scarcity in the number of ICU beds, compared to those required. Hence, we need to use our resources judiciously. It can be said that addressing the knowledge gap can help identify delirium early and reduce the duration of ICU stay.
What is needed?
It is well known that educational programs can improve the knowledge and practices for assessing and managing delirium[4],[6],[14],[15],[16],[17],[18],[19],[20],[21] and patient-related outcomes.[22],[23] The present study further reveals that nurses were very much interested in enhancing their understanding of delirium. Accordingly, there is an urgent need to develop intervention programs and modules to address the nurses' knowledge gaps to improve the outcome of patients with delirium in the Indian setting. The findings of the present study can form the basis of developing the intervention module, which can address the risks such as prevalence, risk factors, assessment, and management of delirium. A previous study from India suggested that providing knowledge about delirium to the nurses was associated with significant improvement in the knowledge and practice of nurses toward delirium.[25]
The present study has certain limitations. The study sample was approached by convenience sampling and cross-sectional study design. The study did not evaluate various other aspects of delirium, such as the need for investigations, understanding about biomarkers of delirium, changes to be done in the ongoing medications, the impact of delirium on the health-care workers, and the health-care system. Further, the present study did not evaluate the actual practices and their impact on patient outcomes. The present study also did not focus on the barriers in learning and updating the knowledge about delirium, barriers in prioritizing delirium assessment and management, issues related to workload and workforce, etc. Future studies must attempt to overcome these limitations.
To conclude, the present study suggests that nurses working in ICUs and emergency settings in a tertiary care hospital in India have inadequate knowledge, negative attitudes, and poor practices in terms of assessment of delirium. Accordingly, there is an urgent need to improve the understanding of nurses toward delirium, so that the negative attitude and poor practices can be changed, which may ultimately lead to an improvement in the patient, caregivers, and health-care workers' outcomes, and health-care system.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
| 1 | Mattoo SK, Grover S, Gupta N. Delirium in general practice. Indian J Med Res 2010;131:387-98. |
| 2 | Grover S, Kate N. Assessment and management of delirium in medical practice. In: Neurointensive Care, Editor: Hemanshu Prabhakar, Oxford Clinical Practice Series. New Delhi: Oxford University Press; 2020. |
| 3 | Solberg LM, Plummer CE, May KN, Mion LC. A quality improvement program to increase nurses' detection of delirium on an acute medical unit. Geriatr Nurs 2013;34:75-9. |
| 4 | Hare M, Wynaden D, McGowan S, Landsborough I, Speed G. A questionnaire to determine nurses' knowledge of delirium and its risk factors. Contemp Nurse 2008;29:23-31. |
| 5 | Christensen M. An exploratory study of staff nurses' knowledge of delirium in the medical ICU: An Asian perspective. Intensive Crit Care Nurs 2014;30:54-60. |
| 6 | Meako ME, Thompson HJ, Cochrane BB. Orthopaedic nurses' knowledge of delirium in older hospitalized patients. Orthop Nurs 2011;30:241-8. |
| 7 | Demir Korkmaz F, Gok F, Yavuz Karamanoglu A. Cardiovascular surgery nurses' level of knowledge regarding delirium. Nurs Crit Care 2016;21:279-86. |
| 8 | Flaigle MC, Ascenzi J, Kudchadkar SR. Identifying barriers to delirium screening and prevention in the pediatric ICU: Evaluation of PICU staff knowledge. J Pediatr Nurs 2016;31:81-4. |
| 9 | Rice KL, Bennett M, Gomez M, Theall KP, Knight M, Foreman MD. Nurses' recognition of delirium in the hospitalized older adult. Clin Nurse Spec 2011;25:299-311. |
| 10 | Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM Jr. Nurses' recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Arch Intern Med 2001;161:2467-73. |
| 11 | McGetrick ME, Lach C, Mullen JE, Munoz-Pareja JC. Assessing nursing and pediatric resident understanding of delirium in the pediatric Intensive Care Unit. Crit Care Nurs Clin North Am 2019;31:481-8. |
| 12 | Park YS, Kim KS, Song KJ, Kang J. A preliminary survey of nurses' understanding of delirium and their need for delirium education – In a university hospital. Taehan Kanho Hakhoe Chi 2006;36:1183-92. |
| 13 | 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;41:571-6. |
| 14 | Gordon SJ, Melillo KD, Nannini A, Lakatos BE. Bedside coaching to improve nurses' recognition of delirium. J Neurosci Nurs 2013;45:288-93. |
| 15 | Ramoo V, Abu H, Rai V, Surat Singh SK, Baharudin AA, Danaee M, et al. Educational intervention on delirium assessment using confusion assessment method-ICU (CAM-ICU) in a general intensive care unit. J Clin Nurs 2018;27:4028-39. |
| 16 | Hickin SL, White S, Knopp-Sihota J. Nurses' knowledge and perception of delirium screening and assessment in the intensive care unit: Long-term effectiveness of an education-based knowledge translation intervention. Intensive Crit Care Nurs 2017;41:43-9. |
| 17 | Middle B, Miklancie M. Strategies to improve nurse knowledge of delirium: A call to the adult-gerontology clinical nurse specialist. Clin Nurse Spec 2015;29:218-29. |
| 18 | Travers C, Henderson A, Graham F, Beattie E. Turning education into action: Impact of a collective social education approach to improve nurses' ability to recognize and accurately assess delirium in hospitalized older patients. Nurse Educ Today 2018;62:91-7. |
| 19 | Speed G. The impact of a delirium educational intervention with intensive care unit nurses. Clin Nurse Spec 2015;29:89-94. |
| 20 | Kang Y, Moyle W, Cooke M, O'Dwyer S. Qualitative evaluation of a delirium prevention and management programme. J Clin Nurs 2017;26:4574-82. |
| 21 | Gesin G, Russell BB, Lin AP, Norton HJ, Evans SL, Devlin JW. Impact of a delirium screening tool and multifaceted education on nurses' knowledge of delirium and ability to evaluate it correctly. Am J Crit Care 2012;21:e1-11. |
| 22 | Detroyer E, Dobbels F, Teodorczuk A, Deschodt M, Depaifve Y, Joosten E, et al. Effect of an interactive E-learning tool for delirium on patient and nursing outcomes in a geriatric hospital setting: Findings of a before-after study. BMC Geriatr 2018;18:19. |
| 23 | Wand AP, Thoo W, Sciuriaga H, Ting V, Baker J, Hunt GE. A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study. Int J Nurs Stud 2014;51:974-82. |
| 24 | Zamoscik K, Godbold R, Freeman P. Intensive care nurses' experiences and perceptions of delirium and delirium care. Intensive Crit Care Nurs 2017;40:94-100. |
| 25 | Varghese NC, Macaden L, Premkumar B, Mathews P, Kumar S. Delirium in older people in hospital: An education programme. Br J Nurs 2014;23:704-9. |
|
