The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses
Introduction
Delirium is an acute or subacute syndrome with a tendency to fluctuate during the day and is characterised by disturbances in consciousness, attention and perception (Truman and Ely, 2003). It is associated with an increased mortality rate (van den Boogaard et al., 2012, Hamdan-Mansour et al., 2010), frequent complications (van den Boogaard et al., 2012), prolonged length of stay in hospital and the intensive care unit (ICU) (Ely et al., 2001a), and increased care costs (Jackson and Khan, 2015).
The incidence of delirium in the ICU is reported to be between 45% and 87% (Jackson and Khan, 2015). The incidence of delirium is higher among patients receiving mechanical ventilation (Sharma et al., 2012, Tsuruta et al., 2010), and delirium is a prognostic indicator of 6-month mortality (van den Boogaard et al., 2012). Although the incidence of delirium is high in ICU, the level of delirium diagnosis and awareness is unsatisfactory (Panitchote et al., 2015, Rice et al., 2011, Hamdan-Mansour et al., 2010). Lack of a regular cognitive assessment in the ICU patients, the difficulty in establishing communication with patients receiving mechanical ventilation, the presence of hypoactive delirium and lack of a formal assessment tool to monitor delirium are reported to affect the recognition rate of delirium (Balas et al., 2016, Eastwood et al., 2012, Solberg et al., 2013). The confusion of hypoactive delirium with depression and dementia and the difficulties in assessing patients under sedation are serious obstacles to the recognition of delirium (Breitbart and Alici, 2008, Cole et al., 2012). Hyperactive delirium is usually associated with agitation and can be more easily recognised than the hypoactive type (Flagg et al., 2010, Pun and Ely, 2007). However, it poses a major problem in terms of ensuring the patient's safety and maintaining patient care (Meagher et al., 2011, Pun and Ely, 2007).
Interventional training programmes to improve the skills of diagnosing and managing delirium increase the efficiency of nurses and improve the patient outcomes (Mistarz et al., 2011, Gesin et al., 2012, Van de Steeg et al., 2014). In the prevention and management of delirium, it is of utmost importance to identify risk factors, evaluate the patient's environment, maintain basic nursing care activities and initially implement nonpharmacological interventions rather than pharmacological therapies in patients with delirium (Holly et al., 2014, Martin et al., 2010, Celis-Rodriguez et al., 2013, Balas et al., 2012, Reston and Schoelles, 2013). Studies have shown that nonpharmacological interventions decreased the incidence (Colombo et al., 2012, Wand et al., 2014, Barr et al., 2013), duration (Brycakowski et al., 2014, Engel et al., 2013, Zaal et al., 2013), and severity of delirium (Irwin et al., 2013, Milisen et al., 2001). In this study, we aimed to investigate the effect of nonpharmacological interventional training on delirium recognition and intervention strategies in ICU nurses.
Section snippets
Method
This is a quasi-experimental study that used a pretest–posttest design. The study was conducted in the medical ICU of a university hospital. The study population consisted of nurses working in and patients admitted to the ICU between December 1, 2012 and April 13, 2014 and between August 1 and November 30, 2014. The total number of nurses and patients in the study population was 23 and 135, respectively. The ICU principal nurse (2), nurses on maternity leave (1), and those who left the ICU due
Ethical approval
Ethical and scientific approval for the study was obtained from Sivas Cumhuriyet University Clinic Research Ethics Committee on June 12, 2012, with approval number as 2012-06/10. Each patient or his/her caregiver were informed about the study before the data collection. A written informed consent was obtained from each patient or his/her caregiver (for confused patients) and each nurse. The hospital in which the research was conducted also issued an institutional approval for the study.
Data collection
The study data was collected using Patient Introduction Form, Confusion Assessment Method for the ICU (CAM-ICU), Delirium Risk Factors Form, Nurse Introduction Form, and Non-pharmacological Interventions in Delirium Prevention Form.
Data analysis
Statistical analysis was performed using SPSS version 21.0 software (SPSS Inc., Chicago, IL, USA). Means and standard deviations were used to present the qualitative data, while frequency and percentage were used to present the quantitative data. Nonparametric chi-square test or Fisher's exact tests were used to assess the interactions between quantitative variables while evaluating the descriptive characteristics of patients and development state of delirium in the pre- and posttraining
Results
Descriptive characteristics of the patients involved in the study in the pre- and posttraining phases are presented in Table 1. Delirium was identified in 26.5% of the patients observed in the pretraining phase of the study and 20.9% of the patients in the posttraining phase (p = 0.627). The incidence of hypoactive delirium was higher in patients in the pre- and posttraining phases of the study (Table 2). When the patients who participated in the study were evaluated in the pre- and posttraining
Discussion
Interventional training programmes are effective approaches for reducing the incidence, severity, and duration of delirium (Barr et al., 2013, Brycakowski et al., 2014, Irwin et al., 2013). In the present study, delirium incidence, which was 26.5% in the pretraining phase, decreased to 20.9% in the posttraining phase. We found some changes in the perspectives of the nurses on delirium management in the posttraining phase, which can be associated with reduced delirium rates. In this study, the
Limitations
There are some limitations to this study. First, the difference in the characteristics of the patients included in the study in the pre- and posttraining phase led to a limited evaluation of the effect of nonpharmacological treatments on delirium. Second, a two-session training may have led to insufficient recognition skills of delirium of the nurses. Third, pretraining phase was conducted to ensure a satisfying observation and prevent any disturbance related to the presence of nurses for the
Conclusion
In conclusion, our study results showed a longer duration of stay in the ICU, higher number of drugs included in treatment, and lower GCS score among patients with delirium. Our findings also demonstrated that the presence of hypo/hypernatremia and use of physical restrictions increased the risk of developing delirium. Despite no significant difference, nonpharmacological interventional training on delirium prevention reduced the incidence of delirium in the ICU by increasing the recognition
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