Chamberlain College of Nursing Delirium Why Are Nurses Confused Analysis HW You must access the following article to answer the questions:Baker, N., Taggar

Chamberlain College of Nursing Delirium Why Are Nurses Confused Analysis HW You must access the following article to answer the questions:Baker, N., Taggart, H., Nivens, A. & Tillman, P. (2015). Delirium: Why are nurses confused? MedSurg Nursing, 24(1), 15-22. permalink (Links to an external site.) Locate the literature review section. Summarize using your own words from one of the study/literature findings. Be sure to identify which study you are summarizing.Discuss how the author’s review of literature (studies) supported the research purpose/problem. Share something that was interesting to you as you read through the literature review section.Describe one strategy that you learned that would help you create a strong literature review/search for evidence. Share your thoughts on the importance of a thorough review of the literature. Delirium : W hy Are Nurses Confused?
Nidsa D. Baker
Helen M. Taggart
Anita Nivens
Paula Tillman
elirium is a serious, costly,
potentially preventable com­
plication for hospitalized
patients age 65 and older (Wofford &
Vacchiano, 2011). This acute, short­
term disturbance of consciousness
may last from a few hours to as long
as a few months. It is characterized
by an acute onset of inattention, dis­
organized thinking, and/or altered
level of consciousness.
Delirium can be categorized as
hyperactive, hypoactive, or mixed
based on symptoms that can fluctu­
ate and change during the course of
the disorder. Hyperactive or excited
delirium involves agitation and hal­
lucinations (American Psychiatric
Association, 2011; Holly, Cantwell,
& Jadotte, 2012). Patients with
hyperactive delirium are more likely
to receive earlier treatment than
patients who exhibit the less easily
recognized signs of hypoactive deliri­
um: lethargy, drowsiness, and inat­
tention. In addition, patients may
show signs of both hyperactive and
hypoactive delirium in a condition
described as mixed variant delirium
(Holly et al., 2012). Health care
providers often confuse delirium
with depression and/or dementia
(Fick, Hodo, & Lawrence, 2007;
Holly et al., 2012; Voyer, Richard,
Doucet, Danjou, & Carmichael,
2008). Unlike delirium, which hap­
pens suddenly over a few hours or
days, dementia usually develops
gradually over months or years,
while depression generally develops
over weeks or months, or, less often,
after a sudden event (Holly et al.,
2012; Young & Inouye, 2007) (see
Table 1).
Delirium is a common multifac­
torial disorder that involves a vul­
nerable patient with predisposing
D
MEDSURG n u r s i n g .
Nurses have a key role in detection of delirium, yet this condition
remains under recognized and poorly managed. The aim of this
study was to explore nurses’ knowledge of delirium-related infor­
mation as well as their perception of their level of knowledge.
factors and exposure to precipitat­
ing factors (Sendelbach & Guthrie,
2009). It can occur at various ages.
However, older adults are particu­
larly vulnerable to delirium, espec­
ially when they are ill (Featherstone
& Hopton, 2010) (see Table 2).
Underlying risk factors are often
contributory to delirium in older
adults. Common triggers are infec­
tion, medications, general pain,
constipation, dehydration, and
environmental factors (Dahlke &
Phinney, 2008; Quinlan et al.,
2011). Although delirium occurs
commonly in acute care settings,
older adult residents of long-term
care and assisted living homes are
vulnerable as well. Rates of delirium
in long-term care settings range
from 1% to 60% (Lee, Ha, Lee,
Kang, & Koo, 2011; Siddiqi, Young,
& Cheater, 2008). Delirium is asso­
ciated with poor patient outcomes
that include longer hospital stays,
increased costs, increased need for
post-acute care, and significant
stress for patients and families
(O’Mahony, Murthy, Akunne, &
Young, 2011). At least 20% of the
12.5 million patients age 65 or older
hospitalized each year have deliri­
um as a complication, causing a
$9,000 to $15,000 increase depend­
ing on the severity in hospital costs
per patient. Delirium attributes to
annual estimated cost of $38 – $152
billion (Kalish, Gillham, & Unwin,
2014; Young & Inouye, 2007).
The prevalence of delirium varies
from 1% to 80% depending on pop­
ulation, the time of delirium assess­
ment, and the assessment method.
In addition, the documented inci­
dence of delirium extended from
3% to 61% (Kalish et al., 2014;
Young & Inouye, 2007). Addition­
ally, the prevalence of this condi­
tion reported in medical and surgi­
cal intensive care unit cohort stud­
ies varied from 20% to 80% (Girard,
Panharipande, & Ely, 2008; Kalish
Nidsa D. Baker, MSN, RN, ANP-BC, is Adult Nurse Practitioner, St. Joseph’s/Candler Health
System St. Mary’s Health Center, Savannah, GA.
Helen M. Taggart, PhD, RN, ACNS-BC, is Professor, Department of Nursing, College of Health
Professions, Armstrong Atlantic State University, Savannah, GA.
Anita Nivens, PhD, RN, FNP-BC, is Graduate Nursing Program Coordinator and Professor,
Department of Nursing, College of Health Professions, Armstrong Atlantic State University,
Savannah, GA.
Paula Tillman, DNP RN, ACNS-BC, is Assistant Professor, Armstrong Atlantic State University,
Savannah, GA, and Informatics Specialist, Memorial Health University Medical Center,
Savannah, GA.
Acknowledgments: The authors thank Malcolm Hare, Fremantle Hospital and Health Service
and Curtin University School of Nursing in Australia, for granting permission to utilize the ques­
tionnaire.
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Vol. 24/No. 1
15
Research for Practice
TABLE 1.
C o m p ariso n o f D e liriu m , D e m e n tia , an d D epression
Delirium
Dementia
Depression
Onset
Sudden: Hours or days
Gradual over months or years
‘
Gradual over weeks or months,
or after an event
Alertness/
Attention
Fluctuates: Sleepy or agitated,
unable to concentrate
Generally stable
Generally stable, some difficulty
concentrating
Sleep
Sudden changes in sleeping
pattern, unusual confusion at night
Can be disturbed, with habitual
night-time wandering
Early morning waking
Thinking
Disorganized, rambling
Specific, difficulty with short-term
memory
Preoccupied with negative
thoughts, hopelessness, help­
lessness, self-depreciation
Perception
Delusions, hallucinations common
Generally normal
Generally normal
Source: Holly et al., 2012
TABLE 2.
Predisposing an d P re c ip ita tin g Factors fo r D eliriu m
Predisposing Factors
Age a 65
Male sex
Co-existing dementia/cognitive
impairment
History of delirium
Depression
Functional dependence
Immobility
Low level of activity
History of falls
Visual impairment
Hearing impairment
Dehydration
Malnutrition
Polypharmacy
Alcohol/drug abuse
Precipitating Factors
Use of sedative hypnotics, opioids, or
anticholinergic drugs
Stroke
Infections
Hypoxia
Shock
Fever or hypothermia
Anemia
Poor nutritional status
Recent surgery (major/minor)
Admission to an intensive care unit
Use of physical restraints
Use of indwelling urinary catheter
Multiple procedures
Pain
Emotional stress
Prolonged sleep deprivation
Source: Sendelbach & Guthrie, 2009
et al., 2014). Delirium is common
among elders in long-term care
(LTC) facilities, with its prevalence
ranging from 9.6% to 89% (Voyer et
al., 2008).
Although common, delirium
often is under-recognized and
under-diagnosed (O’Mahony et al.,
2011). Because of the high incidence
and costs associated with delirium,
prevention should be a high priority
for health care professionals, espe­
cially nurses (Harris, Chodosh,
Vassar, Vickrey, & Shapiro, 2009).
16
Nurses spend more time with
patients, allowing them to observe
any changes in patients’ attention,
level of consciousness, and cognitive
function (Brixey & Mahon, 2010). As
a result, frequent assessments by
nurses are crucial for early detection
of delirium (Girard et al., 2008).
Literature Review
A comprehensive review of the
literature was conducted of all orig­
inal research published 2001-2014
la n u a ry -F e b ru a ry 2015
•
using MEDLINE, CINAHL, and
ProQuest Psychology Journals.
Search terms included delirium or
acute confusion and nurses, nurses’
recognition, nurses’ identification, or
nurses’ knowledge. Exclusion criteria
were studies not reporting primary
data and studies that did not
include m easurem ent of nurse
recognition or knowledge of deliri­
um. Although now dated, the
selected research specifically evalu­
ated nurses’ knowledge deficit for
delirium in studies of various
designs. In addition, fewer studies
actually assessed the levels of
knowledge about delirium factors,
such as definition, available and
appropriate assessment scales/tools,
and risks (Hare, Dianne, Sunita, Ian,
& Gaye, 2008).
Many studies of delirium focused
on the advantages of educated
intervention, such as prevention
practices, increased early detection,
and proper medical management
(Bergmann, Murphy, Kiely, Jones, &
Marcantonio, 2005; Featherstone &
Hopton, 2010; Rapp, Mentes, &
Titler, 2001). Researchers also found
a positive correlation between use
of an educational intervention for
nursing and medical professionals
and positive patient outcomes such
as decreased length of hospital stay
(Meako, Thompson, & Cochrane,
2011; Tabet et al., 2005). Fick and
co-authors (2007) found using case
vignettes could evaluate nurses’
Vol. 2 4 /N o . 1
MEDSURG
N U R S IISTO
Delirium: Why Are Nurses Confused?
knowledge of delirium in patients
with dementia.
Hare and colleagues (2008) tar­
geted 1,097 clinical nurses in a hos­
pital setting with a questionnaire to
assess their knowledge of delirium
and its associated risk factors. Of the
338 (30.8%) returned responses,
64% (n=217) scored 50% or better
on the questionnaire. In addition,
36.3% (n=123) scored 50% or better
for the risk factor questions while
81.9% («=227) scored 50% or better
for the knowledge questions. Find­
ings indicated orthopedic nurses
who had participated in a delirium
education forum prior to the
research scored better on the gener­
al facts portion of the questionnaire
when compared to nurses having
no pre-survey educational interven­
tion. However, the orthopedic nurs­
es did not score higher compared to
other surveyed nurses on the risk
factor questions. The researchers
thus found nurses were not as
knowledgeable about delirium risk
factors as they were about general
facts concerning delirium.
Fick and co-authors (2007) also
assessed nurses’ knowledge of deliri­
um but more narrowly focused on
delirium superimposed on dementia
(DSD), with the goal of determining
if nurses were able to recognize these
conditions using case vignettes. The
case vignettes were designed to eval­
uate knowledge of delirium, its risk
factors, and management. The study
also assessed nurses’ geropsychiatric
knowledge using the Mary Starke
Harper Aging Knowledge Exam
(MSHAKE), a tool that measures gen­
eral geropsychiatric knowledge. Of
29 participating nurses, 41% (n=12)
were able to identify dementia cor­
rectly in the dementia vignette but
had difficulty differentiating deliri­
um factors from DSD factors and
specifically identifying hypoactive
delirium. While this study had a
small sample size, its findings sug­
gested nurses are more likely to dis­
tinguish dementia and hyperactive
delirium than DSD and hypoactive
delirium alone.
Dahlke and Phinney (2008) eval­
uated how nurses assess, prevent,
and treat delirium in older hospital­
ized patients, and identified deliri­
MEDSURG
um-related challenges and barriers
faced by nurses when caring for
patients with delirium. This descrip­
tive qualitative study comprised
interviews with nurses who worked
in a hospital. A convenience sam­
pling included 12 registered nurses
in a mid-sized regional hospital in
western Canada who had manageri­
al, educational, and bedside roles
and worked in various areas such as
medical and surgical units. The nurs­
es in the study had 6-43 years of
nursing experience. Level of profes­
sional education included diploma
(«=7), baccalaureate (n=4), and mas­
ter’s degree {n=1). Each respondent
was interviewed for approximately
1.5 hours with open-ended ques­
tions about his or her clinical and
personal experience with delirium
assessment, recognition, and inter­
vention. Analysis of the recorded
interviews yielded three main deliri­
um-related strategies: Taking a Quick
Look, Keeping an Eye on Them, and
Controlling the Situation.
Taking a Quick Look suggested
nurses quickly assess patients
because of the limited time general­
ly available in a fast-paced acute
care setting (Dahlke & Phinney,
2008). Keeping an Eye on Them rec­
ommended frequent rounding and
monitoring of patients assessed to
be at risk for delirium. Controlling
the Situation focused on intervening
as needed to prevent injury and
provide appropriate therapy. Au­
thors found nurses repeatedly
reported having little to no formal
education about older adults and
had sparse formal knowledge of
delirium; they concluded nurses
would benefit from increased deliri­
um-related educational support.
Additional research assessing
nurses’ knowledge of delirium has
been completed in LTC settings.
Voyer and co-authors (2008)
assessed nurse detection of delirium
in older adults. This prospective
study identified the signs and
symptoms most challenging to dis­
tinguish, as well as delirium factors
most likely to go unnoticed. At
three LTC facilities and a large
regional hospital LTC unit over two
7-day periods, trained research
assistants (nurses who had complet­
n uhs img. J a n u a ry -F e b ru a ry 2015 • Vol. 2 4 /N o . 1
ed 15 hours of instruction on delir­
ium and dementia detection) inter­
viewed 160 consenting patients age
65 and over with no history of psy­
chiatric illness. Investigators collect­
ed relevant demographic and
health information and assessed
patients for delirium as part of their
interviews. Nurses were questioned
about their ability and experience
in assessing delirium in patients.
The incidence of delirium among
patient participants was 71.5%
(n=108); of those, nurses identified
delirium in just 13% (n=14).
Authors concluded nurses under­
recognize delirium in older adults
in the LTC setting.
Purpose
Nurses’ failure to differentiate and
recognize delirium early may be due
to lack of knowledge about delirium,
risk factors, preventive measures,
and treatment. Therefore, the pur­
pose of this study was to assess nurs­
es’ knowledge of delirium and its risk
factors, and correlate findings to
demographic variables, such as nurs­
es’ years of experience, level of edu­
cation, and area of practice. The
study also was designed to evaluate
nurses’ perception of their own level
of competency related to delirium
recognition and management.
Research Questions
Research questions addressed in
this study included the following:
1. W hat was nurses’ level of
knowledge of delirium?
2. What was nurses’ level of know­
ledge of delirium risk factors?
3. Was there a correlation be­
tween nurses’ years of experi­
ence, education, and practice
area, and their knowledge of
delirium and its risk factors?
4. How did nurses perceive their
own knowledge competency
related to delirium?
Hypotheses
1.
2.
Nurses have insufficient knowl­
edge of delirium and its risk fac­
tor as evidenced by scoring less
than 75% on the questionnaire.
A high correlation exists be­
tween a nurse’s level of experi­
ence, education, and area of
17
Research for Practice
practice, and his or her knowl­
edge of delirium and its risk fac­
tors.
M e th o d s
After receiving institutional re­
view board approval from the affili­
ated hospital and university in the
Southeast region of the United
States, researchers sent an an­
nouncement about the study by
mass email to potential respondents
who were nurses employed at this
hospital. This nonexperim ental,
descriptive study was conducted
over a 2-week period. Researchers
manually distributed 150 question­
naires to every hospital unit (med­
ical-surgical, orthopedic, oncology,
progressive care, neuro-intensive
care, medical-surgical intensive
care, cardiac care) to nurses who
volunteered to participate in the
study.
In stru m en tation
The research instrument used in
this study was used previously in a
similar study (Hare et al., 2008).
Permission to use the questionnaire
was obtained from its original
developers (M. Hare, personal com­
munication, March 15, 2011). The
questionnaire, which was untitled
in the previous study, was labeled
for the current study as Nurses’
Knowledge of Delirium (NKD)
(Hare et al., 2008). The NKD ques­
tionnaire has neither been validated
nor had its reliability established
(M. Hare, personal communication,
September 22, 2011). However, the
developer explained many other
researchers and organizations world­
wide, such as National Health
Service in the Great Britain, have
utilized all or part of the question­
naires subsequent to the original
study; thus, validation and reliabili­
ty may have been established with­
out the knowledge of the developers
(M. Hare, personal communication,
September 22, 2011).
The NKD questionnaire has two
sections: a 10-question section for
demographic data collection and 36
specific delirium-related questions
called the knowledge section. The
demographic section required par­
18
ticipants to provide age, sex, prac­
tice setting, specialty, level of educa­
tion, and years of nursing experi­
ence. Participants also were asked if
they had experience in caring for a
patient with delirium; if so, how fre­
quently had they provided care and
had they received any formal deliri­
um-related continuing education?
Respondents also were asked to pro­
vide their perceptions of their cur­
rent personal knowledge of deliri­
um by selecting one of the follow­
ing descriptors: lack competency,
minimal competency, average compe­
tency, above average competency,
advanced competency, or expert com­
petency. The demographic section
required written responses and con­
tained multiple-choice questions
except respondent age.
In the knowledge section of the
questionnaire, participants identi­
fied the definition of delirium in a
multiple-choice question, and seven
scales/tools commonly used when
assessing patients with delirium,
dementia, and/or depression. All 28
remaining questions in this section
assessed respondents’ general
knowledge of delirium and its risk
factors using a Likert-scale (agree,
disagree, or unsure). This section
contained one definition question,
seven scales/tools questions, 14
general questions about delirium,
and 14 questions about risk factors
in a randomly mixed sequence.
Participants independently com ­
pleted just one of the forms in its
entirety and placed finished ques­
tionnaires in a collection folder
located in the nurses’ lounges on
each unit. The tool did not request
any identifying information from
participants so anonym ity was
maintained.
C ollection o f D ata and
Analysis o f Data
Once the questionnaires were
collected, answers were compared
to a codebook or key created to pro­
vide quick, accurate assignment of
numerical values to the different
answers for analysis. Completed
questionnaires were crosschecked
manually with the answer key and
entered into an Excel spreadsheet to
construct a database. Percentages
January-February 2015
•
and means were used to describe
the demographic variables. The
completed database then was
exported to SPSS version 15 (IBM,
Chicago, IL) for detailed analysis.
Researchers used analysis of vari­
ance (ANOVA) to determine if a cor­
relation existed between nurses’
demographic characteristics and
their knowledge of delirium and
delirium risk factors, and nurses’
perceptions of personal competen­
cy related to delirium. For the pur­
pose of this study, p
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