RESEARCH doi: 10.1111/nicc.12184
Cardiovascular surgery nurses’ level of knowledge regarding delirium Fatma Demir Korkmaz, Fadime Gok and Ayla Yavuz Karamanoglu ABSTRACT Background: Studies have shown that nurses have a crucial role in the recognition of delirium; however, they have insufficient knowledge regarding the issue. Objective: The aim of the study is to determine the knowledge level of cardiovascular surgery nurses regarding delirium. Methods: A survey design was used. The population of the study consisted of 124 nurses employed at the cardiovascular surgery wards and intensive care units of universities as well as state and private hospitals located in two different cities in Turkey between May and June 2014. The sample consisted of 97 nurses employed at the aforementioned institutions and time. Data were collected using the questionnaire form depicting the demographic characteristics of the nurses and the knowledge form including the level of nurses’ knowledge regarding delirium. For the evaluation of data, number, percentage, Kruskal-Wallis, Mann-Whitney U- and independent-samples t-test were used. Results: Nurses were between 18 and 47 years of age with a mean 29⋅8 (SD = 6⋅80, the youngest = 18 and the oldest = 47) years. They spent a minimum of 1, a maximum of 25 and a median value of 3 (interquartile range, IQR: 5) years working in cardiovascular surgery. As for the scores received from the knowledge form regarding delirium, the lowest was zero, the highest was 60, and the average score was 41⋅18 ± 12⋅50 (a moderate level of knowledge). It was found that the nurses working in intensive care units, those who were chief nurses and those who received in-service training scored higher than the others. Conclusions: Cardiovascular surgery nurses had a moderate level of knowledge regarding delirium. This may result in the neglect of delirium or a misdiagnosis. Relevance to clinical practice: It is recommended that training is provided that includes recognition, assessment and application of appropriate interventions to minimise the incidence of delirium. Key words: Cardiovascular nursing • Critical care nursing • Delirium • Knowledge level • Nurses’ knowledge level
INTRODUCTION Delirium is a temporary, organic, mental syndrome that is characterised by a sudden and fluctuating course of, generally, cognitive dysfunction, change in consciousness, lack of attention, increased or decreased psychomotor activity and an irregularity of the sleep-wake cycle (Lin et al., 2012; Belanger and Ducharme, 2011; Mc Donnell and Timmins, 2012). According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), delirium is defined as ‘a disturbance of consciousness with reduced ability to focus, sustain or shift attention; a change in cognition; or the development of a perceptual disturbance that occurs over a short Authors: F Demir Korkmaz, RN, PhD, Associate Professor, Faculty of Nursing, Ege University, Izmir, Turkey; F Gok, RN, Research Assistant, Health School, Pamukkale University, Denizli, Turkey; A Yavuz Karamanoglu, RN, Research Assistant, Health School, Pamukkale University, Denizli, Turkey Address for correspondence: F Demir Korkmaz, Associate Professor, Faculty of Nursing, Ege University, Ege Universitesi Hemsirelik Fakultesi Bornova, 35100 Izmir, Turkey E-mail: [email protected]
© 2015 British Association of Critical Care Nurses
period of time and tends to fluctuate over the course of the day’ (American Psychiatric Association, 1994; Koster et al., 2009a, 2009b). The DSM-5 (the newer version of the DSM-IV) lists four criteria for the diagnosis of delirium (Norkiene et al., 2013; Butler et al., 2013; American Psychiatric Association, 2014). These are: (a) Disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and orientation to the environment. (b) The disturbance develops over a short period of time (usually hours to a few days) and represents an acute change from baseline that is not solely attributable to another neurocognitive disorder and tends to fluctuate in severity during the course of a day. (c) A change in an additional cognitive domain, such as memory deficit, disorientation or language disturbance or perceptual disturbance, that is not better accounted for by any other pre-existing, established or evolving neurocognitive disorder. 1
Cardiovascular surgery nurses’ knowledge of delirium
(d) The disturbances in criteria (a) and (c) must not be occurring in the context of a severely reduced level of arousal such as coma. In addition to the short-term effects of delirium such as mortality, morbidity and extension of stay in hospital, long-term effects are also observed, namely permanent cognitive deficit, loss of independence, functional problems, increase in costs and higher mortality for 2 years after episode (Rudolph et al., 2009; Burns et al., 2009; Gottesman et al., 2010; Norkiene et al., 2013). As a complication of cardiac surgery, delirium has been reported for many years. The incidence of postoperative delirium after cardiac surgery is 13⋅5–67%, although it varies according to the method of diagnosis and to a lack of diagnosis at times (Koster et al., 2011; Koster et al., 2009a, 2009b; Gottesman et al., 2010; Norkiene et al., 2013). Despite the advances in cardiac surgical techniques and anaesthesia practice, delirium remains a frequent but under-recognized complication after cardiac surgery (Rudolph et al., 2009; Gottesman et al., 2010; Lin et al., 2012). Cardiac surgery patients are prone to many risk factors for delirium, related to the surgical method or patient profile. Previous studies have shown that there are 33 risk factors (17 predisposing and 16 precipitating) for cardiac surgery patients. Among the preoperative risks are older age, depression, stroke, cognitive impairment, atrial fibrillation, the severity of the current disease, heavy drinking and smoking, diabetes, chronic renal failure, existence of uremia, long and deep anaesthesia during operation, postoperative mechanical ventilation, drugs used, pain, hypoxemia, hypotension, hypoalbuminemia, acidosis and alkalosis, and fluid and electrolyte imbalance (Burns et al., 2009; Koster et al., 2011; Taipale et al., 2012; Lin et al., 2012). Studies have shown that nurses play a key role in the recognition of delirium; however, the symptoms of delirium are usually unrecognized by nurses (Inouye et al., 2001). Because nurses often/constantly spend time together with patients, they have the opportunity to observe, recognize the fluctuations in consciousness and cognitive functions and make an early diagnosis (Inouye et al., 2001; Agar et al., 2011). In contrast, studies have demonstrated that nurses lacked sufficient knowledge regarding delirium, were uncomfortable while giving care to patients with delirium and that they did not integrate the diagnosis and treatment of delirium with their care (Mc Donnell and Timmins, 2012; Hamdan-Mansour et al., 2010; Agar et al., 2011). During our observations in wards, we noticed that no screenings for delirium were made in intensive care units (ICUs). However, the guidelines published 2
by the American College of Critical Care Medicine (2013) recommended routine monitoring of delirium in adult ICU patients and stated that the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist were the most valid and reliable delirium monitoring tools in adult ICU patients (Barr et al., 2013). This study aimed at investigating cardiovascular surgery nurses’ level of knowledge regarding delirium.
STUDY OBJECTIVE This is a descriptive cross sectional survey which aimed to determine the knowledge level of nurses employed in cardiovascular surgery wards and ICUs regarding delirium.
METHOD The population of the study was made up of 124 nurses employed at the cardiovascular surgery wards and ICUs of four institutions, namely, two universities, one hospital under the Ministry of Health and two private hospitals in two separate provinces in Turkey between May 2014 and June 2014. A total of 99 nurses who were employed at the aforementioned institutions and willing to participate in the research filled in the questionnaire. However, because two nurses only provided descriptive data but had not answered the questions on knowledge, the sample consisted of 97 nurses. Data were collected by using the data form prepared by the researchers in accordance with the literature. This form includes 15 questions to determine descriptive information on the nurses and 69 questions that assess the nurses’ level of knowledge regarding delirium.
Validity of the form In order to test the validity of the questionnaire form prepared by the researchers, a total of 15 people were employed including 2 cardiovascular surgery intensive care nurses, 3 cardiovascular surgery ward nurses, 3 psychiatry ward nurses, 2 psychiatry specialists, 2 cardiovascular surgery specialists, an academic nurse who formerly worked as cardiovascular surgery nurse and 2 academic nurses who formerly worked as psychiatric nurses. The knowledge questions prepared by the researchers initially comprised of 73 statements. The specialists were asked to review the competency of the questions and to state whether they would leave out or add any questions. In accordance with the views of the specialists, 14 of the questions were omitted, and 10 new questions were added. Revisions were made in © 2015 British Association of Critical Care Nurses
Cardiovascular surgery nurses’ knowledge of delirium
17 questions, and a total of 69 questions were finally approved. The questionnaire form was pre-tested on 10 nurses employed in either cardiovascular surgery ward or ICU in one of the hospitals included in the sample. During the pre-implementation, interviews were conducted to test the clarity, comprehensibility and functionality of the questions. In accordance with the feedback received, the questionnaire was revised and finalized by the researchers. The Cronbach’s alpha coefficient for internal reliability was found to be 0⋅925. Of the questions, 9 were related to the definition of delirium, 8 to the causes of delirium, 13 to the risk groups, 21 to the symptoms of delirium and 18 to nursing management in case of a delirium. The knowledge questions were constructed in the form of plain information, and the nurses were asked to evaluate the given statements as true, false or do not know. Later on, the mean knowledge score was calculated by scoring the answers given by the nurses; each correct answer received one (1) point while each wrong and ‘don’t know’ answer received zero (0). Of these statements, 19 were prepared inversely so when the nurses stated ‘false’ it actually referred to the correct answer. Taking this fact into consideration while calculating the knowledge scores, ‘false’ replies to these 19 questions were given one (1) point and ‘true’/‘don’t know’ replies were given zero (0). The lowest score nurses could receive from this questionnaire is zero while the highest is 69. Taking the mean value of the correct answers as the cut-off value, the range of 23 points and below was considered to be a low level while 24–47 points was considered to be a moderate level, and 48 points and above was considered to be a high level of knowledge.
Data analysis Statistical Package for the Social Sciences (version 17.0 SPSS 17.0) software was used for statistical analysis. Data were presented as number, percentage and mean ± standard deviation. For the evaluation of the data, standard deviation and independent sample tests were used. Student’s t-test, Kruskal-Wallis, Mann-Whitney U-tests were used to compare data. A p < 0⋅05 was considered statistically significant.
Ethical considerations For the implementation of the research, written consents were received from the Ethical Committee of Scientific Research of the Faculty of Nursing, Ege University and the hospitals where the research was conducted. All nurses working in the ward and ICU were invited to participate in the study. An information sheet, which included the aim and stated © 2015 British Association of Critical Care Nurses
that they had a right to withdraw from the study at any time and for any reason was attached to the questionnaire. Data regarding names and identity of nurses were not necessary in this study and were not asked. Data collected from all the nurses have been kept in strictest confidence. The questionnaire was distributed to all nurses at their work places via the researchers.
RESULTS Of the nurses included within the scope of the study, the average age was 29⋅8 (SD = 6 80, the youngest = 18, the oldest = 47). The maximum year of experience in cardiovascular surgery was found to be 25, the minimum to be 1 and the median value was 3 (IQR: 5) years. As for the weekly hours of work, the minimum value was found to be 40, the maximum to be 60 and the average to be 44⋅18 ± 5⋅34 h. It was determined that intensive care nurses offered care to a minimum of 2, a maximum of 7 and an average of 3⋅61 ± 0⋅97 patients in a shift while ward nurses provided care for a minimum of 2, a maximum of 19 and an average of 9⋅51 ± 4⋅47 patients (Table 1). Table 2 presents the distribution of the nurses’ answers to the questions regarding delirium. Accordingly, 86⋅6% of the nurses were aware that delirium was a temporary organic mental syndrome, 91⋅8% knew that neurological diseases might cause delirium, 77⋅3% were aware of the fact that cognitive disorders (dysfunctioning in consciousness, memory, orientation and perception) of any reason might increase the risk of delirium, 86⋅6% knew that daily fluctuations in consciousness are observed in cases of delirium, again 86⋅6% were aware that patients in delirium temporarily lost their sense of shame, apprehension and inhibition and 84⋅5% were informed about the fact that the major aim for treating patients with the risk of developing delirium was to avoid any tremens. It was determined that the scores obtained by the nurses from the knowledge form regarding delirium varied from zero (0) the lowest to 60 the highest, 41⋅18 ± 12⋅50 being the average score. When the relation between the nurses’ level of knowledge regarding delirium and their department of employment, duty, number of patients they offer care, condition of having received education and sources of education was analysed (Table 3), it was found that there was a statistically significant difference (p < 0⋅05). It was found that among the nurses working in ICUs, those who were chief nurses and those who received education on delirium had a higher level of knowledge. 3
Cardiovascular surgery nurses’ knowledge of delirium
Table 1 Descriptive characteristics of nurses (n = 97) Variables
Number
Age group (years) 18–28 47 29–47 50 Sex Female 88 Male 9 Marital status Married 54 Single 43 Level of education Vocational school of health services 17 Associate’s degree 13 Bachelor’s degree 59 Master’s degree 8 Department of employment Cardiovascular surgery, intensive care unit 52 Cardiovascular surgery, ward 45 Duty Chief nurse 8 Clinical nurse 43 Intensive care unit nurse 46 Type of work Shift 2 Night shift 21 Day shift 19 Years of professional experience 42 1–5 29 6–10 26 Years of experience in cardiovascular surgery 1–5 71 6–21 26 Weekly hours of work 40–44 57 45–60 40 Number of patient per nurse 2–4 49 5 and above 48 Condition of having received education on delirium Yes 21 No 76 Sources of education on delirium (n = 21) (more than one reply) In-service training 10 During undergraduate study 21 No education 76 Willingness to receive education on delirium Yes 77 No 20 Total 97
%
48⋅5 51⋅5 90⋅7 9⋅3 55⋅7 44⋅3 17⋅5 13⋅4 60⋅8 8⋅2 53⋅6 46⋅4 8⋅2 44⋅3 47⋅5 2⋅1 21⋅6 19⋅6 43⋅3 29⋅9 73⋅2 26⋅8 58⋅8 41⋅2 50⋅5 49⋅5 21⋅6 78⋅4 10⋅3 11⋅3 78⋅4 79⋅4 20⋅6 100
A statistically significant difference was not found (p > 0⋅05) between the nurses’ knowledge score and their age, sex, marital status, educational status, type of work, duration of professional experience, duration of experience in cardiovascular surgery and weekly hours of work. 4
DISCUSSION Factors related to knowledge level of nurses regarding delirium In this study, 78⋅4% of the nurses stated that they had not received education regarding delirium. In the study conducted by Elfeky and Ali, 2013 with 120 intensive care nurses, 100% of the nurses stated that they had not received any training on delirium. This percentage was found to be 69⋅3% in the study conducted by Christensen (2014) and 66⋅3% in the study conducted by McDonnell et al. (2012) (Mc Donnell and Timmins, 2012; Elfeky and Ali, 2013; Christensen, 2014). This finding demonstrates a similarity to those of the previous studies in the literature; nevertheless, nurses would be expected to have received training because the incidence of delirium in ICUs was high. In the literature, it is stated that delirium should also be taken into consideration during routine patient care and that such education should ideally start in nursing schools and it should be sustained as a part of continuing education programs (Inouye et al., 2001; Hsu et al., 2005; Hare et al., 2008). However, in this study, very few of the nurses stated that they received education regarding delirium during in-service training (10⋅3%) and during undergraduate education (11⋅3%). International organisations recommend the use of scales for the detection of delirium in adults receiving treatment in ICUs (NICE, 2010; Barr et al., 2013). In contrast, it was found that none of the hospitals where the research was conducted utilized scales for the detection of delirium. We are of the opinion that the implementation of education programs regarding delirium and the use of such scales in ICUs and wards would promote awareness, thus increasing nurses’ level of knowledge. In our country, with the Ministry of Health Certified Training Regulations which came into effect after being published in the Official Gazette dated 4 February 2014, Intensive Care Nursing was also included within the scope of the Certified Training Programs. The fact that this program also includes a course designed to evaluate and prevent the risk of delirium is a pleasing development.
Knowledge levels of cardiovascular surgery nurses In this study, it was determined that the lowest score obtained by the nurses from the knowledge form regarding delirium was zero while the highest was 60 and the average score was 41⋅18 ± 12⋅50 which indicated that they had a ‘moderate’ level of knowledge. Previous studies conducted in the same field also demonstrated that nurses had a low level of knowledge regarding delirium (Steis and Fick, 2008; Agar et al., 2011). In the study conducted by Christensen © 2015 British Association of Critical Care Nurses
Cardiovascular surgery nurses’ knowledge of delirium
Table 2 Distribution of nurses according to their level of knowledge (n = 97) Correct answers Questions Delirium is a temporary organic mental syndrome (true) Memory can be checked in cases of delirium (false) Psychomotor activity is constantly high in delirium (false) The sleep-wake cycle of the patient is normal in case of delirium (false) The pathophysiology of delirium is not clearly understood yet (true) The symptoms of delirium may sometimes demonstrate similarities to the symptoms of depression (true) The Mini-Mental State Examination is one of the best methods of diagnosing delirium (true) The rate of mortality in patients with delirium is high (true) Delirium does not last for more than a few hours (false) Physical illness does not cause delirium (false) Neurological diseases may cause delirium (true) Acute stress may cause delirium (true) Sudden stop of alcohol consumption in addicts may cause delirium (true) Trauma to the head may cause delirium (true) Hypoxia may cause delirium (true) Being under anaesthesia for long periods may cause delirium (true) Increase in the level of nitric oxide may cause delirium (true) Older age increases the risk of delirium (true) Visual impairments increase the risk of developing delirium (true) As the quantity of medication used by the patient increases, the risk of developing delirium also increases (true) Invasive procedures (urinary catheter etc.) may decrease the risk of delirium (false) Vitamin B12 deficiency increases the risk of delirium (true) The risk of delirium is higher in men compared with women (true) Diabetes is a high risk factor for delirium (true) Dehydration may be a risk factor for delirium (true) Hearing loss increases the risk of delirium (true) Obesity is a risk factor in delirium (false) A family history of dementia predisposes a patient to delirium (false) Physical diagnosis may increase the risk of delirium in patients (true) Cognitive disorders (deficit in consciousness, memory, orientation and perception) of any reason may increase the risk of delirium (true) In cases of delirium, daily fluctuations in consciousness are observed (true) Abstract thoughts are observed in delirium (true) The symptoms of delirium, dementia and depression do not generally differ (false) Symptoms of delirium develop suddenly (true) Patients in delirium are energetic (false) Patients in delirium temporarily lose their sense of shame, apprehension and inhibition (true) Patients in delirium constantly experience disorientation in time, place and the identity of others (true) It becomes difficult to communicate with patients diagnosed with delirium (true) Patients in delirium always experience visual and auditory hallucinations (false) Delirium can generally be cured (true) Patients in delirium experience impairments in reality testing (true) There is hardly any loss of concentration in delirium (false) Delirium causes sleep disorders (true) Delirium does not change the personality traits of individuals (false) Anti-cholinergic activity reduces the delirious state (false) Noradrenaline activity increases the delirious state (true) Anxiety and fear are experienced during the delirious state (true) Patients with delirium are always aggressive (false) Behavioural changes in the course of the day are typical of delirium (true) A patient with delirium is easily distracted and has difficulty in following a conversation (true) Patients with delirium often experience perceptual disturbances (true) The major aim for treating patients with the risk of developing delirium is to avoid any tremens (true) Keeping patients diagnosed with delirium in a quiet environment helps manage the symptoms (true) Medication is generally recommended in the treatment of delirium (true) Sedatives and tranquilizers are beneficial for delirium (False)
© 2015 British Association of Critical Care Nurses
n
%
84 19 15 76 46 71 51 22 58 64 89 86 88 73 82 87 56 66 30 56 47 57 32 32 50 34 16 10 66 75 84 74 31 69 10 84 64 84 19 74 80 62 83 45 14 40 73 34 66 76 82 82 73 48 32
86⋅6 19⋅6 15⋅5 78⋅4 47⋅4 73⋅2 52⋅6 22⋅7 59⋅8 66⋅0 91⋅8 88⋅7 90⋅7 75⋅3 84⋅5 89⋅7 57⋅7 68⋅0 30⋅9 57⋅7 48⋅5 58⋅8 33⋅0 33⋅0 51⋅5 35⋅1 16⋅5 10⋅3 68⋅0 77⋅3 86⋅6 76⋅3 32⋅0 71⋅1 10⋅3 86⋅6 66⋅0 86⋅6 19⋅6 76⋅3 82⋅5 63⋅9 85⋅6 46⋅4 14⋅4 41⋅2 75⋅3 35⋅1 68⋅0 78⋅4 84⋅5 84⋅5 75⋅3 49⋅5 33⋅0
5
Cardiovascular surgery nurses’ knowledge of delirium
Table 2 Continued Correct answers Questions The most important thing in the treatment is to provide sedation and sleep (true) The priority in treating delirium is to ensure safety of the patients and provide support (true) Adequate intake of liquids may prevent delirium (true) Using hearing-aids increases the delirious state (false) Using glasses for the visually impaired elderly may reduce the delirious state (true) Reminding the patients of their name, place, time and age causes the symptoms to increase (false) Too much interaction with other people might lead to worsening of delirium (true) Inadequate control of pain might lead to worsening of delirium (true) If the patients in delirium misunderstand a certain thing, it has to be corrected until they get it correctly (true) To keep delirium symptoms under control, bed rest might be recommended when necessary (true) Informing patients of the season, date, day and time and especially the presence of a clock might prevent patients from a delirium tremens (true) In the postoperative period, patients should be stood up and encouraged to walk as soon as possible (true) Patients should not be left without a stimulus (information on place, time, process) for long periods (true) If patients diagnosed with delirium are agitated, they should be monitored to prevent trauma (true)
Table 3 Distribution of the nurses’ mean knowledge scores according to influential factors (n = 97) Mean knowledge score n
X ± SD
Department of employment Intensive care 52 43⋅82 ± 9⋅85 Ward 45 38⋅13 ± 14⋅52 Duty Chief nurse 8 48⋅50 ± 4⋅78 Clinical nurse 43 37⋅46 ± 14⋅51 Intensive care nurse 46 43⋅39 ± 10⋅28 Condition of having received education on delirium Yes 21 46⋅95 ± 7⋅13 No 76 39⋅59 ± 13⋅21 Source of education In-service 10 50⋅00 ± 6⋅91 Undergraduate study 11 44⋅18 ± 6⋅41 No education 76 39⋅59 ± 13⋅21
t = 2⋅285 p = 0⋅025 Kruskal-Wallis = 7⋅076 p = 0⋅029
F = 5⋅995 p = 0⋅016 Kruskal-Wallis = 7⋅479 p = 0⋅024
(2014) to determine the knowledge level of 53 medical intensive care nurses regarding the signs and symptoms, risk factors and outcomes of delirium, it was found that they scored right in 27 of 40 questions (Christensen, 2014). In the study conducted by Hamdan-Mansour et al. (2010) to determine the knowledge level of 232 critical care nurses regarding delirium, it was found that nurses had a ‘moderate’ to ‘low’ level of knowledge (Hamdan-Mansour et al., 2010). In the study conducted by Agar et al., on the decision making strategies of nurses regarding delirium, it was stated that nurses had limited knowledge of delirium (Agar et al. 2011). In the study conducted 6
n
%
58 79 43 19 35 33 54 70 53 72 70
59⋅8 81⋅4 44⋅3 19⋅6 36⋅1 34⋅0 55⋅7 72⋅2 54⋅6 74⋅2 72⋅2
73 75 74
75⋅3 77⋅3 76⋅3
by Topuz and Dogan with ICU nurses, it was determined that the majority of the nurses lacked sufficient knowledge about delirium and that those who stated that they were informed about the subject were not able to identify delirium (Topuz and Dogan, 2012). Although the finding that nurses had a low level of knowledge regarding delirium is consistent with the literature, it brings along certain drawbacks. Cardiac surgery is a department where the incidence of delirium is high and patients have multiple risk factors (Burns et al., 2009; Koster et al., 2011; Lin et al., 2012; Taipale et al., 2012). The fact that nurses have a low level of knowledge regarding delirium may cause late recognition of delirium which may lead to lack of treatment resulting in medical complications, extension of hospital stay or even mortality because early detection and treatment is crucial for delirium (Inouye et al., 2001; Koster et al., 2009a, 2009b; Hamdan-Mansour et al., 2010; Agar et al., 2011; Koster et al., 2011; Taipale et al., 2012). Furthermore, in the literature, it is also stated that nurses have frequent/continuous contact with patients, which makes it easier for them to observe the fluctuations in the level of consciousness and cognitive functioning during the day and make an early diagnosis (Inouye et al., 2001; Agar et al., 2011). The fact that nurses lack sufficient knowledge about delirium may lead to a deficiency in fulfilling their roles and have a negative impact on the quality of the care given. The fact that nurses have a low level of knowledge regarding delirium may lead to a misdiagnosis in patients. Previous studies have demonstrated that the diagnosis of delirium is generally overlooked by nurses and that it is misdiagnosed as depression or © 2015 British Association of Critical Care Nurses
Cardiovascular surgery nurses’ knowledge of delirium
dementia, or considered normal behaviour in elderly patients (Koster et al., 2009a, 2009b; Gottesman et al., 2010; Norkiene et al., 2013). However, nurses are expected to be informed about the definition, risk factors, symptoms and treatment of delirium and make interventions to prevent the condition (Mc Donnell and Timmins, 2012). Another consequence of nurses’ low level of knowledge regarding delirium is related to their workload. Delirium may cause an increase in nurses’ workload as well as the stress level of patients and families. It is stated that the diagnosis, treatment and nursing care of patients with delirium is a stressful process which requires skill. Patients in delirium may refuse the treatment and try to pull out the endotracheal tubes, chest tubes, intravenous cannula and urinary and intra-arterial catheters (Agar et al., 2011; Christensen, 2014). Both patient and staff safety is at risk in cases of delirium (Agar et al., 2011). Because of all these reasons, nurses need to develop a high level of knowledge. Studies show that nurses who have previously received training in delirium are able to manage patients more skillfully and experience little difficulty in giving care (Akechi et al., 2010; Hamdan-Mansour et al., 2010; Mc Donnell and Timmins, 2012). Delirium is a highly distressing experience for the families of patients, as well. Families of patients with delirium express that they could not recognize the patients
and that they have not previously demonstrated such behaviour which leads to a concern regarding their future well-being (Hare et al., 2008; Agar et al., 2011; Mc Donnell and Timmins, 2012; Elfeky and Ali, 2013). Nurses also need to manage the distress of the families and provide them with necessary explanations (Koster et al., 2009a, 2009b; Fan et al., 2012). Thus, they should have a higher level of knowledge regarding delirium and possess competent nursing skills. One of the interesting findings of this study was that the mean knowledge score of ICU nurses was higher than that of ward nurses. We thought that this difference might result from higher delirium incidence in ICUs than wards, and nurses might have encountered more patients with delirium.
CONCLUSIONS It was found that the cardiovascular surgery nurses included within the scope of the sample had a moderate level of knowledge regarding delirium. Because the burden of caring for a patient with delirium is quite high, the first step towards reducing this burden is prevention, early detection and treatment of delirium (Mc Donnell and Timmins, 2012). Therefore, institutional training should be provided to increase awareness of the nurses working in cardiac surgery where patients have a high risk of developing delirium.
WHAT IS KNOWN ABOUT THIS TOPIC • • •
The incidence of delirium is high in cardiovascular surgery patients, and it causes morbidity and mortality as well as an increase in the duration of hospital stay and costs. Nurses have a crucial role in the diagnosis of delirium. Intensive care nurses should screen the patients for delirium.
WHAT THIS PAPER ADDS • • •
It was found that cardiovascular surgery nurses had a low level of knowledge regarding delirium. Nurses who had received education on delirium had a better understanding about it. It is suggested that institutions should organize training programs on delirium.
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after cardiac surgery. The Annals of Thoracic Surgery; 87: 1469–1474. Koster S, Hensens AG, Schuurmans MJ, Van Der Palen J. (2011). Risk factors of delirium after cardiac surgery: a systematic review. European Journal of Cardiovascular Nursing; 10: 197–204. Lin Y, Chen J, Wang Z. (2012). Meta-analysis of factors which influence delirium following cardiac surgery. Journal of Cardiac Surgery; 27: 481–492. Mc Donnell S, Timmins F. (2012). A quantitative exploration of the subjective burden experienced by nurses when caring for patients with delirium. Journal of Clinical Nursing; 21: 2488–2498. National Institute for Health and Clinical Excellence. (2010). Delirium: Diagnosis, Prevention and Management. Manchester: NICE. www.nice.org.uk/guidance/cg103 (accessed 01/11/2014). Norkiene I, Ringaitiene D, Kuzminskaite V, Šipylaite J. (2013). Incidence and risk factors of early delirium after cardiac surgery. BioMed Research International; 2013: 323491. DOI: 10.1155/2013/323491. Rudolph JL, Jones RN, Levkoff SE, Rockett C, Inouye SK, Sellke FW, Khuri SF, Lipsitz LA, Ramlawi B, Levitsky S, Marcantonio ER. (2009). Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation; 119: 229–236. Steis MR, Fick DM. (2008). Are nurses recognizing delirium? A systematic review. Journal of Gerontological Nursing; 34: 40–48. Taipale PG, Ratner PA, Galdas PM, Jillings C, Manning D, Fernandes C, Gallahe J. (2012). The association between nurse-administered midazolam following cardiac surgery and incident delirium: an observational study. International Journal of Nursing Studies; 49: 1064–1073. Topuz S, Dogan N. (2012). Bir universite hastanesinin yogun bakim unitelerinde calisan hemsirelerin deliryum konusuna iliskin bilgi duzeyleri (The Level of Knowledge of Nurses Working at the intensive care units of a university hospital about the subject of delirium). Kirikkale Universitesi Tip Fakultesi Dergisi; 14: 21–26.
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Cardiovascular surgery nurses’ level of knowledge regarding delirium Fatma Demir Korkmaz, Fadime Gok and Ayla Yavuz Karamanoglu ABSTRACT Background: Studies have shown that nurses have a crucial role in the recognition of delirium; however, they have insufficient knowledge regarding the issue. Objective: The aim of the study is to determine the knowledge level of cardiovascular surgery nurses regarding delirium. Methods: A survey design was used. The population of the study consisted of 124 nurses employed at the cardiovascular surgery wards and intensive care units of universities as well as state and private hospitals located in two different cities in Turkey between May and June 2014. The sample consisted of 97 nurses employed at the aforementioned institutions and time. Data were collected using the questionnaire form depicting the demographic characteristics of the nurses and the knowledge form including the level of nurses’ knowledge regarding delirium. For the evaluation of data, number, percentage, Kruskal-Wallis, Mann-Whitney U- and independent-samples t-test were used. Results: Nurses were between 18 and 47 years of age with a mean 29⋅8 (SD = 6⋅80, the youngest = 18 and the oldest = 47) years. They spent a minimum of 1, a maximum of 25 and a median value of 3 (interquartile range, IQR: 5) years working in cardiovascular surgery. As for the scores received from the knowledge form regarding delirium, the lowest was zero, the highest was 60, and the average score was 41⋅18 ± 12⋅50 (a moderate level of knowledge). It was found that the nurses working in intensive care units, those who were chief nurses and those who received in-service training scored higher than the others. Conclusions: Cardiovascular surgery nurses had a moderate level of knowledge regarding delirium. This may result in the neglect of delirium or a misdiagnosis. Relevance to clinical practice: It is recommended that training is provided that includes recognition, assessment and application of appropriate interventions to minimise the incidence of delirium. Key words: Cardiovascular nursing • Critical care nursing • Delirium • Knowledge level • Nurses’ knowledge level
INTRODUCTION Delirium is a temporary, organic, mental syndrome that is characterised by a sudden and fluctuating course of, generally, cognitive dysfunction, change in consciousness, lack of attention, increased or decreased psychomotor activity and an irregularity of the sleep-wake cycle (Lin et al., 2012; Belanger and Ducharme, 2011; Mc Donnell and Timmins, 2012). According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), delirium is defined as ‘a disturbance of consciousness with reduced ability to focus, sustain or shift attention; a change in cognition; or the development of a perceptual disturbance that occurs over a short Authors: F Demir Korkmaz, RN, PhD, Associate Professor, Faculty of Nursing, Ege University, Izmir, Turkey; F Gok, RN, Research Assistant, Health School, Pamukkale University, Denizli, Turkey; A Yavuz Karamanoglu, RN, Research Assistant, Health School, Pamukkale University, Denizli, Turkey Address for correspondence: F Demir Korkmaz, Associate Professor, Faculty of Nursing, Ege University, Ege Universitesi Hemsirelik Fakultesi Bornova, 35100 Izmir, Turkey E-mail: [email protected]
© 2015 British Association of Critical Care Nurses
period of time and tends to fluctuate over the course of the day’ (American Psychiatric Association, 1994; Koster et al., 2009a, 2009b). The DSM-5 (the newer version of the DSM-IV) lists four criteria for the diagnosis of delirium (Norkiene et al., 2013; Butler et al., 2013; American Psychiatric Association, 2014). These are: (a) Disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and orientation to the environment. (b) The disturbance develops over a short period of time (usually hours to a few days) and represents an acute change from baseline that is not solely attributable to another neurocognitive disorder and tends to fluctuate in severity during the course of a day. (c) A change in an additional cognitive domain, such as memory deficit, disorientation or language disturbance or perceptual disturbance, that is not better accounted for by any other pre-existing, established or evolving neurocognitive disorder. 1
Cardiovascular surgery nurses’ knowledge of delirium
(d) The disturbances in criteria (a) and (c) must not be occurring in the context of a severely reduced level of arousal such as coma. In addition to the short-term effects of delirium such as mortality, morbidity and extension of stay in hospital, long-term effects are also observed, namely permanent cognitive deficit, loss of independence, functional problems, increase in costs and higher mortality for 2 years after episode (Rudolph et al., 2009; Burns et al., 2009; Gottesman et al., 2010; Norkiene et al., 2013). As a complication of cardiac surgery, delirium has been reported for many years. The incidence of postoperative delirium after cardiac surgery is 13⋅5–67%, although it varies according to the method of diagnosis and to a lack of diagnosis at times (Koster et al., 2011; Koster et al., 2009a, 2009b; Gottesman et al., 2010; Norkiene et al., 2013). Despite the advances in cardiac surgical techniques and anaesthesia practice, delirium remains a frequent but under-recognized complication after cardiac surgery (Rudolph et al., 2009; Gottesman et al., 2010; Lin et al., 2012). Cardiac surgery patients are prone to many risk factors for delirium, related to the surgical method or patient profile. Previous studies have shown that there are 33 risk factors (17 predisposing and 16 precipitating) for cardiac surgery patients. Among the preoperative risks are older age, depression, stroke, cognitive impairment, atrial fibrillation, the severity of the current disease, heavy drinking and smoking, diabetes, chronic renal failure, existence of uremia, long and deep anaesthesia during operation, postoperative mechanical ventilation, drugs used, pain, hypoxemia, hypotension, hypoalbuminemia, acidosis and alkalosis, and fluid and electrolyte imbalance (Burns et al., 2009; Koster et al., 2011; Taipale et al., 2012; Lin et al., 2012). Studies have shown that nurses play a key role in the recognition of delirium; however, the symptoms of delirium are usually unrecognized by nurses (Inouye et al., 2001). Because nurses often/constantly spend time together with patients, they have the opportunity to observe, recognize the fluctuations in consciousness and cognitive functions and make an early diagnosis (Inouye et al., 2001; Agar et al., 2011). In contrast, studies have demonstrated that nurses lacked sufficient knowledge regarding delirium, were uncomfortable while giving care to patients with delirium and that they did not integrate the diagnosis and treatment of delirium with their care (Mc Donnell and Timmins, 2012; Hamdan-Mansour et al., 2010; Agar et al., 2011). During our observations in wards, we noticed that no screenings for delirium were made in intensive care units (ICUs). However, the guidelines published 2
by the American College of Critical Care Medicine (2013) recommended routine monitoring of delirium in adult ICU patients and stated that the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist were the most valid and reliable delirium monitoring tools in adult ICU patients (Barr et al., 2013). This study aimed at investigating cardiovascular surgery nurses’ level of knowledge regarding delirium.
STUDY OBJECTIVE This is a descriptive cross sectional survey which aimed to determine the knowledge level of nurses employed in cardiovascular surgery wards and ICUs regarding delirium.
METHOD The population of the study was made up of 124 nurses employed at the cardiovascular surgery wards and ICUs of four institutions, namely, two universities, one hospital under the Ministry of Health and two private hospitals in two separate provinces in Turkey between May 2014 and June 2014. A total of 99 nurses who were employed at the aforementioned institutions and willing to participate in the research filled in the questionnaire. However, because two nurses only provided descriptive data but had not answered the questions on knowledge, the sample consisted of 97 nurses. Data were collected by using the data form prepared by the researchers in accordance with the literature. This form includes 15 questions to determine descriptive information on the nurses and 69 questions that assess the nurses’ level of knowledge regarding delirium.
Validity of the form In order to test the validity of the questionnaire form prepared by the researchers, a total of 15 people were employed including 2 cardiovascular surgery intensive care nurses, 3 cardiovascular surgery ward nurses, 3 psychiatry ward nurses, 2 psychiatry specialists, 2 cardiovascular surgery specialists, an academic nurse who formerly worked as cardiovascular surgery nurse and 2 academic nurses who formerly worked as psychiatric nurses. The knowledge questions prepared by the researchers initially comprised of 73 statements. The specialists were asked to review the competency of the questions and to state whether they would leave out or add any questions. In accordance with the views of the specialists, 14 of the questions were omitted, and 10 new questions were added. Revisions were made in © 2015 British Association of Critical Care Nurses
Cardiovascular surgery nurses’ knowledge of delirium
17 questions, and a total of 69 questions were finally approved. The questionnaire form was pre-tested on 10 nurses employed in either cardiovascular surgery ward or ICU in one of the hospitals included in the sample. During the pre-implementation, interviews were conducted to test the clarity, comprehensibility and functionality of the questions. In accordance with the feedback received, the questionnaire was revised and finalized by the researchers. The Cronbach’s alpha coefficient for internal reliability was found to be 0⋅925. Of the questions, 9 were related to the definition of delirium, 8 to the causes of delirium, 13 to the risk groups, 21 to the symptoms of delirium and 18 to nursing management in case of a delirium. The knowledge questions were constructed in the form of plain information, and the nurses were asked to evaluate the given statements as true, false or do not know. Later on, the mean knowledge score was calculated by scoring the answers given by the nurses; each correct answer received one (1) point while each wrong and ‘don’t know’ answer received zero (0). Of these statements, 19 were prepared inversely so when the nurses stated ‘false’ it actually referred to the correct answer. Taking this fact into consideration while calculating the knowledge scores, ‘false’ replies to these 19 questions were given one (1) point and ‘true’/‘don’t know’ replies were given zero (0). The lowest score nurses could receive from this questionnaire is zero while the highest is 69. Taking the mean value of the correct answers as the cut-off value, the range of 23 points and below was considered to be a low level while 24–47 points was considered to be a moderate level, and 48 points and above was considered to be a high level of knowledge.
Data analysis Statistical Package for the Social Sciences (version 17.0 SPSS 17.0) software was used for statistical analysis. Data were presented as number, percentage and mean ± standard deviation. For the evaluation of the data, standard deviation and independent sample tests were used. Student’s t-test, Kruskal-Wallis, Mann-Whitney U-tests were used to compare data. A p < 0⋅05 was considered statistically significant.
Ethical considerations For the implementation of the research, written consents were received from the Ethical Committee of Scientific Research of the Faculty of Nursing, Ege University and the hospitals where the research was conducted. All nurses working in the ward and ICU were invited to participate in the study. An information sheet, which included the aim and stated © 2015 British Association of Critical Care Nurses
that they had a right to withdraw from the study at any time and for any reason was attached to the questionnaire. Data regarding names and identity of nurses were not necessary in this study and were not asked. Data collected from all the nurses have been kept in strictest confidence. The questionnaire was distributed to all nurses at their work places via the researchers.
RESULTS Of the nurses included within the scope of the study, the average age was 29⋅8 (SD = 6 80, the youngest = 18, the oldest = 47). The maximum year of experience in cardiovascular surgery was found to be 25, the minimum to be 1 and the median value was 3 (IQR: 5) years. As for the weekly hours of work, the minimum value was found to be 40, the maximum to be 60 and the average to be 44⋅18 ± 5⋅34 h. It was determined that intensive care nurses offered care to a minimum of 2, a maximum of 7 and an average of 3⋅61 ± 0⋅97 patients in a shift while ward nurses provided care for a minimum of 2, a maximum of 19 and an average of 9⋅51 ± 4⋅47 patients (Table 1). Table 2 presents the distribution of the nurses’ answers to the questions regarding delirium. Accordingly, 86⋅6% of the nurses were aware that delirium was a temporary organic mental syndrome, 91⋅8% knew that neurological diseases might cause delirium, 77⋅3% were aware of the fact that cognitive disorders (dysfunctioning in consciousness, memory, orientation and perception) of any reason might increase the risk of delirium, 86⋅6% knew that daily fluctuations in consciousness are observed in cases of delirium, again 86⋅6% were aware that patients in delirium temporarily lost their sense of shame, apprehension and inhibition and 84⋅5% were informed about the fact that the major aim for treating patients with the risk of developing delirium was to avoid any tremens. It was determined that the scores obtained by the nurses from the knowledge form regarding delirium varied from zero (0) the lowest to 60 the highest, 41⋅18 ± 12⋅50 being the average score. When the relation between the nurses’ level of knowledge regarding delirium and their department of employment, duty, number of patients they offer care, condition of having received education and sources of education was analysed (Table 3), it was found that there was a statistically significant difference (p < 0⋅05). It was found that among the nurses working in ICUs, those who were chief nurses and those who received education on delirium had a higher level of knowledge. 3
Cardiovascular surgery nurses’ knowledge of delirium
Table 1 Descriptive characteristics of nurses (n = 97) Variables
Number
Age group (years) 18–28 47 29–47 50 Sex Female 88 Male 9 Marital status Married 54 Single 43 Level of education Vocational school of health services 17 Associate’s degree 13 Bachelor’s degree 59 Master’s degree 8 Department of employment Cardiovascular surgery, intensive care unit 52 Cardiovascular surgery, ward 45 Duty Chief nurse 8 Clinical nurse 43 Intensive care unit nurse 46 Type of work Shift 2 Night shift 21 Day shift 19 Years of professional experience 42 1–5 29 6–10 26 Years of experience in cardiovascular surgery 1–5 71 6–21 26 Weekly hours of work 40–44 57 45–60 40 Number of patient per nurse 2–4 49 5 and above 48 Condition of having received education on delirium Yes 21 No 76 Sources of education on delirium (n = 21) (more than one reply) In-service training 10 During undergraduate study 21 No education 76 Willingness to receive education on delirium Yes 77 No 20 Total 97
%
48⋅5 51⋅5 90⋅7 9⋅3 55⋅7 44⋅3 17⋅5 13⋅4 60⋅8 8⋅2 53⋅6 46⋅4 8⋅2 44⋅3 47⋅5 2⋅1 21⋅6 19⋅6 43⋅3 29⋅9 73⋅2 26⋅8 58⋅8 41⋅2 50⋅5 49⋅5 21⋅6 78⋅4 10⋅3 11⋅3 78⋅4 79⋅4 20⋅6 100
A statistically significant difference was not found (p > 0⋅05) between the nurses’ knowledge score and their age, sex, marital status, educational status, type of work, duration of professional experience, duration of experience in cardiovascular surgery and weekly hours of work. 4
DISCUSSION Factors related to knowledge level of nurses regarding delirium In this study, 78⋅4% of the nurses stated that they had not received education regarding delirium. In the study conducted by Elfeky and Ali, 2013 with 120 intensive care nurses, 100% of the nurses stated that they had not received any training on delirium. This percentage was found to be 69⋅3% in the study conducted by Christensen (2014) and 66⋅3% in the study conducted by McDonnell et al. (2012) (Mc Donnell and Timmins, 2012; Elfeky and Ali, 2013; Christensen, 2014). This finding demonstrates a similarity to those of the previous studies in the literature; nevertheless, nurses would be expected to have received training because the incidence of delirium in ICUs was high. In the literature, it is stated that delirium should also be taken into consideration during routine patient care and that such education should ideally start in nursing schools and it should be sustained as a part of continuing education programs (Inouye et al., 2001; Hsu et al., 2005; Hare et al., 2008). However, in this study, very few of the nurses stated that they received education regarding delirium during in-service training (10⋅3%) and during undergraduate education (11⋅3%). International organisations recommend the use of scales for the detection of delirium in adults receiving treatment in ICUs (NICE, 2010; Barr et al., 2013). In contrast, it was found that none of the hospitals where the research was conducted utilized scales for the detection of delirium. We are of the opinion that the implementation of education programs regarding delirium and the use of such scales in ICUs and wards would promote awareness, thus increasing nurses’ level of knowledge. In our country, with the Ministry of Health Certified Training Regulations which came into effect after being published in the Official Gazette dated 4 February 2014, Intensive Care Nursing was also included within the scope of the Certified Training Programs. The fact that this program also includes a course designed to evaluate and prevent the risk of delirium is a pleasing development.
Knowledge levels of cardiovascular surgery nurses In this study, it was determined that the lowest score obtained by the nurses from the knowledge form regarding delirium was zero while the highest was 60 and the average score was 41⋅18 ± 12⋅50 which indicated that they had a ‘moderate’ level of knowledge. Previous studies conducted in the same field also demonstrated that nurses had a low level of knowledge regarding delirium (Steis and Fick, 2008; Agar et al., 2011). In the study conducted by Christensen © 2015 British Association of Critical Care Nurses
Cardiovascular surgery nurses’ knowledge of delirium
Table 2 Distribution of nurses according to their level of knowledge (n = 97) Correct answers Questions Delirium is a temporary organic mental syndrome (true) Memory can be checked in cases of delirium (false) Psychomotor activity is constantly high in delirium (false) The sleep-wake cycle of the patient is normal in case of delirium (false) The pathophysiology of delirium is not clearly understood yet (true) The symptoms of delirium may sometimes demonstrate similarities to the symptoms of depression (true) The Mini-Mental State Examination is one of the best methods of diagnosing delirium (true) The rate of mortality in patients with delirium is high (true) Delirium does not last for more than a few hours (false) Physical illness does not cause delirium (false) Neurological diseases may cause delirium (true) Acute stress may cause delirium (true) Sudden stop of alcohol consumption in addicts may cause delirium (true) Trauma to the head may cause delirium (true) Hypoxia may cause delirium (true) Being under anaesthesia for long periods may cause delirium (true) Increase in the level of nitric oxide may cause delirium (true) Older age increases the risk of delirium (true) Visual impairments increase the risk of developing delirium (true) As the quantity of medication used by the patient increases, the risk of developing delirium also increases (true) Invasive procedures (urinary catheter etc.) may decrease the risk of delirium (false) Vitamin B12 deficiency increases the risk of delirium (true) The risk of delirium is higher in men compared with women (true) Diabetes is a high risk factor for delirium (true) Dehydration may be a risk factor for delirium (true) Hearing loss increases the risk of delirium (true) Obesity is a risk factor in delirium (false) A family history of dementia predisposes a patient to delirium (false) Physical diagnosis may increase the risk of delirium in patients (true) Cognitive disorders (deficit in consciousness, memory, orientation and perception) of any reason may increase the risk of delirium (true) In cases of delirium, daily fluctuations in consciousness are observed (true) Abstract thoughts are observed in delirium (true) The symptoms of delirium, dementia and depression do not generally differ (false) Symptoms of delirium develop suddenly (true) Patients in delirium are energetic (false) Patients in delirium temporarily lose their sense of shame, apprehension and inhibition (true) Patients in delirium constantly experience disorientation in time, place and the identity of others (true) It becomes difficult to communicate with patients diagnosed with delirium (true) Patients in delirium always experience visual and auditory hallucinations (false) Delirium can generally be cured (true) Patients in delirium experience impairments in reality testing (true) There is hardly any loss of concentration in delirium (false) Delirium causes sleep disorders (true) Delirium does not change the personality traits of individuals (false) Anti-cholinergic activity reduces the delirious state (false) Noradrenaline activity increases the delirious state (true) Anxiety and fear are experienced during the delirious state (true) Patients with delirium are always aggressive (false) Behavioural changes in the course of the day are typical of delirium (true) A patient with delirium is easily distracted and has difficulty in following a conversation (true) Patients with delirium often experience perceptual disturbances (true) The major aim for treating patients with the risk of developing delirium is to avoid any tremens (true) Keeping patients diagnosed with delirium in a quiet environment helps manage the symptoms (true) Medication is generally recommended in the treatment of delirium (true) Sedatives and tranquilizers are beneficial for delirium (False)
© 2015 British Association of Critical Care Nurses
n
%
84 19 15 76 46 71 51 22 58 64 89 86 88 73 82 87 56 66 30 56 47 57 32 32 50 34 16 10 66 75 84 74 31 69 10 84 64 84 19 74 80 62 83 45 14 40 73 34 66 76 82 82 73 48 32
86⋅6 19⋅6 15⋅5 78⋅4 47⋅4 73⋅2 52⋅6 22⋅7 59⋅8 66⋅0 91⋅8 88⋅7 90⋅7 75⋅3 84⋅5 89⋅7 57⋅7 68⋅0 30⋅9 57⋅7 48⋅5 58⋅8 33⋅0 33⋅0 51⋅5 35⋅1 16⋅5 10⋅3 68⋅0 77⋅3 86⋅6 76⋅3 32⋅0 71⋅1 10⋅3 86⋅6 66⋅0 86⋅6 19⋅6 76⋅3 82⋅5 63⋅9 85⋅6 46⋅4 14⋅4 41⋅2 75⋅3 35⋅1 68⋅0 78⋅4 84⋅5 84⋅5 75⋅3 49⋅5 33⋅0
5
Cardiovascular surgery nurses’ knowledge of delirium
Table 2 Continued Correct answers Questions The most important thing in the treatment is to provide sedation and sleep (true) The priority in treating delirium is to ensure safety of the patients and provide support (true) Adequate intake of liquids may prevent delirium (true) Using hearing-aids increases the delirious state (false) Using glasses for the visually impaired elderly may reduce the delirious state (true) Reminding the patients of their name, place, time and age causes the symptoms to increase (false) Too much interaction with other people might lead to worsening of delirium (true) Inadequate control of pain might lead to worsening of delirium (true) If the patients in delirium misunderstand a certain thing, it has to be corrected until they get it correctly (true) To keep delirium symptoms under control, bed rest might be recommended when necessary (true) Informing patients of the season, date, day and time and especially the presence of a clock might prevent patients from a delirium tremens (true) In the postoperative period, patients should be stood up and encouraged to walk as soon as possible (true) Patients should not be left without a stimulus (information on place, time, process) for long periods (true) If patients diagnosed with delirium are agitated, they should be monitored to prevent trauma (true)
Table 3 Distribution of the nurses’ mean knowledge scores according to influential factors (n = 97) Mean knowledge score n
X ± SD
Department of employment Intensive care 52 43⋅82 ± 9⋅85 Ward 45 38⋅13 ± 14⋅52 Duty Chief nurse 8 48⋅50 ± 4⋅78 Clinical nurse 43 37⋅46 ± 14⋅51 Intensive care nurse 46 43⋅39 ± 10⋅28 Condition of having received education on delirium Yes 21 46⋅95 ± 7⋅13 No 76 39⋅59 ± 13⋅21 Source of education In-service 10 50⋅00 ± 6⋅91 Undergraduate study 11 44⋅18 ± 6⋅41 No education 76 39⋅59 ± 13⋅21
t = 2⋅285 p = 0⋅025 Kruskal-Wallis = 7⋅076 p = 0⋅029
F = 5⋅995 p = 0⋅016 Kruskal-Wallis = 7⋅479 p = 0⋅024
(2014) to determine the knowledge level of 53 medical intensive care nurses regarding the signs and symptoms, risk factors and outcomes of delirium, it was found that they scored right in 27 of 40 questions (Christensen, 2014). In the study conducted by Hamdan-Mansour et al. (2010) to determine the knowledge level of 232 critical care nurses regarding delirium, it was found that nurses had a ‘moderate’ to ‘low’ level of knowledge (Hamdan-Mansour et al., 2010). In the study conducted by Agar et al., on the decision making strategies of nurses regarding delirium, it was stated that nurses had limited knowledge of delirium (Agar et al. 2011). In the study conducted 6
n
%
58 79 43 19 35 33 54 70 53 72 70
59⋅8 81⋅4 44⋅3 19⋅6 36⋅1 34⋅0 55⋅7 72⋅2 54⋅6 74⋅2 72⋅2
73 75 74
75⋅3 77⋅3 76⋅3
by Topuz and Dogan with ICU nurses, it was determined that the majority of the nurses lacked sufficient knowledge about delirium and that those who stated that they were informed about the subject were not able to identify delirium (Topuz and Dogan, 2012). Although the finding that nurses had a low level of knowledge regarding delirium is consistent with the literature, it brings along certain drawbacks. Cardiac surgery is a department where the incidence of delirium is high and patients have multiple risk factors (Burns et al., 2009; Koster et al., 2011; Lin et al., 2012; Taipale et al., 2012). The fact that nurses have a low level of knowledge regarding delirium may cause late recognition of delirium which may lead to lack of treatment resulting in medical complications, extension of hospital stay or even mortality because early detection and treatment is crucial for delirium (Inouye et al., 2001; Koster et al., 2009a, 2009b; Hamdan-Mansour et al., 2010; Agar et al., 2011; Koster et al., 2011; Taipale et al., 2012). Furthermore, in the literature, it is also stated that nurses have frequent/continuous contact with patients, which makes it easier for them to observe the fluctuations in the level of consciousness and cognitive functioning during the day and make an early diagnosis (Inouye et al., 2001; Agar et al., 2011). The fact that nurses lack sufficient knowledge about delirium may lead to a deficiency in fulfilling their roles and have a negative impact on the quality of the care given. The fact that nurses have a low level of knowledge regarding delirium may lead to a misdiagnosis in patients. Previous studies have demonstrated that the diagnosis of delirium is generally overlooked by nurses and that it is misdiagnosed as depression or © 2015 British Association of Critical Care Nurses
Cardiovascular surgery nurses’ knowledge of delirium
dementia, or considered normal behaviour in elderly patients (Koster et al., 2009a, 2009b; Gottesman et al., 2010; Norkiene et al., 2013). However, nurses are expected to be informed about the definition, risk factors, symptoms and treatment of delirium and make interventions to prevent the condition (Mc Donnell and Timmins, 2012). Another consequence of nurses’ low level of knowledge regarding delirium is related to their workload. Delirium may cause an increase in nurses’ workload as well as the stress level of patients and families. It is stated that the diagnosis, treatment and nursing care of patients with delirium is a stressful process which requires skill. Patients in delirium may refuse the treatment and try to pull out the endotracheal tubes, chest tubes, intravenous cannula and urinary and intra-arterial catheters (Agar et al., 2011; Christensen, 2014). Both patient and staff safety is at risk in cases of delirium (Agar et al., 2011). Because of all these reasons, nurses need to develop a high level of knowledge. Studies show that nurses who have previously received training in delirium are able to manage patients more skillfully and experience little difficulty in giving care (Akechi et al., 2010; Hamdan-Mansour et al., 2010; Mc Donnell and Timmins, 2012). Delirium is a highly distressing experience for the families of patients, as well. Families of patients with delirium express that they could not recognize the patients
and that they have not previously demonstrated such behaviour which leads to a concern regarding their future well-being (Hare et al., 2008; Agar et al., 2011; Mc Donnell and Timmins, 2012; Elfeky and Ali, 2013). Nurses also need to manage the distress of the families and provide them with necessary explanations (Koster et al., 2009a, 2009b; Fan et al., 2012). Thus, they should have a higher level of knowledge regarding delirium and possess competent nursing skills. One of the interesting findings of this study was that the mean knowledge score of ICU nurses was higher than that of ward nurses. We thought that this difference might result from higher delirium incidence in ICUs than wards, and nurses might have encountered more patients with delirium.
CONCLUSIONS It was found that the cardiovascular surgery nurses included within the scope of the sample had a moderate level of knowledge regarding delirium. Because the burden of caring for a patient with delirium is quite high, the first step towards reducing this burden is prevention, early detection and treatment of delirium (Mc Donnell and Timmins, 2012). Therefore, institutional training should be provided to increase awareness of the nurses working in cardiac surgery where patients have a high risk of developing delirium.
WHAT IS KNOWN ABOUT THIS TOPIC • • •
The incidence of delirium is high in cardiovascular surgery patients, and it causes morbidity and mortality as well as an increase in the duration of hospital stay and costs. Nurses have a crucial role in the diagnosis of delirium. Intensive care nurses should screen the patients for delirium.
WHAT THIS PAPER ADDS • • •
It was found that cardiovascular surgery nurses had a low level of knowledge regarding delirium. Nurses who had received education on delirium had a better understanding about it. It is suggested that institutions should organize training programs on delirium.
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