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Feature Article Strategies to Improve Nurse Knowledge of Delirium A Call to the Adult-Gerontology Clinical Nurse Specialist Beverly Middle, DNP, MSN, RN, AGCNS-BC n Margaret Miklancie, PhD, RN, CNE

Purpose/Objectives: The purpose of this article is to discuss the role of the adult-gerontology clinical nurse specialist in addressing the problem of delirium in hospitalized older adults through strategies to improve nurse knowledge. Background: Delirium is a significant issue in hospitalized older adults. This acute confusional state can adversely impact older adults in various ways. Delirium has been implicated in (1) poor physical, cognitive, and psychological outcomes, (2) prolonged hospitalizations, (3) increased costs of care, (4) need for continued postacute care, and (5) patient and provider stress. To prevent delirium, nurses must possess the knowledge to identify risk factors and institute preventive strategies. Once a change in mental status occurs, it is critical that nurses recognize delirium and the steps necessary to provide safe, effective care. Nurses are the major providers of bedside care; however, multiple studies have identified a lack of nurse knowledge regarding delirium. The adult-gerontology clinical nurse specialist can be instrumental in fostering knowledge on this important issue. Description: Multiple interventions can be conducted by the adult-gerontology clinical nurse specialist with acute care nurses to increase delirium knowledge. A review of the literature revealed strategies that might be used in the hospital setting. Before educational endeavors, it is crucial to assess baseline nurse knowledge of delirium. Educational strategies can then include use of standardized delirium assessment tools, implementation of the Geriatric Resource Nurse model, fostering geriatric case studies and simulations, conducting geriatric

Author Affiliations: Faculty (Dr Middle) and Assistant Professor (Dr Miklancie), School of Nursing, George Mason University, Fairfax, Virginia. The authors report no conflicts of interest. Correspondence: Beverly Middle, DNP, MSN, RN, AGCNS-BC, 28 Park Road, Stafford, VA 22556 ([email protected]). DOI: 10.1097/NUR.0000000000000138

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grand rounds, and development of structured delirium educational programs. Exploring the patient experience, post delirium, can provide an invaluable, first-hand account of the acute confusional state. This information can impact nurse knowledge as well as patient safety and well-being. Geriatric certification and professional organizational involvement can be encouraged. Numerous online geriatric resources can be shared with nurses to enhance knowledge of delirium. Outcome: Improved nurse knowledge will assist in preventing/decreasing incidents of delirium and thwart the negative outcomes associated with delirium occurrence in hospitalized older adults. Implications: Nurse knowledge can be measured and patient care assessed to determine the effectiveness of the proposed educational strategies. Conclusion: The goal of the identified adult-gerontology clinical nurse specialistYled educational initiatives is to improve knowledge of delirium, which will assist nurses in providing evidence-based, safe, appropriate care to all hospitalized older adults. KEY WORDS: adult-gerontology clinical nurse specialist, delirium, education, nurse

THE PROBLEM: DELIRIUM AND NURSE KNOWLEDGE The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, defines delirium as an acute change in attention, awareness, and cognition from the person’s baseline that tends to fluctuate during the course of the day.1 Delirium is a significant issue in hospitalized older adults. Delirium has been reported in 14% to 24% of older adults on admission to the hospital, and up to 56% may be diagnosed with this acute disorder during their hospital stay.2 Delirium may be difficult to identify based on its transient nature and diverse presentation. There are 3 subtypes of delirium reported in the literature: hyperactive, hypoactive, and a fluctuating

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mixture of the two.2,3 In a 2011 study, nurses failed to recognize delirium in 75% of cases, with hypoactive delirium being one predictor identified in underrecognition.4 Delirium superimposed on dementia also presents a challenge to recognition, often clouding the presentation and making diagnosis difficult. The negative outcomes associated with delirium superimposed on dementia are significant, including death, institutionalization, and cognitive decline.5 Risk factors have been identified that lead to delirium development. Delirium has been proposed as a multifactorial syndrome that is dependent on the relationship of predisposing risk factors, which are present on admission to the hospital, and precipitating factors or insults occurring during hospitalization.6 Predisposing risk factors include age 65 years and older, cognitive impairment and/or dementia, current hip fracture, and severe illness.7,8 Known precipitating risk factors are use of physical restraints, malnutrition, more than 3 medications added during the hospital stay, use of bladder catheters and/or any iatrogenic event,6 hypoxia, infection, dehydration, sodium imbalances, and use of certain medications.8 Nurse awareness of these risk factors is paramount prior to instituting preventive and management strategies. This acute confusional state can adversely impact an older adult in various ways. Delirium has been implicated in (1) poor outcomes (physical, mental, and psychological),1 (2) prolonged hospitalization,4 (3) increased costs of care,2,9 (4) need for continued postacute care,6 (5) patient and provider stress,10Y12 and (6) increased mortality.2 The course of delirium is variable. Resolution of symptoms may occur within hours to days or may persist for weeks to months. Full recovery usually occurs, but delirium may progress to an altered level of consciousness and death if the underlying cause is not promptly identified and treated.2,9 It is evident that nurses play an important role in avoiding these potentially devastating outcomes. To prevent delirium, nurses must possess the knowledge to identify risk factors (predisposing and precipitating) and institute preventive strategies. Once a change in mental status occurs, it is critical that nurses recognize delirium (and the different motoric subtypes) and the steps necessary to provide safe, effective care. Nurses are the major providers of bedside care; however, a systematic review of the literature revealed multiple studies citing a lack of nurse knowledge regarding delirium.3,10,13Y16 Based on the high incidence of delirium, the multiple and variable risks for development and the negative impact that the disorder can have on patients and families/ caregivers, anticipatory care is invaluable. Protocols for best practice highlight the bedside nurse as a pivotal team member for risk factor detection and early delirium recognition because of the nature of their ongoing patient assessments.17 Education is identified as a key element in ensuring that these frontline providers have the knowledge Clinical Nurse Specialist

to prevent, assess, and recognize delirium and care for the patient should it develop.17,18 The adult-gerontology clinical nurse specialist (AGCNS) can provide this expert educational support for delirium care. The ultimate goal for nurses should be to prevent delirium, thus avoiding the negative short- and long-term outcomes associated with this frequent, acute disorder. Prevention should be lauded as the most effective strategy, and adequate knowledge ensures that appropriate preventive measures are instituted.

THE CATALYST: THE AGCNS The Institute of Medicine has reported that fewer than 1% of registered nurses are certified in geriatrics. In ‘‘Retooling for an Aging America,’’ they proposed a clear recommendation to enhance geriatric competence of the workforce in common problems associated with aging.19 This is an important directive owing to the increasing older adult population, the multiple comorbidities that can accompany aging, and the poor outcomes that can occur with illness and prolonged hospitalization. The AGCNS can play an essential role in the momentum of this initiative to improve nurse knowledge and build capacity. The American Association of Colleges of Nursing Adult-Gerontology Clinical Nurse Specialist Core Competencies supports education through formal and informal programs for healthcare providers to enhance knowledge and improve outcomes for older adults.20 The First Step in Nurse Education: Knowledge Assessment The literature reveals that nurses lack knowledge regarding delirium. One possible reason for this knowledge deficit has been theorized by Donahue, Kazer, Smith, and Fitzpatrick. These authors relate that geriatric nursing, as a specialty, is a relatively new science. A wealth of information has been gleaned in the past 2 decades and many nurses practicing today might have been educated at a time when geriatric content was not routinely included in the nursing curriculum.21 Baseline nurse knowledge must be assessed before planning and implementation of educational offerings. Determining the extent of geriatric knowledge, in this case, delirium, will highlight current knowledge needs and facilitate program development. Delirium knowledge can be assessed by administering questionnaires/surveys. Only 3 tools have been identified in the literature to assist with nurse delirium knowledge assessment.13Y15 These surveys are presented in Table 1. This author could find no additional studies using these instruments to further add to their operational definitions. The use of high-quality tools and questionnaires is important in evaluating nurse knowledge of delirium. Determining nurse knowledge is vital in order to design and implement appropriate educational programs that address this acute confusional state. In addition to assessing knowledge needs,

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Feature Article Table 1. Nurse Knowledge of Delirium Assessment Tools Tool

Setting/Population

Description

Operationalization

‘‘Barriers to Delirium Assessment,’’13 developed based on review of the literature

RNs from medical-surgical and intensive care units from 2 midsized hospitals in the Midwest, United States.

Consists of 24 true/false and Likert-type scale questions assessing nurse knowledge on 3 subscales & Nurse knowledge of delirium outcomes (13 true/false statements) & Overall knowledge of delirium (8 items rated on a 5-point Likert scale) & Confidence levels regarding delirium assessment (3 questions rated on a 5-point Likert scale)

Content validity was established after 2 trials of expert review. Internal consistency reliability, using Cronbach’s !, was .81 and above on the 3 subscales.14

Survey questionnaire developed to determine nurses’ level of knowledge regarding delirium and its risk factors14

All nurses working in a teaching hospital in Perth WA, Australia.

Consists of 28 items rated on a 3-point Likert scale (agree, disagree, or unsure) & 14 of the questions relate to general delirium knowledge (including presentation and management) and & 14 relate to risk factors for delirium

This tool was not formally assessed for content validity. Face validity was established via subject experts and piloting.

Survey questionnaire developed to assess nursing knowledge of delirium15

Orthopedic nurses in a NICHE-designated hospital.

10-item multiple-choice questionnaire Tool measures knowledge of & Delirium & Associated risk factors & Ability to differentiate between delirium and dementia & Ability to identify common medications that can contribute to delirium

This is a pretest/posttest questionnaire developed by the first author. Content validity was established by nurse experts. Questionnaire was pilot tested.

Abbreviations: NICHE, Nurses Improving Care for Healthsystem Elders; RN, registered nurse.

nurses should be queried as to the preferred method of information dissemination with consideration to time and budgetary constraints. New surveys can be developed, or published tools used. Further validity and reliability testing could be assessed on the 3 instruments mentioned from the literature. The AGCNS can administer, analyze results, and circulate findings of these delirium assessments. Results identify knowledge gaps and educational preferences that could be effectively addressed in programs to ensure that nurses have evidence-based information to care for this acute medical emergency. Knowledge assessment is prerequisite to effective educational endeavors.

THE SOLUTION/EDUCATIONAL STRATEGIES TO PROMOTE NURSE KNOWLEDGE Utilization of Delirium Assessment Tools Operationalized tools used to identify delirium in the clinical setting can be used to improve nurse knowledge. The AGCNS can be instrumental in ensuring that appropriate delirium assessment and screening tools are used and nurses are knowledgeable in how to implement them. It is important that the correct tool be used for the appropriate patient population and setting. For instance, the Confusion Assessment Method has been adapted for the intensive care unit and the emergency department.22 By guiding assessments, these scales can assist nurses in recognizing delirium indices. A summary of the most widely used and studied 220

delirium screening tools, developed for nurses, can be found in Table 2. Instruments, like those in the table, are vital components in documenting the patient’s baseline and ongoing neurological assessment. These tools, when properly administered, have the potential to identify changes in mental status and diagnose delirium and even its severity. The use of a delirium screening tool, along with a multifaceted educational program, has been shown to improve nurse knowledge and perceptions regarding delirium recognition. The use of the Intensive Care Delirium Screening Checklist (Table 2), supported by delirium education, improved the ability of nurses working in the surgicaltrauma intensive care unit to correctly evaluate patients for delirium. The authors support the use of validated screening methods accompanied by educational interventions, which incorporates didactic and point-of-care teaching, using live and Web-based strategies, as an effective approach to improve delirium care.35 Using standardized delirium assessment tools can assist nurses in recognizing and assessing for delirium in their older adult patients. To aid in choosing the most appropriate tool, the AGCNS must consider the psychometric properties and feasibility of the instrument, the patient population and care setting. A variety of tools might need to be adopted within the hospital setting, and the AGCNS is the optimal expert to review the literature and determine the best instrument

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5-item screening scale Assesses disorientation, inappropriate behavior, inappropriate communication, hallucination, and psychomotor retardation Each item rated on a 3-point scale (0Y2) Total score varies from 0 from 10. Delirium reported with a score of 2 10-item clinician evaluation to assess delirium severity Areas of measurement: level of consciousness (awareness), disorientation, short-term memory impairment, impaired digit span, reduced ability to maintain and shift attention, disorganized thinking, perceptual disturbance, delusions, decreased/ increased psychomotor activity, and sleep-wake cycle disturbance Items measured on a 4-point Likert scale Possible range, 0Y30 Score of Q10 indicates a positive test for delirium.

Medical patients

ICU and non-ICU settings

Medical patients

Nursing Delirium Screening Scale27

Memorial Delirium Assessment Scale28

Delirium Index29,30

Adapted from the CAM Measures the severity of delirium based on patient observation Includes 7 domains: disorders of attention, thought, consciousness, orientation, memory, perception, and psychomotor activity Each domain scored 0 = absent to 3 = present and severe The score can range from 0 to 21, with higher scores indicating greater severity.

Original scale (DOSS) consisted of 25-item scale and was subsequently reduced to 13 items (DOS). Symptoms scored dichotomously as ‘‘present’’ or ‘‘absent’’ Total score 0Y13 per assessment Score >3 indicates delirium.

Geriatric medicine and hip fracture patients

Delirium Observation Screening (DOS) Scale26

Description Requires subjective clinical judgment by the rater Based on 4 cardinal features of delirium (1) Acute onset and fluctuating course (2) Inattention (3) Disorganized thinking (4) Altered level of consciousness Delirium is identified if evidence of features 1 and 2 and either 3 or 4 (or both).

Setting

Non-ICU settings

Confusion Assessment Method (CAM)23

Screening Tool

Table 2. Delirium Screening Tools

Interrater reliability, 0.98 Cronbach’s !, .7429

Demonstrated high internal consistency, interrater reliability, and concurrent validity28 Pooled sensitivity, 92% Pooled specificity, 92%24

Sensitivity, 85.7% Specificity, 86.8%27

Reliability and validity established against other rating scales Content validity established by 7 experts26 Pooled sensitivity, 92% Pooled specificity, 82%24

Sensitivity, 94%Y100% Specificity, 90%Y95% Positive predictive accuracy High interrater reliability Pooled sensitivity, 86% Pooled specificity, 93%

Operationalization

Can be administered by nonpsychiatrist clinician without information needed from family, nursing staff, or medical record A reliable, valid, and responsive measure of delirium severity in patients with or without dementia

Requires 10 min to complete Based on patient observations during routine care Has been translated into Spanish

Designed to be administered by nurse based on clinical observation in routine care Takes 1 min to complete

Designed for nurses to be able to identify delirium as part of routine care

Widely used and studied Can be administered by nonpsychiatric clinicians Takes 5Y10 min to administer Translated into >20 languages25 Adapted for use in the ICU and ED settings Assists to distinguish dementia from delirium

Strengths

(continues)

Based on DSM-III, DSM-III-R, and DSM-IV criteria

Developed according to DSM-IV criteria

Requires training

Weaknesses

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. 12-item behavioral observation scale for determining the severity of delirium but may be used to differentiate between patients with or without delirium Multiple categories measured on a 4-point Likert scale (0 = absent/no pathology to 3 = severe) Total scores range from 0 to 36, with higher scores indicating higher severity of delirium. Version of the CAM includes the same 4 features but incorporates nonverbal tasks such as picture recognition and yes/no questions Adds the key elements of the Richmond Agitation and Sedation Scale and uses the Attention Screening examination 8-item scale used for evaluation of disorientation, hallucination, delusion or psychosis, psychomotor agitation or retardation, inappropriate speech or mood, sleep-wake cycle disturbance, and symptom fluctuation Each item scored as absent (0) or present (1) and summed A score of Q4 indicates delirium.

Older general hospital patients

ICU and nonverbal/ ventilated patients

ICU

Delirium-O-Meter (DOM)32

CAM for the ICU (CAM- ICU)33

Intensive Care Delirium Screening Checklist34

Can be easily used in a critical care setting when communication is compromised

Unrestricted in terms of use Permission for implementation and clinical use not required Can be completed in a few minutes

High interrater reliability33 Variable sensitivity, 64%Y100% High specificity24

Sensitivity, 99% Specificity, 64%34

For use by nurses without geriatric background Sensitive to hypoactive and hyperactive delirium Takes 3Y5 min to score DOM score form printed on a single page

Nursing instrument used to assess patient observable responses Minimal respondent burden Incorporates physiologic findings Assesses risk, presence, and severity of confusion Takes approximately 10 min to complete

Strengths

Reliable, valid, and sensitive measure of delirium severity Reliability: Cronbach’s !, .87Y.92 32

Internal consistency (Cronbach’s !), .85 Interrater reliability, 0.9131

Operationalization

Based on previous DSM criteria

Based on criteria from DSM-IV

Weaknesses

Abbreviations: DSM-III, Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition; DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; ED, emergency department; ICU, intensive care unit.

Assesses the risk, presence, and severity of confusion 9 scaled items divided into 3 subscales: information processing, behavior and performance, and vital functions Scores range from 0 to 30 points. 0Y19: severe-moderate confusion 20Y24: mild or early confusion 25Y26: normal function with risk for acute confusion 27Y30: normal functioning

Description

Used with medical patients, ICUs, and LTC facilities

Setting

Neelon and Champagne (NEECHAM) Confusion Scale31

Screening Tool

Table 2. Delirium Screening Tools, Continued

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for use in each care area. Tool adoption should be considered before any educational offerings to capture the tool characteristics and proper usage. Chart audits and direct observations by the AGCNS can validate the correct use of these instruments and identify areas of educational need. Incorporating evidence-based and validated tools is necessary to keep older adults safe and healthy. By advocating for the use of operationalized instruments to care for geriatric patients, the AGCNS can promote quality care, benefiting patients, nurses, and the organization. Assessment tools incorporate domains of delirium and highlight features that nurses need to be aware of. Hence, they are useful to determine and supplement nurse knowledge and they have the potential to guide or augment educational content. The Geriatric Resource Nurse: A Crucial Member of the Healthcare Team An additional strategy for improving nurse knowledge could be facilitated through the promotion and implementation of the Geriatric Resource Nurse (GRN) model. This is a successful model of nursing care that was established through the Nurses Improving Care for Health System Elders (NICHE). Founded in 1992 at New York University, the general goals of NICHE are to assist and support hospital staff in fostering care for the geriatric population.36 To promote the NICHE ideals and improve nurse competence, the GRN model was developed. Motivated individuals, who volunteer to be GRNs, receive additional education and training regarding evidence-based care of older adults, optimally, in coordination with an advanced practice registered nurse as supportVthe AGCNS. This GRN would then become a resource for the nursing unit(s) to facilitate and provide best practice geriatric care, a ‘‘train-the-trainer approach.’’ With NICHE-facilitated training, GRNs have the knowledge and ability to assist other nurses in preventing, detecting, and managing conditions, such as geriatric syndromes, which includes delirium. It is important to note that NICHE designation is not necessary to initiate this GRN model. A hospital without this support could implement the program using free online resources. Several studies have shown that the GRN model has been successful in improving nurse knowledge,37,38 confidence,37 satisfaction,37 and attitudes38 regarding geriatric care as well as patient care practices/outcomes.37,39 Implementing the GRN model would assist in improving nurse knowledge in all geriatric areas, including delirium, with the potential of improving outcomes for older adult patients. Additional studies should be conducted to determine the effectiveness of such models in improving nurse knowledge of delirium and improving patient outcomes through prevention or early recognition. The AGCNS can advocate for geriatric initiatives, such as nurse role models, and provide initial and ongoing education and training to improve nurse knowledge and patient care activities. Clinical Nurse Specialist

Case Studies to Facilitate Learning Case studies can be useful and effective tools to teach staff nurses about delirium. The AGCNS can facilitate such an activity. One such example is the use of a scripted unfolding case study focusing on delirium in older adult patients.40 The authors used this low-cost, innovative, interactive strategy for improving nurse knowledge of delirium in a workshop setting. An unfolding case allows the learners to experience what occurs in this syndrome as the clinical case progresses. Critical thinking is fostered as time is allowed during the scenario for participant questions and discussion. The workshop culminates with a debriefing session and case study evaluation. Participants rated this learning experience positively and felt that this strategy improved their ability to recognize and manage acute confusion.40 A geriatric self-learning module on confusion was developed by Lee.41 An inpatient, as well as an outpatient, case study was presented to provide educational information to nurses working in these settings. An overview of acute confusion was presented, then the case study, followed by a discussion of possible contributing factors for the acute confusion, parameters to assess and nursing interventions to consider specific to the case. A brief posttest was provided along with answers. Such examples, using case studies, have the potential to be effective in educating nurses. The AGCNS can write the case studies or use cases found in the literature, follow through with case delivery as part of a 1-time or ongoing educational opportunity, and present guidelines for analysis along with postYcase study questions to evaluate nurse knowledge. Gaps in knowledge can then be addressed via informal or formal educational offerings. Use of Simulation Focusing on Geriatric Syndromes Many healthcare facilities own, or have access to, simulators to educate medical, nursing, and ancillary staff. This is an exceptional method to teach nurses about geriatric issues and syndromes, including delirium. Simulators can be manikins or humans trained in a specific scenario. Whether using highfidelity human patient simulation manikins (HPSMs)42,43 or standardized patients (SPs)44 with a script, the simulation experienceallows theparticipants tosynthesizeinformationlearned and critically think about the situation. It provides the opportunity to properly and accurately assess, prioritize and plan care, implement appropriate actions and discover what affect these actions have on the ‘‘patient’’ in a safe, controlled environment. The simulation session provides time for participant debriefing about the interaction. This debriefing session allows participants to self-evaluate their performance and allows for instructor feedback, which includes observed strengths and weakness. Participant self-reflection is thought to impact professional growth and lifelong learning.45 This technologically advanced participatory method of learning is especially appealing to today’s millennial generation of

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Feature Article learners.42,46 Participants have reported high levels of learner satisfaction with HPSMs.43 Learner satisfaction increases motivation and engagement. The use of simulation with a group of nurses fosters team work and collaboration, important skills as the nurse interacts within complex health settings.45,46 In her testimony at the Forum on the Future of Nursing, Fay Raines encourages the use of simulation and technology in education to foster safe practice.47 Simulation allows participants the opportunity to identify threats to patient safety, prioritize actions, engage in preventive behaviors, recognize appropriate resources, and enhance communication skills. In a multisite study, researchers found that the use of multiplepatient simulation experiences ‘‘increases the achievement and implementation of patient safety competencies.’’48(p336) Clinical simulations have been used successfully in geriatric nursing continuing education (CE). This milieu offers nurses the ability to problem solve in a risk-free environment. This educational modality has been shown to significantly improve nurse knowledge regarding geriatrics and was rated highly as a means of improving skills. Participants involved with geriatric scenarios have related positive experiences working with both HPSMs and SPs.49 Simulation is an appropriate tool that fosters integration of knowledge and skills into practice. The simulation experience reinforces information, enhances technical skills, provides immediate feedback, improves confidence and satisfaction, cultivates teamwork, and promotes the development of clinical reasoning skills, all in a concerted effort to optimize outcomes for all older adults receiving nursing care. Such experiences also have the potential to strongly and effectively support interdisciplinary delirium care. The AGCNS can be instrumental in writing geriatric scenarios, supervising the simulation experience, and lending expertise during the debriefing period, all with the goal in improving nurse delirium knowledge and geriatric competence. Conduct Geriatric Nursing Grand Rounds Grand rounds within the medical community have been conducted for many years as a forum to discuss specific cases and appropriate care. Nursing grand rounds (NGRs) have the same potential. It provides an opportunity to link evidence from the literature to clinical nursing practice. In a 2012 published study, 2 aims that the researchers investigated were (1) the relevance of NGRs to practice and (2) educational preference and methods of NGR delivery.50 Of the nurses surveyed in the 2 hospitals, 80.3% to 85.4% rated NGR as being relevant or very relevant to practice. The recorded NGR available for online viewing was the top preferred method of educational delivery. This asynchronous learning environment affords greater convenience than other modalities.50 In a small pilot study, the effect of NGR on nurse knowledge and the value of such an activity were assessed. Results demonstrated positive knowledge acquisition, which was 224

retained over time, and a high perceived value in such an activity. The use of NGR was thought to be an effective strategy for teaching and learning.51 Nursing grand rounds were successfully implemented in a community hospital. The project was facilitated by advanced practice nurses (CNSs and nurse practitioners) and included staff nurses with various levels of experience/ expertise. Case studies from topics of interest were used. Participating nurses felt that this educational strategy provided the opportunity to share clinical knowledge and experience and participate in professional development. It also was found to provide a means for the advanced practice nurse to cultivate nurses from novice to expert.52 These findings support the AGCNS’s introduction and implementation of NGR into practice within the acute care facility. Such methods for case presentation and discussion can be a creative way to focus on specific geriatric illnesses/ disorders, especially the all-too-frequent occurrence of hospitalacquired delirium. By sharing the findings from the literature on delirium and highlighting what is actually being done at the bedside, the AGCNS facilitates knowledge translationV assisting the primary provider of healthcare to use the evidence in routine practice. Explore the Patient’s Experience Patients are often aware that they have experienced an episode of confusion. In a phenomenologic study, McCurren and Cronin53 sought to describe the ‘‘lived experience’’ of delirium from the patient’s perspective. The patients in this study revealed often terrifying incidents, findings that support measures to prepare and educate vulnerable older adults and their families, supply appropriate alterations to the environment, and provide therapeutic counsel for those who are experiencing/have experienced delirium. The goal is to intervene appropriately to diminish the resulting fear, anxiety, frustration, and anger often associated with this altered mental state. Debriefing a patient who has experienced delirium can be beneficial for the patient and enlightening for the interviewer. Investigating delirium from the patient’s perspective can be a compelling force to gain knowledge and improve care in this area. The postdelirium patient experience can be shared and explored with nurses as the AGCNS conducts NGR. The negative manifestations experienced by the patients expose appropriate care considerations for practicing nurses, as well as other members of the geriatric team. As consultant, the AGCNS can be notified of cases of delirium to provide acute and ongoing assistance to the patient/family and nurses and opens the door to discover the patient’s perceptions of the acute confusional state. Encouraging Geriatric Certification Nurse certification in a specialty area, such as geriatrics, can contribute to personal, as well as agency, goals. Certification requires reading/studying and a time commitment focused

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on a content area. Striving for geriatric certification can promote advanced knowledge. For the nurse, the reward of achieving certification can result in a sense of personal and professional accomplishment and assist in climbing the clinical ladder and may result in salary compensation. Institutions may reimburse for testing fees associated with certification or pay for it upfront, through programs such as ‘‘Success Pays.’’ This initiative, offered by American Nurses Credentialing Center, is an effective way to increase the number of board certified nurses in the facility without financial risk for participants. Information about the program can be found at http://www.nursecredentialing.org/Certification/SuccessPays. Nurse certification is a goal for any facility striving for Magnet status. Attaining certification as a geriatric nurse through the American Nurses Credentialing Center is ‘‘a mark of geriatric nursing excellence’’ that shows individual and organizational commitment to exceptional practice.21 Information on geriatric certification FAQs can be found at http://consultgerirn.org/ resources/gerontological_certification_faqs/. Experts propose a required certification in delirium, similar to the model used for cardiopulmonary resuscitation certification.54 Such a certification would ensure that nurses have the most current knowledge and skills necessary to render safe, appropriate care. The acute care AGCNS can be instrumental in spearheading the push for certification and, in turn, measure outcomes of care. The AGCNS can develop and conduct geriatric certification review courses to assist nurses in meeting this achievement signaling excellence. The AGCNS can keep track of certifications and provide friendly reminders for those approaching recertification. Continuing education (CE) requirements are mandated for nurse licensure renewal in most states and the AGCNS would be involved in developing, promoting, and conducting programs where nurses can earn CEs. Providing information and programs for the development of healthcare providers is a core competency (E.7) for AGCNS practice.20 Through mentoring and role-modeling, the AGCNS can represent the passion and motivation for improving measurable knowledge that will positively impact patient care. Improving geriatric nurse knowledge, through processes such as certification, can reap rewards for nurse, agency and patient, all important foci for the AGCNS. A

Structured CE Programs in Geriatrics A structured geriatric nurse education program can affect knowledge, attitudes, and certification of hospital nurses. An example of one such program involved geriatric content based on the Hartford Institute for Geriatric Nursing (2011) Try This series. Content was presented via lecture, PowerPoint slides, group exercises, and discussions, videos, and games in a 21-hour course over three 1-day sessions: 1 session per week for 3 consecutive weeks. There was a significant difference in pretest and posttest knowledge and attitudes. Participants viewed the program positively, and 6 of Clinical Nurse Specialist

92 nurses had taken and passed the geriatric nurse certification examination.21 A structured program such as this illustrates success in improving nurse knowledge of geriatrics, including the syndrome of delirium. A structured Web-based educational program was developed by Australian authors entitled ‘‘learnaboutdelirium.’’ The Web site included the definition of delirium, types, prevalence, management strategies, and how to recognize delirium using the Confusion Assessment Method.23 Videotaped vignettes of actors displaying various clinical presentations of delirium were shown. Questions and answers were reviewed, and links to educational Web sites were provided to participants. Those exposed to this intervention performed significantly better than a nonintervention group on delirium knowledge and recognition.55 Nurses from 18 Dutch hospitals working on the general medical and surgical units were introduced to an e-learning course on delirium, developed by a commercial publisher. The goal of the course was to increase awareness of delirium and its risk factors and to improve nurse knowledge of delirium. The content of the course was consistent with the Dutch guidelines for delirium care. Content areas included clinical features of delirium, risk factors for development, diagnostics, and prevention and treatment strategies. Case studies and short self-assessment tests were utilized. This structured e-learning opportunity significantly increased screening for delirium and had a significant positive effect on nurse knowledge.56 The AGCNS can be instrumental in working with administration, nurse managers, and nurses in developing similar structured CE programs. The consulting, collaborating, and patient care aspects of the AGCNS role allow connections to be made with other healthcare team members. The networking that occurs across disciplines can afford the opportunity for the AGCNS to identify guest speakers for such an educational offering to promote geriatric/delirium care. Encourage Nurse Organizational Involvement There are benefits associated with membership in geriatric associations. As a repository for geriatric information, the AGCNS is able to share these organizations with nurses as a means to improve knowledge. Networking with likeminded individuals has the potential to influence awareness of specific topics and improve care. Encouraging and supporting nurse expertise in the field of geriatrics through mentoring are subroles of the AGCNS supported by American Association of Colleges of Nursing Core Competencies.20 Joining the National Gerontological Nursing Association provides access to a wide range of geriatric information, such as webinars, newsletters, publications, fellowships, and discounts on certification materials, examinations, and national conventions. Visit http://www.ngna.org/. Membership in the American Geriatrics Society offers access to multiple

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Feature Article publications, geriatric evaluation and management tools, guidelines and clinical tools, public education resources for patients/caregivers, smartphone apps, networking resources, and awards/recognitions for members. Additional information can be found at http://www.americangeriatrics .org/. The American Delirium Society Web site offers information on the condition to healthcare professionals, as well as for patients/families. The society was formed to improve collaborative efforts, which can foster research, education, and clinical efforts.54 Joining the American Delirium Society rewards its members with a variety of information and resources on delirium. To learn more, visit http://www .americandeliriumsociety.org/. Duffy et al57 relate the multitude of potential membership benefits, including journal subscriptions, newsletters, networking opportunities, a platform for the subscribers’ voice, listserv participation, volunteer opportunities, continuing educational programs, and reduced rates for insurance or other group benefits, certification examinations, fees to sponsored conferences, and products. Participating in a professional organization has the potential to improve staff nurse knowledge on geriatric topics, including delirium. As facility content expert, with a responsibility to educate and elevate nurses, the AGCNS can highlight these associations and convey the positive consequences associated with membership.

education/patient_family/. Also offered is the Want to Know More seriesV‘‘Geriatric Nursing Protocol: Delirium: Prevention, Early Recognition and Treatment’’Vat http://consultgerirn .org/topics/delirium/want_to_know_more. The Try This series educates nurses on assessment/screening tools for delirium. Visit http://consultgerirn.org/resources. The Portal of Geriatrics Online Education, sponsored by the Hartford Geriatric Nursing Initiative and John A. Hartford Foundation, offers ‘‘Continuing Education in Nursing: Delirium’’58 at http://www.pogoe.org/productid/20706. An additional content area is offered: ‘‘Infusing Geropsychiatric Nursing into CurriculaVResources for Teaching Key Concept I.B. (Assessment: Appropriate Instruments/Clinical Evaluation Tools)’’ available at http://www.pogoe.org/productid/20949. The Hospital Elder Life Program is a patient care program designed to prevent delirium in hospitalized older adults. The Hospital Elder Life Program Web site provides information to clinicians, as well as patients/families, on the program and on the topic of delirium. Visit www.hospitalelderlifeprogram.org. A summary of these resources can be found in Table 3. It is evident that there is a wealth of geriatric educational materials offered online, free of charge, to enhance nurse knowledge of geriatrics and specifically delirium. As the geriatric expert, the AGCNS can encourage nurse engagement with these valuable online resources.

Introduce/Promote Gerontological Nursing Resources A great number of resources exist on the World Wide Web regarding care of older adults and, more specifically, about delirium. Through education and experience, the advanced practice nurse has awareness of and exposure to these important and helpful sites. The AGCNS can investigate and collect/compile lists of geriatric/delirium resources. A geriatric resource notebook could be developed and kept on each unit for quick reference. By virtue of their educational subrole, the AGCNS has the ability and responsibility to disseminate information about these resources to nurses to improve knowledge. ConsultGeriRN.org has numerous offerings on delirium, including 2 modules that focus on a patient/family-centered care approach to delirium, at http://www.hartfordign.org/

RECOMMENDATIONS The AGCNS can be instrumental in imparting crucial content to acute care nurses regarding delirium. Their licensure, accreditation, certification, and education, along with geriatric knowledge and experience, affords them an important position to influence care and keep vulnerable older adults safe during their hospital stay. A summary of strategies is presented in Table 4. Although this article addresses strategies for improving delirium knowledge for nurses, AGCNSs can and should expand their scope of influence to include other crucial members of the nursing staff and members of the interprofessional care team. In the report ‘‘The Future of Nursing: Leading Change, Advancing Health,’’ the Institute of Medicine calls

Table 3. Delirium Resources Online Resource

Web Site

ConsultGeriRN.orgV2 modules on delirium

http://www.hartfordign.org/education/patient_family/

Want to Know More SeriesVGeriatric Nursing Protocol: Delirium: Prevention, Early Recognition, and Treatment

http://consultgerirn.org/topics/delirium/want_to_ know_more

Try This series for delirium screening tools

http://consultgerirn.org/resources

Portal of Geriatrics Online Education: Continuing Education in Nursing: Delirium

http://www.pogoe.org/productid/20706

Portal of Geriatrics Online Education: Infusing Geropsychiatric Nursing into Curricula-Resources for Teaching Key Concept I.B.

http://www.pogoe.org/productid/20949

Hospital Elder Life Program (HELP)

www.hospitalelderlifeprogram.org

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Table 4. Tips for the AGCNS to Improve Nurse Knowledge of Delirium As patient care experts Become experts on delirium: incidence, negative outcomes associated with its occurrence, preventive strategies, predisposing and precipitating risk factors, assessment tools, and management. Develop policy and procedures surrounding delirium (delirium order sets, care plans, restraint use, falls prevention). As consultants Assess and assist with management of delirium. Be actively involved with IT to implement delirium screening tools and order sets into the electronic medical record. As educators Conduct delirium nurse knowledge assessments. Knowledge assessments would identify gaps so that effective educational programs could be designed. Survey nursing staff on learning styles and preferred method of content delivery. Determining nurse needs and desires regarding in-services would facilitate knowledge transfer and foster the translation of evidence-based knowledge into practice. Conduct ‘‘just in time’’ teaching at the bedside to correct or reinforce information. Develop and conduct geriatric certification review courses. Generate continuing education units for educational offerings. As leaders Develop programs to support geriatric care: NICHE designation, GRN model, nursing grand rounds. Introduce initiatives surrounding delirium to hospital administrators and staff. Ensure adequate reliable and validated tools are used throughout the facility to screen for delirium. As evidence-based practitioners Investigate educational program effectiveness on nurse knowledge and patient outcomes. Quantitative and qualitative data can be assessed. Initiate journal clubs to foster reading and analyzing the evidence in the literature on delirium. As collaborators Participate in interdisciplinary care rounds to prevent and manage delirium with combined efforts of all team members. Work with area community care settings to foster quality care practices. Collaborate with area schools of nursing Assist in educating nursing students in the clinical setting, eg, a postconference on delirium. Mentor future AGCNS students in best practice geriatric care. Promote the APRN role to ensure continuing programs. Work with faculty in providing geriatric education: guest lecturer. Share resources (Sim labs) to promote education and improve care of older adults in the community. Gain knowledge of the scope of geriatric content in the curriculum. Offer suggestions from the perspective of a current acute care practitioner. These subrole activities influence the patient, nurse/nursing practice, and the organization. Abbreviations: AGCNS, adult-gerontology clinical nurse specialist; APRN, advanced practice registered nurse; IT, information technology; GRN, geriatric resource nurse; NICHE, Nurses Improving Care for Healthsystem Elders.

on nurses to collaborate closely with a variety of healthcare professionals in the delivery of safe, quality care.59 The AGCNS is poised to lead such an effort in education and practice.

CONCLUSION Based on the rapidly increasing size of the geriatric population, the incidence and significance of delirium for hospiClinical Nurse Specialist

talized older adults, and the published evidence of the knowledge deficit of nurses regarding delirium, acute care facilities should take action to educate nurses regarding this potentially devastating disorder. The AGCNS can be the catalyst in meeting the needs of patients, nurses and the organization in improving delirium care. The goal is to improve geriatric nursing knowledge to prevent, screen, and

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Feature Article adequately manage the acute confusion often experienced in the hospital setting. The strategies outlined in this article offer multiple suggestions regarding how nurse knowledge can be enriched. Understanding the staff nurses’ knowledge of delirium will identify gaps before educational program development. Promoting the use of operationalized instruments to assess for delirium is an additional tactic to assist nurses in clarifying parameters of delirium and strengthening understanding. The AGCNS can strive to use innovative models of care, such as the GRN, and creative strategies such as simulation, case studies, NGRs, and structured programs to educate nurses on this frequent disorder. The postdelirious patient can be interviewed and debriefed to gain insight from the patient’s perspective. There are numerous online resources that can effectively improve nurse knowledge. Encouraging geriatric certification ensures competency and continuing commitment to the field. Organizational membership affords participants a variety of supports in geriatric care. As agency expert and advocate for the older adult patient population, the AGCNS can use any one of these measures to assist nurses in rendering competent care. The AGCNS has the potential to exert enormous influence over geriatric initiatives and educational programs to improve delirium care. By improving nurse knowledge, safe, quality care can be provided to hospitalized older adults. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. dsm.psychiatryonline.org. Accessed June 1, 2013. http://dsm.psychiatryonline.org.mutex.gmu.edu/content .aspx?bookid=556§ionid=41101783&resultclick=1#103441511. Accessed March 28, 2014. 2. Inouye S. Delirium in older persons. N Engl J Med. 2006;354(11): 1157Y1165. 3. Fick D, Hodo D, Frank L, Inouye S. Recognizing delirium superimposed on dementia. J Gerontol Nurs. 2007;33:40Y47. 4. Rice K, Gomez M, Goreman M. Nurses’ recognition of delirium in the hospitalized older adult. Clin Nurse Spec. 2011;25:299Y311. doi:10.1097/NUR.0b013e318234897b. 5. Fong TG, Jones RN, Marcantonio ER. Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Ann Intern Med. 2012;156:848Y856. 6. Inouye S, Charpentier P. Precipitating factors for delirium in hospitalized elderly persons. JAMA. 1996;275:852Y857. 7. National Collaborating Centre for Acute and Chronic Conditions. Delirium: diagnosis, prevention and management (Clinical Guideline; no. 103). London (UK): National Institute for Health and Clinical Excellence (NICE); 2010. 8. Tullmann D, Mion L, Fletcher K, Foreman M. Need help statVconsider: delirium. http://consultgerirn.org/topics/delirium/need_help_stat. Updated July 2008. Accessed April 12, 2014. 9. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168(1):27Y32. 10. Dahlke S, Phinney A. Caring for hospitalized older adults at risk for delirium: the silent, unspoken piece of nursing practice. J Gerontol Nurs. 2008;34:41Y47. 11. Davydow D. Symptoms of depression and anxiety after delirium. Psychosomatics. 2009;50:309Y316.

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