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Contents lists available at ScienceDirect
Intensive and Critical Care Nursing journal homepage: www.elsevier.com/iccn
Original article
The experience of intensive care nurses caring for patients with delirium: A phenomenological study Allana LeBlanc ∗ , Frances Fothergill Bourbonnais, Denise Harrison, Kelly Tousignant University of Ottawa, 75 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
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Article history: Received 5 January 2017 Received in revised form 31 August 2017 Accepted 1 September 2017 Keywords: Critical care Critical care nursing Delirium ICU delirium Intensive care Nursing Phenomenology
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Objectives: The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses’ experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients. Research methodology: This study utilised an interpretive phenomenological approach as described by van Manen. Setting: Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada. Findings: The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It’s Exhausting; Making a Picture of the Patient’s Mental Status; Keeping Patients Safe: It’s aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You. Conclusion: The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience. © 2017 Elsevier Ltd. All rights reserved.
Implications for clinical practice • • • •
The nurse-patient relationship is crucial and is reflected in the importance of moment by moment patient assessment. Building relationships with families is essential and contributes to both the assessment and management of these patients. Patient safety is an overarching concern as well as a challenge that is impacted by workload issues and teamwork. Experiential learning is essential in educating nurses about delirium.
Introduction Delirium is a temporary disturbance of attention and awareness that is associated with a change in cognition. It develops over a short period of time and tends to fluctuate in severity throughout the day (Adamis et al., 2015; American Psychiatric Association, 2013). Symptoms include disorientation, hallucinations or delusions, psychomotor agitation and/or hypoactivity and lethargy (Page and
∗ Corresponding author. Present address: Permanent address: Intensive Care Unit, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada. E-mail address: [email protected] (A. LeBlanc).
Ely, 2015). Delirium may affect greater than 80% of adult patients in intensive care units (ICU) and is associated with longer ICU and hospital length of stay, as well as increased mortality (Pisani et al., 2009; Shehabi et al., 2010). Other impacts of delirium in ICU patients include increased risk for long-term cognitive impairments, greater functional dependency following hospital discharge, increased frequency of patient safety events, decreased quality of life, short- and long-term emotional and psychological distress and increased hospital and health system costs (Awissi et al., 2012; Barr et al., 2013; Girard et al., 2010; Pandharipande et al., 2013; Salluh et al., 2015). Patients who have experienced delirium in the ICU describe feelings of fear and struggling to make meaning or to find human connection (Whitehorne et al., 2015). The emotional and
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Please cite this article in press as: LeBlanc, A., et al., The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.09.002
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psychological impacts can have consequences for patients after the delirium has resolved (Brummel et al., 2014; Pandharipande et al., 2013). Clinicians must be knowledgeable about delirium in ICU patients in order to identify it early and implement care and treatment strategies. Identifying delirium in an ICU setting can be challenging because patients are frequently unable to communicate due to their severe illness and/or endotracheal intubation. Key recommendations for delirium prevention and management include regular assessment for delirium with a valid and reliable tool, such as the Confusion Assessment Method for ICU (CAM-ICU), early mobilisation, targeting light levels of sedation, promoting sleep and using an interprofessional team approach to patient care (Barr et al., 2013). Increasingly, ICUs are implementing protocols aimed at preventing delirium and minimizing its impact on patient outcomes (Balas et al., 2013; Barr et al., 2013; Barr and Pandharipande, 2013; Reade and Finfer, 2014). Intensive care nurses typically coordinate and participate in implementing these protocols for the patients under their care (Balas et al., 2012; Balas et al., 2014). However, the successful use of such protocols can be challenging in daily practice due to a variety of organisational and human factors (Balas et al., 2013; Barr et al., 2013; Basset et al., 2015; Carrothers et al., 2013; Zamoscik et al., 2017). Additionally, Belanger and Ducharme (2011) have pointed out that such protocols rarely provide guidance on establishing therapeutic relationships with patients with delirium, or techniques that might reduce the negative emotional consequences of the experience for patients and their families. Studies on the nursing care of critically ill patients with delirium have tended to focus on the accuracy and use of assessment tools, risk factors, prevention, pharmacological and non-pharmacological interventions, physical restraints, nurses’ beliefs and protocol compliance and implementation, (Balas et al., 2014; Bassett et al., 2015; Carrothers et al., 2013; Freeman et al., 2015; Gesin et al., 2012; Oosterhouse et al., 2016; Oxenbøll-Collet et al., 2016; van Eijk et al., 2011; Vasilevskis et al., 2011). Implementing best practices for patients with delirium depends largely on the knowledge and skill of nurses and their ability to communicate and coordinate effectively with the interprofessional team (Balas et al., 2013; Bassett et al., 2015; Oxenbøll-Collett et al., 2016). Despite the frequency with which intensive care nurses encounter these patients, inquiries into nurses’ experiences in the ICU setting are limited. The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) to examine intensive care nurses’ experiences of caring for adult patients with delirium; and 2) to identify factors that facilitated or hindered intensive care nurses caring for these patients.
Methods Design. Van Manen’s approach, based in the hermeneutic phenomenological tradition, provided the methodological lens for this study (van Manen, 1997). He describes hermeneutic phenomenological research as the study of a person’s lived experience (the person’s reality as it is immediately experienced in the world). The findings of phenomenological research reveal an ‘understanding’ of the moment (van Manen et al., 2016) so that persons who have had, or could have had that experience, can recognize it. Setting. Participants in this study were recruited from two ICUs in a university- affiliated, tertiary care academic health care centre in Canada. One ICU had 27 beds for patients with neurosurgical, trauma, vascular and general medical-surgical conditions while the other ICU had 26 beds with primarily oncology, pulmonary and medical-surgical patients. Both units had a policy of delirium
assessment by the bedside nurse each shift using the CAM-ICU and a delirium protocol was available to use for patients who screened positive. The delirium protocol consisted of a physician’s order set for pharmacologic and non-pharmacologic interventions for delirium. Participants. Prior to data collection, meetings were held with the nursing managers and educators to explain the study. Nursing staff were then notified about the study by informational posters and emails. A purposive sample of eight intensive care registered nurses was recruited. Inclusion criteria were: 1) Registered nurse (RN) who has cared for intensive care unit patient(s) with delirium in the last 12 months; 2) employed full or part-time in the unit, with greater than one year of intensive care experience. The participants’ ages ranged from 21 to 60 years, years of nursing experience was from one to >35 years and ICU experience varied from one year to >25 years. Therefore, the sample consisted of less experienced as well as very experienced nurses. Five participants were male and three were female. Data collection. One-to-one interviews of approximately one hour were held in a conversational style using open-ended questions. Participants were invited to share personal stories or anecdotes to stimulate their recollections and to provide rich data. A reflexive journal was maintained to record methodological decisions, initial assumptions and impressions throughout the data collection process. Having eight participants with varied experience levels describe caring for patients with delirium facilitated obtaining thick and rich descriptions (Morse, 2015). Overlapping of key issues occurred in the transcribed data by the eighth interview. Data analysis. The researchers analysed the interview transcripts (text) to reveal the essence of the lived experience of intensive care nurses caring for patients with delirium. The process of data analysis was based on three approaches to textual analysis as described by van Manen (1997): (1) Holistic approach: The researcher read the transcript (text) as a whole to try to capture a sense of its overall significance; (2) Selective or highlighting approach: The researcher returned to the text regularly in order to underline within the participants’ statements those phrases that were revealing to the experience under study. Revealing statements were collected and sorted into folders and re-examined until themes and subthemes emerged. (3) Detailed line- by- line approach: The researcher read every line of the text and asked what it revealed about the phenomenon. Quotations which supported themes were extracted from the data. The relationship both within and between themes was analysed until a comprehensive description of the experience of participants was uncovered. Ethical approval. Ethical approval was obtained from the affiliated university’s and the participating institution’s research ethics boards, approval number 20140066-01H. Informed consent was obtained from participants prior to each interview. Methods to ensure rigor. Trustworthiness of the findings was established using the criteria outlined by Lincoln and Guba (1985): credibility, transferability, confirmability and dependability. To ensure credibility (truth value), the first author (an MScN student at that time) had consistent consultation with the members of her thesis committee who had expertise in nursing, delirium, critical care and qualitative research. Member check interviews were employed for participants to comment on the research findings and themes (Noble and Smith, 2015). To enhance transferability, detailed descriptions of the setting have been presented, as well as descriptions of participants. Confirmability refers to the extent to which the study findings originate from the experiences of the participants and not as a result of researcher supposition or bias (Lincoln and Guba, 1985). Quotes from the participants were used to explicate each theme to ensure confirmability. In addition, the second author read all the transcripts and assisted in developing themes which were then verified by the remaining authors. To
Please cite this article in press as: LeBlanc, A., et al., The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.09.002
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can be frustrating for the nurse and the patient, participants described trying to meet patient’s needs for safety and for delivering care: “Most of the stories are all the same. The worst one is when they have no idea of where they are and their main goal is getting home. It doesn’t matter what you tell them or what they’re hooked up to, they’re climbing out of bed. . . .it could be dangerous. So you’re constantly going back to the bedside.” (Steven) Participants described in the subtheme Not being able to give optimal care, how difficult it was to provide care when patients were uncooperative or unable to communicate: “There may be some hidden needs that are very necessary that I can’t identify. I would not be able to give them the best care that I could so I find this is quite hard.” (Jessica) This left participants feeling dissatisfied. Participants experienced frustration when there was lack of agreement among the health care team about how to manage patients’ agitation. The subtheme Being on guard o described the experience of caring for disorientated, agitated patients. Being on guard meant maintaining personal safety as well as the patients’ safety: “If you get report that this patient is going to be fighting you and aggressive. You just get this feeling, ‘Oh this is going to be a long day.”’ (Steven) Conversely, the subtheme Feeling challenged revealed how working with these patients could be a positive experience when participants felt they were able to nurse them effectively (Alan, Steven, Donald, Ben, Joann) even if the patients’ symptoms did not fully resolve: “I find it is a challenge but I like that challenge because I find it very rewarding and I can just calm my patient with talking.” (Alan) Taking on the challenge was easier when the participants felt they had support and ‘a plan’ for managing the patient. Making a picture of the patients’ mental status. Participants drew upon professional knowledge, previous experiences with patients, as well as information from family members to fill in this picture. They noted behaviours, monitored for changes and sometimes used the CAM-ICU. Considered together, all of this information helped participants to make a picture of the patients’ mental status in the moment. This picture was continually revised:
Fig. 1. Overview of themes and subthemes. A diagram of themes and subthemes that emerged from the analysis. The essence of the experience was finding a way to help them come through it.
enhance dependability, the researcher maintained a decision trail to record methodological decisions as well as decisions related to data analysis (Noble and Smith, 2015). Findings The essence of the experience of intensive care nurses caring for adult patients with delirium can be described as finding a way to help them come through it. Participants were challenged to find ways to provide safe, person-centred care in order to help patients come through the temporary state of delirium. Six themes emerged: It’s Exhausting; Making a Picture of the Patient’s Mental Status; Keeping Patients Safe: It’s a Really Big Job; Everyone is Unique; Riding it Out with Families; and Taking Every Experience With You. (See Fig. 1. Overview of Themes and Subthemes.) It’s exhausting. Participants described feeling mentally and emotionally exhausted by their efforts to care for patients with symptoms of disorientation and/or agitation. In the subtheme It
“We have our tools in the ICU like our CAM score...But also by just observing the patient. See how he is responding. (. . .) and you sort of start making a picture of how their mental status is.” (Alan) The subtheme Assessing the patient as a whole described the participants’ holistic assessments which included baseline level of function, medical history, current status and treatment plan, past and present interventions and “getting a sense of what is normal for him” (Gary) from family. Participants made note of small changes and continuously assessed for altered mental status as described in the subtheme Filling in the picture: moment by moment: “He was calmer. Things seem to start to come back as to why he was in the hospital. Start to recall the surgery that he had whereas before he didn’t know what he had, where he was.” (Steven) Some participants stated that moment by moment assessments were not “believed” by the medical team and that they needed other strategies to communicate. Some would call the physician to the bedside to “capture the moment” (Gail), others used the CAM-ICU findings to be “believed”: “I get people to believe me by objective evidence [emphatic tonelaughs]. So, using your CAM tool.” (Ben)
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Not all participants considered the CAM-ICU helpful for assessing patients. The subtheme Using tools but using judgment described how participants used, or did not use, the CAM-ICU and other scales, such as the Richmond Agitation Sedation Scale and the delirium protocol into their daily practice. “We have to fill out forms, we have to sign here we have to sign there. It becomes sort of a cookie cutter nursing. Where is my professional autonomy here?” (Alan) Participants who did use the CAM-ICU varied in how they applied it with patients and some mistrusted the results: “I guess there are patients that’ll be fine on the CAM . . . but they could get all the questions right but still be seeing things everywhere, confused.” (Steven) All of the participants who used the CAM-ICU in any way supplemented their findings with other assessments to make a picture of the patient’s mental status. Few participants had used the delirium protocol. Those who did found it helpful to obtain drug orders from physicians. None of the participants considered it helpful to guide non-pharmacologic interventions. Keeping patient’s safe: it’s a really big job. This theme reflected the challenges participants faced when patients were disoriented, agitated, or unable to protect themselves from harm: “When he started to get really agitated and restless. He totally could not recognize any person now and [he was] just agitated and just kept climbing out of the bed. . . and just keeping him safe is a really big job.” (Jessica) These patients required the continuous presence of the nurse to ensure that they did not harm themselves (e.g. by accidentally removing a life-supporting device). The subtheme Keeping an eye on the patient reflected the vigilance required which was difficult in a busy environment and sometimes impossible to do alone: “the fridge is in the middle of the unit. So it takes us about a minute to go and get the [medication] and come back. . .and with those kinds of patients, a minute, everything could happen in a minute.” (Gary) The subtheme Knowing when and how to respond revealed that participants prioritized when to intervene and how to manage patient care: “It means putting other things aside and treating the immediate needs. . . I have to divert my attention to helping them with whatever is happening right now.” (Ben) This subtheme contained participants’ thoughts about chemical and physical restraint which were considered last resort: “Sometimes you just have to physically restrain them. . . to make it safe for him and for you. . . It’s not nice but sometimes you have to. We’ll give medications for it. . . hopefully calm it down.” (Steven) They expressed concerns about adverse effects of sedation, such as prolonged ICU stay. Everyone is unique. This theme captured the efforts taken to provide person-centred care. The participants used their knowledge of each patient to tailor their interventions and drew upon past experiences: “I find that everyone is unique and every patient is unique in how you care for them. As long as you have the support behind you. We’re there to help them and we’re there to support them and when you have a great team behind you, you can do it.” (Gail) Additional nursing time was needed to care for these patients. The subtheme Taking the time also revealed that mind set was
important, participants described needing to be ‘patient’, or ‘accept’ who the patient was at that moment in time (Gail, Ben Alan, Donald, Steven). Taking the time involved: “being a willing participant to the care that you give to your patient. Instead of rushing and getting through everything you might have to take extra time to do things with the patient. . . and be calm and be kind to patients too.” (Gail) In the subtheme, Finding the proper way, the participants described using trial and error to find effective strategies. For example, manipulating the environment by modifying noise and light, or providing comfort by bathing or repositioning, ‘just open the curtains so they can see it’s daylight’ (Joann). They used knowledge and clinical judgment to tailor practices to patients’ individual needs. Riding it out with families. This theme captured the experiences that were shared with families. Two subthemes emerged: Partnering with the family to work together to care for the patient more effectively and Caring for the family in which participants provided direct emotional and educational interventions. Participants described moving back and forth between these roles: “It was him and his wife. (. . .) I explained to her that he would come through this. She calmed down. She was able to talk with him a little more. (. . .) And for the next two days − me and her − we just rode it out (. . .) and it worked out fine.” (Steven) Taking every experience with you. This theme involved building up personal resources, skills and knowledge to effectively care for these challenging patients: “I think you’ve got to take every experience with you. That’s what nursing’s all about and you learn something new every day.” (Gail) They built up a store of strategies they could try with patients to find out “what works well and what doesn’t” (Donald) and developed expertise over time. Factors facilitating and inhibiting caring for patients with delirium. Participants’ experiences were influenced by contextual factors that helped or hindered. These were grouped into: the environment of care, patient-related factors and nurse-related factors. Environmental factors such as high acuity, medical technology and devices, high workload made caring for these patients more difficult. It was easier to care for patients when interprofessional communication was good and when a culture of safety aided team cooperation. Individual nurse factors that were helpful included knowledge of and experience with delirium, being able to be calm and accepting with the patients and relationships with other nurses and the interprofessional team. Caring for these patients was more difficult when they were physiologically unstable, when the treatment for delirium or the need to maintain safety conflicted with the treatment for other clinical goals and when the patients were unsafe due to agitation. Family involvement was at times difficult, but was helpful when a partnership could be achieved. Fig. 2 illustrates the researchers’ interpretation of the factors contributing to the complexity of caring for patients. The participants navigated through these factors in order to find a way to help them come through it. The intersection of the circles indicates that these factors interacted within the circle and could also interact with factors present in the surrounding circles. In this view, the nurse interacted with the complexities of the patient and family as well as those of the ICU environment. Discussion Caring for patients with delirium in the ICU is a complex process and the participants in this study focused on: Finding a way to help
Please cite this article in press as: LeBlanc, A., et al., The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.09.002
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Fig. 2. Factors contributing to the complexity of caring for patients in ICU with delirium. A diagram of the researchers’ interpretation of the factors contributing to complexity of care that the nurses must navigate in order to find a way to help them come through it. Factors are grouped into patient-related, nurse-related, and environment-related factors. Intersecting circles indicate that these factors interact within the circle, and can also interact with factors present in the surrounding circles.
them come through it to provide person-centred care. The participants’ interpretation of their experience was bound by the nature of the ICU as a highly technological and interventionist space, the resources available and their relationships with team members, patients and families. These descriptions underscore the significant work that is required to manage these patients within the context of life threatening illness, high technology, family distress and interprofessional team care. Surveillance required to protect patients and themselves was unremitting throughout the workday and contributed to feeling exhausted. Increased strain and workload when caring for these patients has been reported in numerous studies (Jung et al., 2013; Mc Donnell and Timmins, 2012; Yue et al., 2015; Zamoscik et al., 2017). Significantly, the examples shared focused on descriptions of agitated behaviours. The participants appeared to equate delirium with agitation which could indicate an incomplete understanding of delirium. Current recommendations include that patients be assessed for delirium using tools such as the CAM-ICU at least once per nursing shift (Barr et al., 2013). However, many participants in this study did not trust the CAM-ICU results, or found it difficult to use in everyday practice. This is supported by findings from Oosterhouse et al. (2016) who observed that even when tools for identifying delirium were available, they were inconsistently used and that simply having a tool did not necessarily warrant its use. The participants in this current study assessed patients’ mental status moment by moment in order to plan and evaluate nursing care regardless of whether the patient was CAM-ICU positive or negative. The dichotomous categorisation of the CAM-ICU results clashed with the way the participants experienced these patients as changing moment by moment. However, they were expected to communicate with the interprofessional team using the CAM-ICU results. The
participants’ differing perceptions of the CAM-ICU suggest that its use in daily clinical practice is complicated. Oxenbøll-Collet et al. (2016) detailed similar concerns about the CAM-ICU from Danish nurses and physicians including that it should not replace nursing judgment and clinical assessment. Acknowledging the contribution of both moment by moment assessments and CAM-ICU results places the use of this tool within the realm of nursing judgment and not in opposition to it. Maintaining the patient’s safety was viewed as optimal and professional care. Interventions for safety included constant observation, verbal reorientation, a calm approach and using physical and/or chemical restraints as a last resort. Other studies have emphasized the need to keep an eye on patients (Dahlke and Phinney, 2008; Schmidt, 2010). Participants considered restraints necessary at times to maintain safety but were concerned about adverse effects such as over-sedation. Chemical restraints have been associated with increased length of ICU stay and delayed weaning from mechanical ventilation and therefore, their use should be minimized whenever possible (Barr et al., 2013). When adverse events did occur, such as an unplanned extubation, the participants in this current study felt personally at fault. As Schofield et al. (2012) noted, safety is one of the major discourses influencing nurses’ practice. The time required to assess and care for patients’ unique needs was stressed by the participants. Trying to connect with patients could be seen as a process of ‘getting to know’ the patient in the midst of delirium. The participants described tailoring their interventions, such as modifying noise and light, to meet the unique needs of each patient. Zolnierek defined knowing the patient as “in-depth knowledge of the patient’s patterns of responses and knowing the patient as a person” (2013, p. 3). Knowing the patient
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assists nurses to provide safe care, develop relationships and utilize expertise (Zolnierek, 2013). The subthemes Partnering with the family and Caring for the family echoed the findings of a study about the roles of family members of ICU patients (Frivold et al., 2015). They described the family members’ experience of being cared for by nurses and physicians as “being in a participating role” and “being in a receiving role” (p. 1). Family members who were able to participate in care activities and decision making, developed a sense of meaningfulness and those whose psychosocial needs were met were more likely to express feelings of confidence in the health care system (Frivold et al., 2015). Integrating family members into the routine care of ICU patients, irrespective of delirium, has been associated with improved communication and relationships with the health care team, reduced anxiety and improved satisfaction, as well as the potential for enhanced patient care (Al-Multair et al., 2013). Promising areas of research on partnering with families involve inclusion during rounds (Davidson et al., 2017), active involvement in care in adult ICUs (Liput et al., 2016) and even family interventions to reduce delirium (Mitchell et al., 2017). However, the extent to which family should be involved and maintaining the balance with providing adequate support remains unclear (Davidson et al., 2017; Olding et al., 2016). This study demonstrated the central role of experience in learning to care for these patients and developing expertise over time. When learning to care for patients with delirium attention must be paid to the complexities of the patient and family as well as those of the ICU environment. Combining an educational intervention for nurses with an intervention to promote discussion of delirium during interprofessional rounds may have a greater effect than either of the interventions alone. Further, integrating delirium into comprehensive ICU care including management of pain, agitation, early mobility and family engagement is likely to be more beneficial than focusing on delirium in isolation (Barnes-Daly et al., 2017). In this study, barriers and facilitators to caring for patients were contextually bound. Previous studies have identified factors that are important to consider when implementing new practices or guidelines related to delirium (Bassett et al., 2015; Carrothers et al., 2013; Oxenbøll-Collet et al., 2016). Improving care for these patients requires careful consideration of the barriers and facilitators present in the local context to achieve sustainable practice (Barnes-Daly et al., 2017; Bassett et al., 2015; Rowley-Conwy, 2017; Zamoscik et al., 2017). Finally, several participants described positive reactions to caring for patients with delirium. This finding was not present in any of the literature retrieved regarding the experience of caring for these patients. Participants felt energised and satisfied when they could see patients “coming out of the fog” or when they had been able to effectively manage the agitation. They described feeling privileged to work with these patients, loving their work and feeling “professional.” Further research would help to understand the impact of the nurse-patient relationship in contributing to the positive aspects of caring for patients with delirium. Since this study was conducted, the participating ICUs have embedded the CAM-ICU and the delirium protocol into a comprehensive care bundle that includes pain, early mobility, delirium, sleep and sedation assessments and interventions.
Limitations The intent of phenomenological inquiry is not to develop generalisable results that are applicable in all contexts. As such, the findings of this study may not be representative of the experience of all nurses who have cared for ICU patients with delirium. The participants were recruited from two ICUs in a large university affiliated
Canadian hospital and may not reflect the experiences of nurses in smaller, non-academic ICUs, or ICUs in other countries or contexts. The sample was non-random and therefore the participants may have had a particular interest in the study topic. A strength of this study is that the participants varied widely in age and years of experience and both males and females were represented. Conclusion This study examined intensive care nurses’ experiences of caring for patients with delirium. The essence of the experience was revealed to be: finding a way to help them come through it. In spite of the many challenges faced while caring for these patients, nurses found a way through the complexity to provide individualised, person-centred care to patients and their families. Many of the nurses who participated in this study found this care rewarding and felt privileged to do so. Conflicts of interest None. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical statement Ethical approval was obtained from the affiliated university’s and the participating institution’s research ethics boards (Ottawa Health Science Network Research Ethics Board). Informed consent was obtained from participants prior to each interview. Acknowledgements We would like to thank the participants for sharing their time and experiences. References Adamis, D., Rooney, S., Meagher, D., Mulligan, O., McCarthy, G., 2015. A comparison of delirium diagnosis in elderly medical inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 criteria. Int. Psychogeriatr. 27 (6), 883–889. Al-Multair, A., Plummer, V., O’Brien, A., Clerehan, R., 2013. Family needs and involvement in the intensive care unit: a literature review. J. Clin. Nurs. 22, 1805–1817. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association, Washington, DC. Awissi, D.K., Bégin, C., Moisan, J., Lachaine, J., Skrobik, Y., 2012. I-SAVE study: impact of sedation, analgesia, and delirium protocols evaluated in the intensive care unit: an economic evaluation. Ann. Pharmacother. 46 (1), 21–28. Balas, M.C., Vasilevskis, E.E., Burke, W.J., Boehm, L., Pun, B.T., Olsen, K.M., et al., 2012. Critical care nurses’ role in implementing the “ABCDE Bundle” into practice. Crit. Care Nurse 32 (2), 35–47. Balas, M.C., Burke, W.J., Gannon, D., Cohen, M.Z., Colburn, L., Bevil, C., et al., 2013. Implementing the ABCDE bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU pain, agitation and delirium (PAD) guidelines. Crit. Care Med. 41 (1), S116–27. Balas, M.C., Vasilevskis, E.E., Olsen, K.M., Schmidt, K.K., Shostrom, V., Cohen, M.Z., et al., 2014. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit. Care Med. 42 (5), 1024–1036. Barnes-Daly, M.A., Phillips, G., Ely, W., 2017. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6, 064 patients. Crit. Care Med. 45 (2), 171–178. Barr, J., Pandharipande, P.P., 2013. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 pain, agitation, and delirium guidelines in an integrated and interdisciplinary fashion. Crit. Care Med. 41 (1), S99–S115. Barr, J., Fraser, G.L., Puntillo, K., Ely, E.W., Gelinas, C., Dasta, J.F., et al., 2013. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit. Care Med. 41 (1), 263–306.
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Oxenbøll-Collet, M., Egerod, I., Christensen, V., Jensen, J., Thomsen, T., 2016. Nurses’ and physicians’ perceptions of Confusion Assessment Method for the intensive care unit for delirium detection: focus group study. Br. Assoc. Crit. Care Nurses, http://dx.doi.org/10.1111/nicc.12254. Page, V., Ely, E.W., 2015. Delirium in Critical Care, 2nd ed. Cambridge University Press, Cambridge. Pandharipande, P.P., Girard, T., Jackson, J., Morandi, A., Thompson, J., Pun, B., 2013. Long-term cognitive impairment after critical illness. New Engl. J. Med. 369, 1306–1316. Pisani, M.A., Kong, S.Y., Kasi, S.V., Murphy, T.E., Aaujo, K.L., Van Ness, P.H., et al., 2009. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am. J. Respir. Crit. Care Med. 180, 1092–1097. Reade, M.C., Finfer, S., 2014. Sedation and delirium in the intensive care unit. New Engl. J. Med. 370 (5), 444–454. Rowley-Conwy, G., 2017. Critical care nurses’ knowledge and practice of delirium assessment. Br. J. Nurs. 26 (7), 412–417. Salluh, J.I., Wang, H., Schneider, E.B., Nagaraja, N., Yenokyan, G., Damjluhi, A., et al., 2015. Outcome of delirium in critically ill patients: systematic review and metaanalysis. Br. Med. J. 350, 1–9. Schmidt, L.A., 2010. Making sure: registered nurses watching over their patients. Nurs. Res. 59 (6), 400–406. Schofield, I., Tolson, D., Fleming, V., 2012. How nurses understand and care for older people with delirium in the acute hospital: a critical discourse analysis. Nurs. Inq. 19 (2), 165–176. Shehabi, Y., Riker, R.R., Bokesh, P.M., Wisemandle, W., Shintani, A., Ely, W., 2010. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit. Care Med. 38 (12), 2311–2318. Vasilevskis, E.E., Morandi, A., Boehm, L., Pandharipande, P.P., Girard, T.D., Jackson, J.C., et al., 2011. Delirium and sedation recognition using validated instruments: reliability of bedside intensive care unit nursing assessments from 2007 to 2010. J. Am. Geriatr. Soc. 59 (Suppl. 2), S249–55. Whitehorne, K., Gaudine, A., Meadus, R., Solberg, S., 2015. Lived experience of the intensive care unit for patients who experienced delirium. Am. J. Crit. Care 24 (6), 474–479. Yue, P., Wang, L., Liu, C., Wu, Y., 2015. A qualitative study on experience of nurses caring for patients with delirium in ICUs in China: barriers, burdens and decision making dilemmas. Int. J. Nurs. Sci. 2, 2–8. Zamoscik, K., Godbold, R., Freeman, P., 2017. Intensive care nurses’ experiences and perceptions of delirium and delirium care. Intensive Crit. Care Nurs. 40, 94–100. Zolnierek, C., 2013. An integrative review of knowing the patient. J. Nurs. Scholarsh. 46 (1), 3–10. van Eijk, M.M., van den Boogaard, M., van Marum, R.J., Benner, P., Eikelenboom, P., Honing, M.L., et al., 2011. Routine use of the confusion assessment method for the intensive care unit: a multicenter study. Am. J. Respir. Crit. Care Med. 184 (3), 340–344. van Manen, M., Higgins, I., van der Riet, P., 2016. A conversation with Max van Manen on phenomenology in its original sense. Nurs. Health Sci. 18, 4–7. van Manen, M., 1997. Researching Lived Experience: Human Science for an Action Sensitive Pedagogy, 2nd ed. State University of New York Press, Albany, NY.
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Original article
The experience of intensive care nurses caring for patients with delirium: A phenomenological study Allana LeBlanc ∗ , Frances Fothergill Bourbonnais, Denise Harrison, Kelly Tousignant University of Ottawa, 75 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
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Article history: Received 5 January 2017 Received in revised form 31 August 2017 Accepted 1 September 2017 Keywords: Critical care Critical care nursing Delirium ICU delirium Intensive care Nursing Phenomenology
a b s t r a c t
Objectives: The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses’ experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients. Research methodology: This study utilised an interpretive phenomenological approach as described by van Manen. Setting: Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada. Findings: The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It’s Exhausting; Making a Picture of the Patient’s Mental Status; Keeping Patients Safe: It’s aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You. Conclusion: The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience. © 2017 Elsevier Ltd. All rights reserved.
Implications for clinical practice • • • •
The nurse-patient relationship is crucial and is reflected in the importance of moment by moment patient assessment. Building relationships with families is essential and contributes to both the assessment and management of these patients. Patient safety is an overarching concern as well as a challenge that is impacted by workload issues and teamwork. Experiential learning is essential in educating nurses about delirium.
Introduction Delirium is a temporary disturbance of attention and awareness that is associated with a change in cognition. It develops over a short period of time and tends to fluctuate in severity throughout the day (Adamis et al., 2015; American Psychiatric Association, 2013). Symptoms include disorientation, hallucinations or delusions, psychomotor agitation and/or hypoactivity and lethargy (Page and
∗ Corresponding author. Present address: Permanent address: Intensive Care Unit, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada. E-mail address: [email protected] (A. LeBlanc).
Ely, 2015). Delirium may affect greater than 80% of adult patients in intensive care units (ICU) and is associated with longer ICU and hospital length of stay, as well as increased mortality (Pisani et al., 2009; Shehabi et al., 2010). Other impacts of delirium in ICU patients include increased risk for long-term cognitive impairments, greater functional dependency following hospital discharge, increased frequency of patient safety events, decreased quality of life, short- and long-term emotional and psychological distress and increased hospital and health system costs (Awissi et al., 2012; Barr et al., 2013; Girard et al., 2010; Pandharipande et al., 2013; Salluh et al., 2015). Patients who have experienced delirium in the ICU describe feelings of fear and struggling to make meaning or to find human connection (Whitehorne et al., 2015). The emotional and
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Please cite this article in press as: LeBlanc, A., et al., The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.09.002
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psychological impacts can have consequences for patients after the delirium has resolved (Brummel et al., 2014; Pandharipande et al., 2013). Clinicians must be knowledgeable about delirium in ICU patients in order to identify it early and implement care and treatment strategies. Identifying delirium in an ICU setting can be challenging because patients are frequently unable to communicate due to their severe illness and/or endotracheal intubation. Key recommendations for delirium prevention and management include regular assessment for delirium with a valid and reliable tool, such as the Confusion Assessment Method for ICU (CAM-ICU), early mobilisation, targeting light levels of sedation, promoting sleep and using an interprofessional team approach to patient care (Barr et al., 2013). Increasingly, ICUs are implementing protocols aimed at preventing delirium and minimizing its impact on patient outcomes (Balas et al., 2013; Barr et al., 2013; Barr and Pandharipande, 2013; Reade and Finfer, 2014). Intensive care nurses typically coordinate and participate in implementing these protocols for the patients under their care (Balas et al., 2012; Balas et al., 2014). However, the successful use of such protocols can be challenging in daily practice due to a variety of organisational and human factors (Balas et al., 2013; Barr et al., 2013; Basset et al., 2015; Carrothers et al., 2013; Zamoscik et al., 2017). Additionally, Belanger and Ducharme (2011) have pointed out that such protocols rarely provide guidance on establishing therapeutic relationships with patients with delirium, or techniques that might reduce the negative emotional consequences of the experience for patients and their families. Studies on the nursing care of critically ill patients with delirium have tended to focus on the accuracy and use of assessment tools, risk factors, prevention, pharmacological and non-pharmacological interventions, physical restraints, nurses’ beliefs and protocol compliance and implementation, (Balas et al., 2014; Bassett et al., 2015; Carrothers et al., 2013; Freeman et al., 2015; Gesin et al., 2012; Oosterhouse et al., 2016; Oxenbøll-Collet et al., 2016; van Eijk et al., 2011; Vasilevskis et al., 2011). Implementing best practices for patients with delirium depends largely on the knowledge and skill of nurses and their ability to communicate and coordinate effectively with the interprofessional team (Balas et al., 2013; Bassett et al., 2015; Oxenbøll-Collett et al., 2016). Despite the frequency with which intensive care nurses encounter these patients, inquiries into nurses’ experiences in the ICU setting are limited. The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) to examine intensive care nurses’ experiences of caring for adult patients with delirium; and 2) to identify factors that facilitated or hindered intensive care nurses caring for these patients.
Methods Design. Van Manen’s approach, based in the hermeneutic phenomenological tradition, provided the methodological lens for this study (van Manen, 1997). He describes hermeneutic phenomenological research as the study of a person’s lived experience (the person’s reality as it is immediately experienced in the world). The findings of phenomenological research reveal an ‘understanding’ of the moment (van Manen et al., 2016) so that persons who have had, or could have had that experience, can recognize it. Setting. Participants in this study were recruited from two ICUs in a university- affiliated, tertiary care academic health care centre in Canada. One ICU had 27 beds for patients with neurosurgical, trauma, vascular and general medical-surgical conditions while the other ICU had 26 beds with primarily oncology, pulmonary and medical-surgical patients. Both units had a policy of delirium
assessment by the bedside nurse each shift using the CAM-ICU and a delirium protocol was available to use for patients who screened positive. The delirium protocol consisted of a physician’s order set for pharmacologic and non-pharmacologic interventions for delirium. Participants. Prior to data collection, meetings were held with the nursing managers and educators to explain the study. Nursing staff were then notified about the study by informational posters and emails. A purposive sample of eight intensive care registered nurses was recruited. Inclusion criteria were: 1) Registered nurse (RN) who has cared for intensive care unit patient(s) with delirium in the last 12 months; 2) employed full or part-time in the unit, with greater than one year of intensive care experience. The participants’ ages ranged from 21 to 60 years, years of nursing experience was from one to >35 years and ICU experience varied from one year to >25 years. Therefore, the sample consisted of less experienced as well as very experienced nurses. Five participants were male and three were female. Data collection. One-to-one interviews of approximately one hour were held in a conversational style using open-ended questions. Participants were invited to share personal stories or anecdotes to stimulate their recollections and to provide rich data. A reflexive journal was maintained to record methodological decisions, initial assumptions and impressions throughout the data collection process. Having eight participants with varied experience levels describe caring for patients with delirium facilitated obtaining thick and rich descriptions (Morse, 2015). Overlapping of key issues occurred in the transcribed data by the eighth interview. Data analysis. The researchers analysed the interview transcripts (text) to reveal the essence of the lived experience of intensive care nurses caring for patients with delirium. The process of data analysis was based on three approaches to textual analysis as described by van Manen (1997): (1) Holistic approach: The researcher read the transcript (text) as a whole to try to capture a sense of its overall significance; (2) Selective or highlighting approach: The researcher returned to the text regularly in order to underline within the participants’ statements those phrases that were revealing to the experience under study. Revealing statements were collected and sorted into folders and re-examined until themes and subthemes emerged. (3) Detailed line- by- line approach: The researcher read every line of the text and asked what it revealed about the phenomenon. Quotations which supported themes were extracted from the data. The relationship both within and between themes was analysed until a comprehensive description of the experience of participants was uncovered. Ethical approval. Ethical approval was obtained from the affiliated university’s and the participating institution’s research ethics boards, approval number 20140066-01H. Informed consent was obtained from participants prior to each interview. Methods to ensure rigor. Trustworthiness of the findings was established using the criteria outlined by Lincoln and Guba (1985): credibility, transferability, confirmability and dependability. To ensure credibility (truth value), the first author (an MScN student at that time) had consistent consultation with the members of her thesis committee who had expertise in nursing, delirium, critical care and qualitative research. Member check interviews were employed for participants to comment on the research findings and themes (Noble and Smith, 2015). To enhance transferability, detailed descriptions of the setting have been presented, as well as descriptions of participants. Confirmability refers to the extent to which the study findings originate from the experiences of the participants and not as a result of researcher supposition or bias (Lincoln and Guba, 1985). Quotes from the participants were used to explicate each theme to ensure confirmability. In addition, the second author read all the transcripts and assisted in developing themes which were then verified by the remaining authors. To
Please cite this article in press as: LeBlanc, A., et al., The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.09.002
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can be frustrating for the nurse and the patient, participants described trying to meet patient’s needs for safety and for delivering care: “Most of the stories are all the same. The worst one is when they have no idea of where they are and their main goal is getting home. It doesn’t matter what you tell them or what they’re hooked up to, they’re climbing out of bed. . . .it could be dangerous. So you’re constantly going back to the bedside.” (Steven) Participants described in the subtheme Not being able to give optimal care, how difficult it was to provide care when patients were uncooperative or unable to communicate: “There may be some hidden needs that are very necessary that I can’t identify. I would not be able to give them the best care that I could so I find this is quite hard.” (Jessica) This left participants feeling dissatisfied. Participants experienced frustration when there was lack of agreement among the health care team about how to manage patients’ agitation. The subtheme Being on guard o described the experience of caring for disorientated, agitated patients. Being on guard meant maintaining personal safety as well as the patients’ safety: “If you get report that this patient is going to be fighting you and aggressive. You just get this feeling, ‘Oh this is going to be a long day.”’ (Steven) Conversely, the subtheme Feeling challenged revealed how working with these patients could be a positive experience when participants felt they were able to nurse them effectively (Alan, Steven, Donald, Ben, Joann) even if the patients’ symptoms did not fully resolve: “I find it is a challenge but I like that challenge because I find it very rewarding and I can just calm my patient with talking.” (Alan) Taking on the challenge was easier when the participants felt they had support and ‘a plan’ for managing the patient. Making a picture of the patients’ mental status. Participants drew upon professional knowledge, previous experiences with patients, as well as information from family members to fill in this picture. They noted behaviours, monitored for changes and sometimes used the CAM-ICU. Considered together, all of this information helped participants to make a picture of the patients’ mental status in the moment. This picture was continually revised:
Fig. 1. Overview of themes and subthemes. A diagram of themes and subthemes that emerged from the analysis. The essence of the experience was finding a way to help them come through it.
enhance dependability, the researcher maintained a decision trail to record methodological decisions as well as decisions related to data analysis (Noble and Smith, 2015). Findings The essence of the experience of intensive care nurses caring for adult patients with delirium can be described as finding a way to help them come through it. Participants were challenged to find ways to provide safe, person-centred care in order to help patients come through the temporary state of delirium. Six themes emerged: It’s Exhausting; Making a Picture of the Patient’s Mental Status; Keeping Patients Safe: It’s a Really Big Job; Everyone is Unique; Riding it Out with Families; and Taking Every Experience With You. (See Fig. 1. Overview of Themes and Subthemes.) It’s exhausting. Participants described feeling mentally and emotionally exhausted by their efforts to care for patients with symptoms of disorientation and/or agitation. In the subtheme It
“We have our tools in the ICU like our CAM score...But also by just observing the patient. See how he is responding. (. . .) and you sort of start making a picture of how their mental status is.” (Alan) The subtheme Assessing the patient as a whole described the participants’ holistic assessments which included baseline level of function, medical history, current status and treatment plan, past and present interventions and “getting a sense of what is normal for him” (Gary) from family. Participants made note of small changes and continuously assessed for altered mental status as described in the subtheme Filling in the picture: moment by moment: “He was calmer. Things seem to start to come back as to why he was in the hospital. Start to recall the surgery that he had whereas before he didn’t know what he had, where he was.” (Steven) Some participants stated that moment by moment assessments were not “believed” by the medical team and that they needed other strategies to communicate. Some would call the physician to the bedside to “capture the moment” (Gail), others used the CAM-ICU findings to be “believed”: “I get people to believe me by objective evidence [emphatic tonelaughs]. So, using your CAM tool.” (Ben)
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Not all participants considered the CAM-ICU helpful for assessing patients. The subtheme Using tools but using judgment described how participants used, or did not use, the CAM-ICU and other scales, such as the Richmond Agitation Sedation Scale and the delirium protocol into their daily practice. “We have to fill out forms, we have to sign here we have to sign there. It becomes sort of a cookie cutter nursing. Where is my professional autonomy here?” (Alan) Participants who did use the CAM-ICU varied in how they applied it with patients and some mistrusted the results: “I guess there are patients that’ll be fine on the CAM . . . but they could get all the questions right but still be seeing things everywhere, confused.” (Steven) All of the participants who used the CAM-ICU in any way supplemented their findings with other assessments to make a picture of the patient’s mental status. Few participants had used the delirium protocol. Those who did found it helpful to obtain drug orders from physicians. None of the participants considered it helpful to guide non-pharmacologic interventions. Keeping patient’s safe: it’s a really big job. This theme reflected the challenges participants faced when patients were disoriented, agitated, or unable to protect themselves from harm: “When he started to get really agitated and restless. He totally could not recognize any person now and [he was] just agitated and just kept climbing out of the bed. . . and just keeping him safe is a really big job.” (Jessica) These patients required the continuous presence of the nurse to ensure that they did not harm themselves (e.g. by accidentally removing a life-supporting device). The subtheme Keeping an eye on the patient reflected the vigilance required which was difficult in a busy environment and sometimes impossible to do alone: “the fridge is in the middle of the unit. So it takes us about a minute to go and get the [medication] and come back. . .and with those kinds of patients, a minute, everything could happen in a minute.” (Gary) The subtheme Knowing when and how to respond revealed that participants prioritized when to intervene and how to manage patient care: “It means putting other things aside and treating the immediate needs. . . I have to divert my attention to helping them with whatever is happening right now.” (Ben) This subtheme contained participants’ thoughts about chemical and physical restraint which were considered last resort: “Sometimes you just have to physically restrain them. . . to make it safe for him and for you. . . It’s not nice but sometimes you have to. We’ll give medications for it. . . hopefully calm it down.” (Steven) They expressed concerns about adverse effects of sedation, such as prolonged ICU stay. Everyone is unique. This theme captured the efforts taken to provide person-centred care. The participants used their knowledge of each patient to tailor their interventions and drew upon past experiences: “I find that everyone is unique and every patient is unique in how you care for them. As long as you have the support behind you. We’re there to help them and we’re there to support them and when you have a great team behind you, you can do it.” (Gail) Additional nursing time was needed to care for these patients. The subtheme Taking the time also revealed that mind set was
important, participants described needing to be ‘patient’, or ‘accept’ who the patient was at that moment in time (Gail, Ben Alan, Donald, Steven). Taking the time involved: “being a willing participant to the care that you give to your patient. Instead of rushing and getting through everything you might have to take extra time to do things with the patient. . . and be calm and be kind to patients too.” (Gail) In the subtheme, Finding the proper way, the participants described using trial and error to find effective strategies. For example, manipulating the environment by modifying noise and light, or providing comfort by bathing or repositioning, ‘just open the curtains so they can see it’s daylight’ (Joann). They used knowledge and clinical judgment to tailor practices to patients’ individual needs. Riding it out with families. This theme captured the experiences that were shared with families. Two subthemes emerged: Partnering with the family to work together to care for the patient more effectively and Caring for the family in which participants provided direct emotional and educational interventions. Participants described moving back and forth between these roles: “It was him and his wife. (. . .) I explained to her that he would come through this. She calmed down. She was able to talk with him a little more. (. . .) And for the next two days − me and her − we just rode it out (. . .) and it worked out fine.” (Steven) Taking every experience with you. This theme involved building up personal resources, skills and knowledge to effectively care for these challenging patients: “I think you’ve got to take every experience with you. That’s what nursing’s all about and you learn something new every day.” (Gail) They built up a store of strategies they could try with patients to find out “what works well and what doesn’t” (Donald) and developed expertise over time. Factors facilitating and inhibiting caring for patients with delirium. Participants’ experiences were influenced by contextual factors that helped or hindered. These were grouped into: the environment of care, patient-related factors and nurse-related factors. Environmental factors such as high acuity, medical technology and devices, high workload made caring for these patients more difficult. It was easier to care for patients when interprofessional communication was good and when a culture of safety aided team cooperation. Individual nurse factors that were helpful included knowledge of and experience with delirium, being able to be calm and accepting with the patients and relationships with other nurses and the interprofessional team. Caring for these patients was more difficult when they were physiologically unstable, when the treatment for delirium or the need to maintain safety conflicted with the treatment for other clinical goals and when the patients were unsafe due to agitation. Family involvement was at times difficult, but was helpful when a partnership could be achieved. Fig. 2 illustrates the researchers’ interpretation of the factors contributing to the complexity of caring for patients. The participants navigated through these factors in order to find a way to help them come through it. The intersection of the circles indicates that these factors interacted within the circle and could also interact with factors present in the surrounding circles. In this view, the nurse interacted with the complexities of the patient and family as well as those of the ICU environment. Discussion Caring for patients with delirium in the ICU is a complex process and the participants in this study focused on: Finding a way to help
Please cite this article in press as: LeBlanc, A., et al., The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.09.002
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Fig. 2. Factors contributing to the complexity of caring for patients in ICU with delirium. A diagram of the researchers’ interpretation of the factors contributing to complexity of care that the nurses must navigate in order to find a way to help them come through it. Factors are grouped into patient-related, nurse-related, and environment-related factors. Intersecting circles indicate that these factors interact within the circle, and can also interact with factors present in the surrounding circles.
them come through it to provide person-centred care. The participants’ interpretation of their experience was bound by the nature of the ICU as a highly technological and interventionist space, the resources available and their relationships with team members, patients and families. These descriptions underscore the significant work that is required to manage these patients within the context of life threatening illness, high technology, family distress and interprofessional team care. Surveillance required to protect patients and themselves was unremitting throughout the workday and contributed to feeling exhausted. Increased strain and workload when caring for these patients has been reported in numerous studies (Jung et al., 2013; Mc Donnell and Timmins, 2012; Yue et al., 2015; Zamoscik et al., 2017). Significantly, the examples shared focused on descriptions of agitated behaviours. The participants appeared to equate delirium with agitation which could indicate an incomplete understanding of delirium. Current recommendations include that patients be assessed for delirium using tools such as the CAM-ICU at least once per nursing shift (Barr et al., 2013). However, many participants in this study did not trust the CAM-ICU results, or found it difficult to use in everyday practice. This is supported by findings from Oosterhouse et al. (2016) who observed that even when tools for identifying delirium were available, they were inconsistently used and that simply having a tool did not necessarily warrant its use. The participants in this current study assessed patients’ mental status moment by moment in order to plan and evaluate nursing care regardless of whether the patient was CAM-ICU positive or negative. The dichotomous categorisation of the CAM-ICU results clashed with the way the participants experienced these patients as changing moment by moment. However, they were expected to communicate with the interprofessional team using the CAM-ICU results. The
participants’ differing perceptions of the CAM-ICU suggest that its use in daily clinical practice is complicated. Oxenbøll-Collet et al. (2016) detailed similar concerns about the CAM-ICU from Danish nurses and physicians including that it should not replace nursing judgment and clinical assessment. Acknowledging the contribution of both moment by moment assessments and CAM-ICU results places the use of this tool within the realm of nursing judgment and not in opposition to it. Maintaining the patient’s safety was viewed as optimal and professional care. Interventions for safety included constant observation, verbal reorientation, a calm approach and using physical and/or chemical restraints as a last resort. Other studies have emphasized the need to keep an eye on patients (Dahlke and Phinney, 2008; Schmidt, 2010). Participants considered restraints necessary at times to maintain safety but were concerned about adverse effects such as over-sedation. Chemical restraints have been associated with increased length of ICU stay and delayed weaning from mechanical ventilation and therefore, their use should be minimized whenever possible (Barr et al., 2013). When adverse events did occur, such as an unplanned extubation, the participants in this current study felt personally at fault. As Schofield et al. (2012) noted, safety is one of the major discourses influencing nurses’ practice. The time required to assess and care for patients’ unique needs was stressed by the participants. Trying to connect with patients could be seen as a process of ‘getting to know’ the patient in the midst of delirium. The participants described tailoring their interventions, such as modifying noise and light, to meet the unique needs of each patient. Zolnierek defined knowing the patient as “in-depth knowledge of the patient’s patterns of responses and knowing the patient as a person” (2013, p. 3). Knowing the patient
Please cite this article in press as: LeBlanc, A., et al., The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.09.002
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assists nurses to provide safe care, develop relationships and utilize expertise (Zolnierek, 2013). The subthemes Partnering with the family and Caring for the family echoed the findings of a study about the roles of family members of ICU patients (Frivold et al., 2015). They described the family members’ experience of being cared for by nurses and physicians as “being in a participating role” and “being in a receiving role” (p. 1). Family members who were able to participate in care activities and decision making, developed a sense of meaningfulness and those whose psychosocial needs were met were more likely to express feelings of confidence in the health care system (Frivold et al., 2015). Integrating family members into the routine care of ICU patients, irrespective of delirium, has been associated with improved communication and relationships with the health care team, reduced anxiety and improved satisfaction, as well as the potential for enhanced patient care (Al-Multair et al., 2013). Promising areas of research on partnering with families involve inclusion during rounds (Davidson et al., 2017), active involvement in care in adult ICUs (Liput et al., 2016) and even family interventions to reduce delirium (Mitchell et al., 2017). However, the extent to which family should be involved and maintaining the balance with providing adequate support remains unclear (Davidson et al., 2017; Olding et al., 2016). This study demonstrated the central role of experience in learning to care for these patients and developing expertise over time. When learning to care for patients with delirium attention must be paid to the complexities of the patient and family as well as those of the ICU environment. Combining an educational intervention for nurses with an intervention to promote discussion of delirium during interprofessional rounds may have a greater effect than either of the interventions alone. Further, integrating delirium into comprehensive ICU care including management of pain, agitation, early mobility and family engagement is likely to be more beneficial than focusing on delirium in isolation (Barnes-Daly et al., 2017). In this study, barriers and facilitators to caring for patients were contextually bound. Previous studies have identified factors that are important to consider when implementing new practices or guidelines related to delirium (Bassett et al., 2015; Carrothers et al., 2013; Oxenbøll-Collet et al., 2016). Improving care for these patients requires careful consideration of the barriers and facilitators present in the local context to achieve sustainable practice (Barnes-Daly et al., 2017; Bassett et al., 2015; Rowley-Conwy, 2017; Zamoscik et al., 2017). Finally, several participants described positive reactions to caring for patients with delirium. This finding was not present in any of the literature retrieved regarding the experience of caring for these patients. Participants felt energised and satisfied when they could see patients “coming out of the fog” or when they had been able to effectively manage the agitation. They described feeling privileged to work with these patients, loving their work and feeling “professional.” Further research would help to understand the impact of the nurse-patient relationship in contributing to the positive aspects of caring for patients with delirium. Since this study was conducted, the participating ICUs have embedded the CAM-ICU and the delirium protocol into a comprehensive care bundle that includes pain, early mobility, delirium, sleep and sedation assessments and interventions.
Limitations The intent of phenomenological inquiry is not to develop generalisable results that are applicable in all contexts. As such, the findings of this study may not be representative of the experience of all nurses who have cared for ICU patients with delirium. The participants were recruited from two ICUs in a large university affiliated
Canadian hospital and may not reflect the experiences of nurses in smaller, non-academic ICUs, or ICUs in other countries or contexts. The sample was non-random and therefore the participants may have had a particular interest in the study topic. A strength of this study is that the participants varied widely in age and years of experience and both males and females were represented. Conclusion This study examined intensive care nurses’ experiences of caring for patients with delirium. The essence of the experience was revealed to be: finding a way to help them come through it. In spite of the many challenges faced while caring for these patients, nurses found a way through the complexity to provide individualised, person-centred care to patients and their families. Many of the nurses who participated in this study found this care rewarding and felt privileged to do so. Conflicts of interest None. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical statement Ethical approval was obtained from the affiliated university’s and the participating institution’s research ethics boards (Ottawa Health Science Network Research Ethics Board). Informed consent was obtained from participants prior to each interview. Acknowledgements We would like to thank the participants for sharing their time and experiences. References Adamis, D., Rooney, S., Meagher, D., Mulligan, O., McCarthy, G., 2015. A comparison of delirium diagnosis in elderly medical inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 criteria. Int. Psychogeriatr. 27 (6), 883–889. Al-Multair, A., Plummer, V., O’Brien, A., Clerehan, R., 2013. Family needs and involvement in the intensive care unit: a literature review. J. Clin. Nurs. 22, 1805–1817. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association, Washington, DC. Awissi, D.K., Bégin, C., Moisan, J., Lachaine, J., Skrobik, Y., 2012. I-SAVE study: impact of sedation, analgesia, and delirium protocols evaluated in the intensive care unit: an economic evaluation. Ann. Pharmacother. 46 (1), 21–28. Balas, M.C., Vasilevskis, E.E., Burke, W.J., Boehm, L., Pun, B.T., Olsen, K.M., et al., 2012. Critical care nurses’ role in implementing the “ABCDE Bundle” into practice. Crit. Care Nurse 32 (2), 35–47. Balas, M.C., Burke, W.J., Gannon, D., Cohen, M.Z., Colburn, L., Bevil, C., et al., 2013. Implementing the ABCDE bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU pain, agitation and delirium (PAD) guidelines. Crit. Care Med. 41 (1), S116–27. Balas, M.C., Vasilevskis, E.E., Olsen, K.M., Schmidt, K.K., Shostrom, V., Cohen, M.Z., et al., 2014. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit. Care Med. 42 (5), 1024–1036. Barnes-Daly, M.A., Phillips, G., Ely, W., 2017. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6, 064 patients. Crit. Care Med. 45 (2), 171–178. Barr, J., Pandharipande, P.P., 2013. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 pain, agitation, and delirium guidelines in an integrated and interdisciplinary fashion. Crit. Care Med. 41 (1), S99–S115. Barr, J., Fraser, G.L., Puntillo, K., Ely, E.W., Gelinas, C., Dasta, J.F., et al., 2013. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit. Care Med. 41 (1), 263–306.
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