Clinical Nurse SpecialistA Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
Feature Article The Impact of a Delirium Educational Intervention With Intensive Care Unit Nurses Genna Speed, MSN, RN, ACCNS-AG, CCRN
Background: Delirium is a frequently encountered condition in critically ill patients that has significant clinical impacts. Associated costs for patients impacted by delirium are higher, including a 39% higher intensive care unit (ICU) cost and 31% higher hospital costs, yet delirium goes unnoticed in up to 72% of cases. If ICU nurses are not aware of risk factors and presentation of delirium, the condition may go unrecognized, allowing for development of negative sequelae. Objectives: The purpose of this research study was to examine delirium knowledge levels of ICU nurses at a single level I trauma hospital both before and after a tailored educational intervention. Methods: A preintervention/postintervention research study design in conjunction with a tailored educational intervention was utilized. Preintervention/postintervention delirium knowledge testing was completed through the use of the Nurses’ Knowledge of Delirium Questionnaire. Results: The results indicated a significant difference in preintervention scores (mean, 74.65 [SD, 8.68]) and postintervention scores (mean, 84.95 [SD, 5.73]); t23 = j5.256, P = .000. These results suggest that an educational intervention does have an impact on ICU nurses’ knowledge level of delirium. Conclusions: If ICU nurses are not aware of the fluctuating nature of delirium and its varied clinical presentations, they cannot be expected to consistently identify its development when providing care. Through educational activities, it is possible to increase team
Author Affiliation: Graduate Student, Department of Nursing, Armstrong Atlantic State University, Savannah, Georgia. There are no funding sources to report. The author report no conflicts of interest. Correspondence: Genna Speed, MSN, RN, ACCNS-AG, CCRN, Armstrong Atlantic State University, 22207 Tower Ter, San Antonio, TX 78234 ([email protected]). DOI: 10.1097/NUR.0000000000000106
Clinical Nurse Specialist
member knowledge levels, potentially resulting in increased identification of delirium and a reduction in negative sequelae. KEY WORDS: continuing education, delirium, nurse clinicians, nursing
D
elirium is a frequently encountered condition in the critical care patient population that has significant clinical impacts with prevalence rates ranging from 32% to 87% in the intensive care unit (ICU) patient.1Y7 Delirium is a mental disorder that results in a change in cognition and subsequent disruption in awareness or attention. The onset of delirium may be acute or subacute and has a fluctuating nature. The cornerstone characteristic of delirium is confusion, and patients may exhibit a range of behavior from hypoactive to hyperactive states.1 The range in behavior of patients experiencing delirium exemplifies the varied nature and subtypes of delirium, including hyperactive, hypoactive, and mixed subtypes. Hyperactive delirium can demonstrate restlessness, agitation, and aggression, whereas at the opposite end of the spectrum, hypoactive delirium exhibits a slowing or absence of movement, a decrease in patient communication, and unresponsiveness. In mixed delirium, the patient demonstrates characteristics of both hyperactive and hypoactive delirium.8 Hyperactive delirium is typically more easily identified by members of the healthcare team and is associated with lower rates of mortality, yet it occurs less frequently than hypoactive or mixed-type delirium. In contrast, hypoactive delirium states often go unrecognized or are misdiagnosed, potentially contributing to higher rates of mortality in patients experiencing this type of delirium.1 The overall etiology of delirium remains poorly understood. Associated healthcare costs for those patients impacted by delirium are higher, including a 39% higher ICU and 31% higher hospital cost compared with patients who do not develop delirium, even after adjusting for age, comorbidities, severity of illness, degree of organ dysfunction, and other confounders.4 Delirium is associated with a 3-fold increase in mortality 6 months after discharge, even after
A
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89
Feature Article controlling for variables such as preexisting disease processes and severity of illness.3 Despite these notable consequences, delirium goes unnoticed by healthcare team members in as many as 32% to 72% of patients who experience this condition.9,10 Prompt identification of and intervention for delirium in hospitalized patients are imperative to defend against the negative sequelae associated with this condition.9,11Y13 The magnitude of the impact of delirium warrants continued focus on education for staff members, early screening and assessment of critically ill patients, and research concerning the care of patients affected by this condition.
BACKGROUND Despite the sequelae associated with the development of delirium in ICU patients, nurses’ knowledge regarding delirium has been demonstrated to be low in various studies.11,14,15 In a research study examining nurses’ knowledge regarding delirium and its associated risk factors, the mean for correctly answering the knowledge questions was found to be 64.91%, whereas the mean for correctly answering the risk factor questions was found to be 46.15%.15 In another research study examining medical-surgical and ICU nurses’ knowledge of signs and symptoms of delirium, recognition of delirium outcomes, and nursing confidence concerning delirium, it was revealed that almost 25% of the nurses surveyed did not identify delirium as a problem within their care setting. Whereas 90% of participants could positively identify signs and symptoms associated with hyperactive delirium, less than 77% of participants were able to successfully identify symptoms associated with a hypoactive presentation of delirium.11 In a study examining the delirium knowledge of only ICU nurses, it was demonstrated that nurses in general had a moderate to low level of knowledge related to delirium, with a mean score of 64.4% on a 25-item questionnaire.14 The low percentage of correctly answered items in these studies has significant implications for patient care and prevention of delirium. Improved knowledge may assist nurses and other members of the healthcare team to identify or even prevent the development of delirium, mitigating some of the negative sequelae associated with delirium. The inability of nurses to effectively assess for delirium is an area of great concern, and continued education of nurses regarding detection of delirium and its key features during care of critically ill patients is warranted alongside more traditional staff education measures, such as pain assessment.13,16 STATEMENT OF PURPOSE Failure to recognize delirium in ICU patients may be attributed to several factors, including knowledge deficits possessed by healthcare providers caring for the patient population, particularly deficits regarding patient presentation of delirium as well as risk factors associated with delirium. If nursing 90
staff members are not aware of the risk factors and presentation of delirium, the condition may go unrecognized, allowing for the development of additional negative sequelae secondary to delirium’s presence.1,11 One of the aims of this research study was to examine the preintervention delirium knowledge level of nurses within the ICU environment at a single level I trauma hospital. An additional aim of this research study was to examine the effect of an educational intervention on the delirium knowledge level of ICU nurses. A preintervention/postintervention design in conjunction with a tailored educational intervention was utilized. The knowledge level of ICU nurses was assessed both before and after a tailored educational intervention, and factors such as educational background, length of ICU experience, and specific shift worked were considered. Preintervention knowledge levels were used to tailor the education intervention.
METHODS This research study was a quasi-experimental 1-group pretestposttest design that was conducted over a 2-month period. The major components of the research included the Nurses’ Knowledge of Delirium Questionnaire (NKDQ) (see Instrumentation) and the educational intervention. An online survey application, SurveyMonkey, was used for completion of all NKDQs. Participants completed the NKDQ 2 weeks prior to the educational intervention and then again 1 month after receiving the educational intervention. The NKDQ completed prior to the educational intervention was considered the pretest, and the NKDQ completed after the educational intervention was considered the posttest for each participant. In order to limit attrition during the study, participants completing all 3 phases of the study (pretest, educational intervention, and posttest) were eligible to receive one of three $20 Visa gift cards. During completion of the NKDQ, participants used the last 4 digits of their hospital identification badge number as an identifier when completing the NKDQ. Only the primary investigator had access to the NKDQ results. The data reported were compiled from the participants’ responses on the questionnaires, which contained background demographic information and responses concerning each participant’s knowledge of delirium and its risk factors. Those NKDQs that did not have a pretest and posttest pairing by the last 4 digits of a hospital identification badge number were not included in the data interpretation. All material that was produced in hard copy was kept in a locked cabinet. After an elapsed period of 1 year post-study, all materials generated were destroyed. The results of each NKDQ completion were calculated, examining preintervention knowledge level, postintervention knowledge level, and any potential correlation or difference in knowledge regarding delirium related to professional educational background, length of ICU experience, or shift worked.
www.cns-journal.com
March/April 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sample The convenience sample for this research study included registered nurses (RNs) working in the ICUs of a 610-bed nonprofit academic level I trauma hospital. To be eligible to participate, an RN must have been working in 1 of the 4 ICUs at the beginning of the study, remain employed in 1 of the 4 ICUs for the duration of the study, and be primarily assigned to 1 of the ICU cost centers. Registered nurses who were float pool nurses (non-ICU cost center), who were not working in 1 of the ICUs at the outset of the study, or who did not remain employed in 1 of the 4 ICUs for the duration of the study were not eligible to participate. At the time of the study, there were 89 RNs eligible to participate. Each RN was recruited to participate through the use of a target-audience employee e-mail and unit-based announcement flyers. Protection of Human Rights The institutional review board of the hospital where the research was conducted and the university of the primary researcher approved the research study in advance. Written consent from each participant was obtained, and each participant was provided an electronic copy of the consent form with the target-audience employee e-mail. Instrumentation The research instrument used in this study was based on an instrument previously used in another research study examining nurses’ knowledge of delirium.15 Permission to use the instrument was obtained by the instrument’s original developers. While the instrument was not given a formal title in the previous study, it was labeled the NKDQ. The NKDQ has not been formally validated, nor has its reliability been established at the time of this research. Despite this, the questionnaire has been used in at least 12 different countries, including in the United Kingdom where the National Health Service has employed it in a system-wide education program. The National Health Service is conducting a validation study for the instrument, but the results of the validation study were not yet available at the time of this current research study (M. Hare, e-mail communication, May 13, 2013). The NKDQ was divided into sections. The first section consisted of items designed to collect the demographic data of participants, including information regarding the participant’s highest level of nursing education completed, number of years practicing as an RN, number of years practicing as an RN in an intensive care environment, predominant shift worked, and specific area of practice. It also required the participants to report whether they had ever cared for a patient with delirium and, if the answer was yes, how often this occurred. Final items in this section required participants to identify if they had ever received formal education concerning delirium, as well as their perception of their indiClinical Nurse Specialist
vidual knowledge competency concerning delirium. All items in this section contained categorical response options. The second section of the NKDQ, which consisted of 36 items related to delirium and its associated risk factors, was used to calculate scores for each participant. The first of these items required the participants to select the multiplechoice option that best described or defined delirium. For the next 7 items, participants were required to select the condition that a given rating scale or instrument most appropriately evaluated for, with answer multiple-choice options that consisted of ‘‘delirium,’’ ‘‘dementia,’’ ‘‘depression,’’ or ‘‘none of these.’’ For these 7 items, participants were able to select more than one option for each scale/instrument if the scale/instrument was believed to evaluate for multiple conditions. In the final portion of the questionnaire, participants were required to select ‘‘agree,’’ ‘‘disagree,’’ or ‘‘unsure’’ for 28 different statements related to delirium. Of these 28 statements, 14 were related to basic delirium knowledge, and 14 were related to risk factors for the development of delirium. This research sought to examine the correct response percentage score, or knowledge level of items in section 2, both before and after a tailored educational intervention. Educational Intervention A review of the literature was utilized to shape the content of the educational intervention and address the knowledge deficits of the ICU nurses participating. Those items on the initial, or pretest, NKDQ with the lowest correct responses were stressed during the educational intervention. The educational intervention was 20 minutes in length and discussed the various aspects of delirium, including causes and signs and symptoms of delirium. Participants were able to select 1 of 10 possible educational intervention sessions to attend. Each session occurred in a centrally located ICU conference room and utilized the audiovisual equipment located therein to present the information. The educational intervention was delivered by PowerPoint and used basic presentation, case study, and interactive discussion techniques. The primary researcher conducted all educational intervention sessions. A handout with resources on delirium was also provided to each participant at the conclusion of the intervention. Collection and Analysis of Data The NKDQ was used for both the preintervention and postintervention data collection. Utilizing features available through the SurveyMonkey Web site, unique target-audience e-mails were distributed for both the preintervention and postintervention data collection that contained primary investigator contact information, basic instructions for completing the NKDQ, and a hyperlink to access the NKDQ via the Internet. Responses to each NKDQ were then electronically downloaded into an Excel spreadsheet database. Responses for
A
www.cns-journal.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
91
Feature Article both the preintervention data set and postintervention data set were manually crosschecked with the answer key, and the percentage correct (score) for each NKDQ was added to the database. The preintervention and postintervention scores were then exported to Statistical Package for Social Sciences software version 18 (SPSS Inc, Chicago, Illinois) for analysis.
Table. Demographics and Self-reported
Delirium Items for Participants Completing All Study Requirements (n = 24) Variable
No. (%) of Registered Nurses (RNs)
Professional educational background
RESULTS Of the 89 ICU nurses eligible to participate, 32 nurses completed both the consent form and preintervention NKDQ, with 24 of these nurses also completing the educational intervention and postintervention NKDQ, resulting in a sample of 27% of the possible participants. There was no attrition of the sample between the educational intervention and postintervention NKDQ. Of the participants who completed all requirements of the study, a majority of participants were bachelor of science degree in nursing prepared, had more than 10 years of RN experience, and had more than 10 years’ ICU experience. Dayshift weekday and dayshift weekend were the predominant shifts worked for 17 participants (71%). All demographic information is outlined in the Table. Caring for a patient with delirium occurred at least monthly for 21 participants (87%) according to the participants’ selfreporting. In response to the item regarding having ever receiving education (including seminars, in-services, and/or reading articles) on delirium, 7 participants (29%) reported that they had not. When self-reporting on competency related to delirium, a majority of participants (20, 83%) reported ‘‘average competency’’ (Table). No participants reported that they either ‘‘lacked competency’’ or were at the ‘‘expert competency’’ level. Overall, there were 36 scored items on the NKDQ, and participants answered an average of 26.88 items (74.65%) correctly on the preintervention administration of the questionnaire. Of the 24 participants, 9 (37.5%) answered less than 75% of the items on the NKDQ correctly. The range of scores was from 58.33% to 88.89%. As previously discussed, within the NKDQ, there were 14 scored items addressing basic delirium knowledge and 14 scored items addressing risk factors for the development of delirium. When examining performance on the basic delirium knowledge items, participants answered an average of 11.99 items (85.71%) correctly. However, participants answered an average of only 8.25 items (58.93%) related to the risk factors for delirium correctly on the preintervention administration of the questionnaire. A paired-samples t test was conducted to compare preintervention NKDQ scores with postintervention NKDQ scores. There was a significant difference in the scores for the preintervention NKDQ (mean, 74.65 [SD, 8.68]) and postintervention NKDQ (mean, 84.95 [SD, 5.73]); t23 = j5.256, P < .001. These results suggest that an educational intervention did 92
Associate degree Bachelor of science degree in nursing
9 (38) 13 (54) 2 (8)
Master of science degree in nursing or higher Years of RN experience 2 y to
Feature Article The Impact of a Delirium Educational Intervention With Intensive Care Unit Nurses Genna Speed, MSN, RN, ACCNS-AG, CCRN
Background: Delirium is a frequently encountered condition in critically ill patients that has significant clinical impacts. Associated costs for patients impacted by delirium are higher, including a 39% higher intensive care unit (ICU) cost and 31% higher hospital costs, yet delirium goes unnoticed in up to 72% of cases. If ICU nurses are not aware of risk factors and presentation of delirium, the condition may go unrecognized, allowing for development of negative sequelae. Objectives: The purpose of this research study was to examine delirium knowledge levels of ICU nurses at a single level I trauma hospital both before and after a tailored educational intervention. Methods: A preintervention/postintervention research study design in conjunction with a tailored educational intervention was utilized. Preintervention/postintervention delirium knowledge testing was completed through the use of the Nurses’ Knowledge of Delirium Questionnaire. Results: The results indicated a significant difference in preintervention scores (mean, 74.65 [SD, 8.68]) and postintervention scores (mean, 84.95 [SD, 5.73]); t23 = j5.256, P = .000. These results suggest that an educational intervention does have an impact on ICU nurses’ knowledge level of delirium. Conclusions: If ICU nurses are not aware of the fluctuating nature of delirium and its varied clinical presentations, they cannot be expected to consistently identify its development when providing care. Through educational activities, it is possible to increase team
Author Affiliation: Graduate Student, Department of Nursing, Armstrong Atlantic State University, Savannah, Georgia. There are no funding sources to report. The author report no conflicts of interest. Correspondence: Genna Speed, MSN, RN, ACCNS-AG, CCRN, Armstrong Atlantic State University, 22207 Tower Ter, San Antonio, TX 78234 ([email protected]). DOI: 10.1097/NUR.0000000000000106
Clinical Nurse Specialist
member knowledge levels, potentially resulting in increased identification of delirium and a reduction in negative sequelae. KEY WORDS: continuing education, delirium, nurse clinicians, nursing
D
elirium is a frequently encountered condition in the critical care patient population that has significant clinical impacts with prevalence rates ranging from 32% to 87% in the intensive care unit (ICU) patient.1Y7 Delirium is a mental disorder that results in a change in cognition and subsequent disruption in awareness or attention. The onset of delirium may be acute or subacute and has a fluctuating nature. The cornerstone characteristic of delirium is confusion, and patients may exhibit a range of behavior from hypoactive to hyperactive states.1 The range in behavior of patients experiencing delirium exemplifies the varied nature and subtypes of delirium, including hyperactive, hypoactive, and mixed subtypes. Hyperactive delirium can demonstrate restlessness, agitation, and aggression, whereas at the opposite end of the spectrum, hypoactive delirium exhibits a slowing or absence of movement, a decrease in patient communication, and unresponsiveness. In mixed delirium, the patient demonstrates characteristics of both hyperactive and hypoactive delirium.8 Hyperactive delirium is typically more easily identified by members of the healthcare team and is associated with lower rates of mortality, yet it occurs less frequently than hypoactive or mixed-type delirium. In contrast, hypoactive delirium states often go unrecognized or are misdiagnosed, potentially contributing to higher rates of mortality in patients experiencing this type of delirium.1 The overall etiology of delirium remains poorly understood. Associated healthcare costs for those patients impacted by delirium are higher, including a 39% higher ICU and 31% higher hospital cost compared with patients who do not develop delirium, even after adjusting for age, comorbidities, severity of illness, degree of organ dysfunction, and other confounders.4 Delirium is associated with a 3-fold increase in mortality 6 months after discharge, even after
A
www.cns-journal.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
89
Feature Article controlling for variables such as preexisting disease processes and severity of illness.3 Despite these notable consequences, delirium goes unnoticed by healthcare team members in as many as 32% to 72% of patients who experience this condition.9,10 Prompt identification of and intervention for delirium in hospitalized patients are imperative to defend against the negative sequelae associated with this condition.9,11Y13 The magnitude of the impact of delirium warrants continued focus on education for staff members, early screening and assessment of critically ill patients, and research concerning the care of patients affected by this condition.
BACKGROUND Despite the sequelae associated with the development of delirium in ICU patients, nurses’ knowledge regarding delirium has been demonstrated to be low in various studies.11,14,15 In a research study examining nurses’ knowledge regarding delirium and its associated risk factors, the mean for correctly answering the knowledge questions was found to be 64.91%, whereas the mean for correctly answering the risk factor questions was found to be 46.15%.15 In another research study examining medical-surgical and ICU nurses’ knowledge of signs and symptoms of delirium, recognition of delirium outcomes, and nursing confidence concerning delirium, it was revealed that almost 25% of the nurses surveyed did not identify delirium as a problem within their care setting. Whereas 90% of participants could positively identify signs and symptoms associated with hyperactive delirium, less than 77% of participants were able to successfully identify symptoms associated with a hypoactive presentation of delirium.11 In a study examining the delirium knowledge of only ICU nurses, it was demonstrated that nurses in general had a moderate to low level of knowledge related to delirium, with a mean score of 64.4% on a 25-item questionnaire.14 The low percentage of correctly answered items in these studies has significant implications for patient care and prevention of delirium. Improved knowledge may assist nurses and other members of the healthcare team to identify or even prevent the development of delirium, mitigating some of the negative sequelae associated with delirium. The inability of nurses to effectively assess for delirium is an area of great concern, and continued education of nurses regarding detection of delirium and its key features during care of critically ill patients is warranted alongside more traditional staff education measures, such as pain assessment.13,16 STATEMENT OF PURPOSE Failure to recognize delirium in ICU patients may be attributed to several factors, including knowledge deficits possessed by healthcare providers caring for the patient population, particularly deficits regarding patient presentation of delirium as well as risk factors associated with delirium. If nursing 90
staff members are not aware of the risk factors and presentation of delirium, the condition may go unrecognized, allowing for the development of additional negative sequelae secondary to delirium’s presence.1,11 One of the aims of this research study was to examine the preintervention delirium knowledge level of nurses within the ICU environment at a single level I trauma hospital. An additional aim of this research study was to examine the effect of an educational intervention on the delirium knowledge level of ICU nurses. A preintervention/postintervention design in conjunction with a tailored educational intervention was utilized. The knowledge level of ICU nurses was assessed both before and after a tailored educational intervention, and factors such as educational background, length of ICU experience, and specific shift worked were considered. Preintervention knowledge levels were used to tailor the education intervention.
METHODS This research study was a quasi-experimental 1-group pretestposttest design that was conducted over a 2-month period. The major components of the research included the Nurses’ Knowledge of Delirium Questionnaire (NKDQ) (see Instrumentation) and the educational intervention. An online survey application, SurveyMonkey, was used for completion of all NKDQs. Participants completed the NKDQ 2 weeks prior to the educational intervention and then again 1 month after receiving the educational intervention. The NKDQ completed prior to the educational intervention was considered the pretest, and the NKDQ completed after the educational intervention was considered the posttest for each participant. In order to limit attrition during the study, participants completing all 3 phases of the study (pretest, educational intervention, and posttest) were eligible to receive one of three $20 Visa gift cards. During completion of the NKDQ, participants used the last 4 digits of their hospital identification badge number as an identifier when completing the NKDQ. Only the primary investigator had access to the NKDQ results. The data reported were compiled from the participants’ responses on the questionnaires, which contained background demographic information and responses concerning each participant’s knowledge of delirium and its risk factors. Those NKDQs that did not have a pretest and posttest pairing by the last 4 digits of a hospital identification badge number were not included in the data interpretation. All material that was produced in hard copy was kept in a locked cabinet. After an elapsed period of 1 year post-study, all materials generated were destroyed. The results of each NKDQ completion were calculated, examining preintervention knowledge level, postintervention knowledge level, and any potential correlation or difference in knowledge regarding delirium related to professional educational background, length of ICU experience, or shift worked.
www.cns-journal.com
March/April 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sample The convenience sample for this research study included registered nurses (RNs) working in the ICUs of a 610-bed nonprofit academic level I trauma hospital. To be eligible to participate, an RN must have been working in 1 of the 4 ICUs at the beginning of the study, remain employed in 1 of the 4 ICUs for the duration of the study, and be primarily assigned to 1 of the ICU cost centers. Registered nurses who were float pool nurses (non-ICU cost center), who were not working in 1 of the ICUs at the outset of the study, or who did not remain employed in 1 of the 4 ICUs for the duration of the study were not eligible to participate. At the time of the study, there were 89 RNs eligible to participate. Each RN was recruited to participate through the use of a target-audience employee e-mail and unit-based announcement flyers. Protection of Human Rights The institutional review board of the hospital where the research was conducted and the university of the primary researcher approved the research study in advance. Written consent from each participant was obtained, and each participant was provided an electronic copy of the consent form with the target-audience employee e-mail. Instrumentation The research instrument used in this study was based on an instrument previously used in another research study examining nurses’ knowledge of delirium.15 Permission to use the instrument was obtained by the instrument’s original developers. While the instrument was not given a formal title in the previous study, it was labeled the NKDQ. The NKDQ has not been formally validated, nor has its reliability been established at the time of this research. Despite this, the questionnaire has been used in at least 12 different countries, including in the United Kingdom where the National Health Service has employed it in a system-wide education program. The National Health Service is conducting a validation study for the instrument, but the results of the validation study were not yet available at the time of this current research study (M. Hare, e-mail communication, May 13, 2013). The NKDQ was divided into sections. The first section consisted of items designed to collect the demographic data of participants, including information regarding the participant’s highest level of nursing education completed, number of years practicing as an RN, number of years practicing as an RN in an intensive care environment, predominant shift worked, and specific area of practice. It also required the participants to report whether they had ever cared for a patient with delirium and, if the answer was yes, how often this occurred. Final items in this section required participants to identify if they had ever received formal education concerning delirium, as well as their perception of their indiClinical Nurse Specialist
vidual knowledge competency concerning delirium. All items in this section contained categorical response options. The second section of the NKDQ, which consisted of 36 items related to delirium and its associated risk factors, was used to calculate scores for each participant. The first of these items required the participants to select the multiplechoice option that best described or defined delirium. For the next 7 items, participants were required to select the condition that a given rating scale or instrument most appropriately evaluated for, with answer multiple-choice options that consisted of ‘‘delirium,’’ ‘‘dementia,’’ ‘‘depression,’’ or ‘‘none of these.’’ For these 7 items, participants were able to select more than one option for each scale/instrument if the scale/instrument was believed to evaluate for multiple conditions. In the final portion of the questionnaire, participants were required to select ‘‘agree,’’ ‘‘disagree,’’ or ‘‘unsure’’ for 28 different statements related to delirium. Of these 28 statements, 14 were related to basic delirium knowledge, and 14 were related to risk factors for the development of delirium. This research sought to examine the correct response percentage score, or knowledge level of items in section 2, both before and after a tailored educational intervention. Educational Intervention A review of the literature was utilized to shape the content of the educational intervention and address the knowledge deficits of the ICU nurses participating. Those items on the initial, or pretest, NKDQ with the lowest correct responses were stressed during the educational intervention. The educational intervention was 20 minutes in length and discussed the various aspects of delirium, including causes and signs and symptoms of delirium. Participants were able to select 1 of 10 possible educational intervention sessions to attend. Each session occurred in a centrally located ICU conference room and utilized the audiovisual equipment located therein to present the information. The educational intervention was delivered by PowerPoint and used basic presentation, case study, and interactive discussion techniques. The primary researcher conducted all educational intervention sessions. A handout with resources on delirium was also provided to each participant at the conclusion of the intervention. Collection and Analysis of Data The NKDQ was used for both the preintervention and postintervention data collection. Utilizing features available through the SurveyMonkey Web site, unique target-audience e-mails were distributed for both the preintervention and postintervention data collection that contained primary investigator contact information, basic instructions for completing the NKDQ, and a hyperlink to access the NKDQ via the Internet. Responses to each NKDQ were then electronically downloaded into an Excel spreadsheet database. Responses for
A
www.cns-journal.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
91
Feature Article both the preintervention data set and postintervention data set were manually crosschecked with the answer key, and the percentage correct (score) for each NKDQ was added to the database. The preintervention and postintervention scores were then exported to Statistical Package for Social Sciences software version 18 (SPSS Inc, Chicago, Illinois) for analysis.
Table. Demographics and Self-reported
Delirium Items for Participants Completing All Study Requirements (n = 24) Variable
No. (%) of Registered Nurses (RNs)
Professional educational background
RESULTS Of the 89 ICU nurses eligible to participate, 32 nurses completed both the consent form and preintervention NKDQ, with 24 of these nurses also completing the educational intervention and postintervention NKDQ, resulting in a sample of 27% of the possible participants. There was no attrition of the sample between the educational intervention and postintervention NKDQ. Of the participants who completed all requirements of the study, a majority of participants were bachelor of science degree in nursing prepared, had more than 10 years of RN experience, and had more than 10 years’ ICU experience. Dayshift weekday and dayshift weekend were the predominant shifts worked for 17 participants (71%). All demographic information is outlined in the Table. Caring for a patient with delirium occurred at least monthly for 21 participants (87%) according to the participants’ selfreporting. In response to the item regarding having ever receiving education (including seminars, in-services, and/or reading articles) on delirium, 7 participants (29%) reported that they had not. When self-reporting on competency related to delirium, a majority of participants (20, 83%) reported ‘‘average competency’’ (Table). No participants reported that they either ‘‘lacked competency’’ or were at the ‘‘expert competency’’ level. Overall, there were 36 scored items on the NKDQ, and participants answered an average of 26.88 items (74.65%) correctly on the preintervention administration of the questionnaire. Of the 24 participants, 9 (37.5%) answered less than 75% of the items on the NKDQ correctly. The range of scores was from 58.33% to 88.89%. As previously discussed, within the NKDQ, there were 14 scored items addressing basic delirium knowledge and 14 scored items addressing risk factors for the development of delirium. When examining performance on the basic delirium knowledge items, participants answered an average of 11.99 items (85.71%) correctly. However, participants answered an average of only 8.25 items (58.93%) related to the risk factors for delirium correctly on the preintervention administration of the questionnaire. A paired-samples t test was conducted to compare preintervention NKDQ scores with postintervention NKDQ scores. There was a significant difference in the scores for the preintervention NKDQ (mean, 74.65 [SD, 8.68]) and postintervention NKDQ (mean, 84.95 [SD, 5.73]); t23 = j5.256, P < .001. These results suggest that an educational intervention did 92
Associate degree Bachelor of science degree in nursing
9 (38) 13 (54) 2 (8)
Master of science degree in nursing or higher Years of RN experience 2 y to
