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Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units

      Abstract

      Background

      Delirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention.

      Objectives

      The aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity.

      Methods

      We based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test–retest reliability.

      Results

      Exploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68–.87) and test–retest reliability (intraclass correlation coefficients = .46–.62) were confirmed.

      Conclusion

      We developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.

      Keywords

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      References

        • Pandharipande P.
        • Jackson J.
        • Ely E.W.
        Delirium: acute cognitive dysfunction in the critically ill.
        Curr Opin Crit Care. 2005; 11: 360-368https://doi.org/10.1097/01.ccx.0000170503.76528.4b
        • Miller 3rd, R.R.
        • Ely E.W.
        Delirium and cognitive dysfunction in the intensive care unit.
        Semin Respir Crit Care Med. 2006; 27: 210-220https://doi.org/10.1055/s-2006-945532
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders: dsm-5.
        5th ed. American Psychiatric Association, Arlington, VA2013
        • Lipowski Z.J.
        Delirium in the elderly patient.
        N Engl J Med. 1989; 320: 578-582https://doi.org/10.1056/NEJM198903023200907
        • McNicoll L.
        • Pisani M.A.
        • Zhang Y.
        • Ely E.W.
        • Siegel M.D.
        • Inouye S.K.
        Delirium in the intensive care unit: occurrence and clinical course in older patients.
        J Am Geriatr Soc. 2003; 51: 591-598https://doi.org/10.1034/j.1600-0579.2003.00201.x
        • Ely E.W.
        • Inouye S.K.
        • Bernard G.R.
        • Gordon S.
        • Francis J.
        • May L.
        • et al.
        Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU).
        JAMA. 2001; 286: 2703-2710https://doi.org/10.1001/jama.286.21.2703
        • Pandharipande P.
        • Cotton B.A.
        • Shintani A.
        • Thompson J.
        • Costabile S.
        • Truman Pun B.
        • et al.
        Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients.
        Intensive Care Med. 2007; 33: 1726-1731https://doi.org/10.1007/s00134-007-0687-y
        • Inouye S.K.
        • Westendorp R.G.
        • Saczynski J.S.
        Delirium in elderly people.
        Lancet. 2014; 383: 911-922https://doi.org/10.1016/S0140-6736(13)60688-1
        • Dubois M.J.
        • Bergeron N.
        • Dumont M.
        • Dial S.
        • Skrobik Y.
        Delirium in an intensive care unit: a study of risk factors.
        Intensive Care Med. 2001; 27: 1297-1304https://doi.org/10.1007/s001340101017
        • Pandharipande P.P.
        • Girard T.D.
        • Jackson J.C.
        • Morandi A.
        • Thompson J.L.
        • Pun B.T.
        • et al.
        • BRAIN-ICU Study Investigators
        Long-term cognitive impairment after critical illness.
        N Engl J Med. 2013; 369: 1306-1316https://doi.org/10.1056/NEJMoa1301372
        • Abelha F.J.
        • Luís C.
        • Veiga D.
        • Parente D.
        • Fernandes V.
        • Santos P.
        • et al.
        Outcome and quality of life in patients with postoperative delirium during an ICU stay following major surgery.
        Crit Care. 2013; 17: R257https://doi.org/10.1186/cc13084
        • Ely E.W.
        • Gautam S.
        • Margolin R.
        • Francis J.
        • May L.
        • Speroff T.
        • et al.
        The impact of delirium in the intensive care unit on hospital length of stay.
        Intensive Care Med. 2001; 27: 1892-1900https://doi.org/10.1007/s00134-001-1132-2
        • Leslie D.L.
        • Marcantonio E.R.
        • Zhang Y.
        • Leo-Summers L.
        • Inouye S.K.
        One-year health care costs associated with delirium in the elderly population.
        Arch Intern Med. 2008; 168: 27-32https://doi.org/10.1001/archinternmed.2007.4
        • Pisani M.A.
        • Kong S.Y.
        • Kasl S.V.
        • Murphy T.E.
        • Araujo K.L.
        • Van Ness P.H.
        Days of delirium are associated with 1-year mortality in an older intensive care unit population.
        Am J Respir Crit Care Med. 2009; 180: 1092-1097https://doi.org/10.1164/rccm.200904-0537OC
        • Shehabi Y.
        • Riker R.R.
        • Bokesch P.M.
        • Wisemandle W.
        • Shintani A.
        • Ely E.W.
        SEDCOM (Safety and Efficacy of Dexmedetomidine Compared with Midazolam) Study Group. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients.
        Crit Care Med. 2010; 38: 2311-2318https://doi.org/10.1097/CCM.0b013e3181f85759
        • Balas M.C.
        • Rice M.
        • Chaperon C.
        • Smith H.
        • Disbot M.
        • Fuchs B.
        Management of delirium in critically ill older adults.
        Crit Care Nurse. 2012; 32: 15-26https://doi.org/10.4037/ccn2012480
        • Devlin J.W.
        • Skrobik Y.
        • Gélinas C.
        • Needham D.M.
        • Slooter A.J.C.
        • Pandharipande P.P.
        • et al.
        Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
        Crit Care Med. 2018; 46: e825-e873https://doi.org/10.1097/CCM.0000000000003299
        • Birge A.O.
        • Aydin H.T.
        The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses.
        Intensive Crit Care Nurs. 2017; 41: 33-42https://doi.org/10.1016/j.iccn.2016.08.009
        • Oh E.S.
        • Fong T.G.
        • Hshieh T.T.
        • Inouye S.K.
        Delirium in older persons: advances in diagnosis and treatment.
        JAMA. 2017; 318: 1161-1174https://doi.org/10.1001/jama.2017.12067
        • Morandi A.
        • Piva S.
        • Ely E.W.
        • Myatra S.N.
        • Salluh J.I.F.
        • Amare D.
        • et al.
        Worldwide survey of the "assessing pain, both spontaneous awakening and breathing trials, choice of drugs, delirium monitoring/management, early exercise/mobility, and family empowerment" (ABCDEF) bundle.
        Crit Care Med. 2017; 45: e1111-e1122https://doi.org/10.1097/CCM.0000000000002640
        • Barnes-Daly M.A.
        • Phillips G.
        • Ely E.W.
        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. 2017; 45: 171-178https://doi.org/10.1097/CCM.0000000000002149
        • Marra A.
        • Ely E.W.
        • Pandharipande P.P.
        • Patel M.B.
        The ABCDEF Bundle in critical care.
        Crit Care Clin. 2017; 33: 225-243https://doi.org/10.1016/j.ccc.2016.12.005
        • Marino J.
        • Bucher D.
        • Beach M.
        • Yegneswaran B.
        • Cooper B.
        Implementation of an intensive care unit delirium protocol: an interdisciplinary quality improvement project.
        Dimens Crit Care Nurs. 2015; 34: 273-284https://doi.org/10.1097/DCC.0000000000000130
        • Mc Donnell S.
        • Timmins F.
        A quantitative exploration of the subjective burden experienced by nurses when caring for patients with delirium.
        J Clin Nurs. 2012; 21: 2488-2498https://doi.org/10.1111/j.1365-2702.2012.04130.x
        • Schmitt E.M.
        • Gallagher J.
        • Albuquerque A.
        • Tabloski P.
        • Lee H.J.
        • Gleason L.
        • et al.
        Perspectives on the delirium experience and its burden: common themes among older patients, their family caregivers, and nurses.
        Gerontol. 2019; 59: 327-337https://doi.org/10.1093/geront/gnx153
        • Partridge J.S.
        • Martin F.C.
        • Harari D.
        • Dhesi J.K.
        The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this?.
        Int J Geriatr Psychiatr. 2013; 28: 804-812https://doi.org/10.1002/gps.3900
        • Morandi A.
        • Lucchi E.
        • Turco R.
        • Morghen S.
        • Guerini F.
        • Santi R.
        • et al.
        Delirium superimposed on dementia: a quantitative and qualitative evaluation of informal caregivers and health care staff experience.
        J Psychosom Res. 2015; 79: 272-280https://doi.org/10.1016/j.jpsychores.2015.06.012
        • Bélanger L.
        • Ducharme F.
        Patients' and nurses' experiences of delirium: a review of qualitative studies.
        Nurs Crit Care. 2011; 16: 303-315https://doi.org/10.1111/j.1478-5153.2011.00454.x
        • Zamoscik K.
        • Godbold R.
        • Freeman P.
        Intensive care nurses' experiences and perceptions of delirium and delirium care.
        Intensive Crit Care Nurs. 2017; 40: 94-100https://doi.org/10.1016/j.iccn.2017.01.003
        • van den Boogaard M.
        • Schoonhoven L.
        • van der Hoeven J.G.
        • van Achterberg T.
        • Pickkers P.
        Incidence and short-term consequences of delirium in critically ill patients: a prospective observational cohort study.
        Int J Nurs Stud. 2012; 49: 775-783https://doi.org/10.1016/j.ijnurstu.2011.11.016
        • Dahlke S.
        • Phinney A.
        Caring for hospitalized older adults at risk for delirium: the silent, unspoken piece of nursing practice.
        J Gerontol Nurs. 2008; 34: 41-47https://doi.org/10.3928/00989134-20080601-03
        • Milisen K.
        • Cremers S.
        • Foreman M.D.
        • Vandevelde E.
        • Haspeslagh M.
        • Geest S.D.
        • et al.
        The Strain of Care for Delirium Index: a new instrument to assess nurses' strain in caring for patients with delirium.
        Int J Nurs Stud. 2004; 41: 775-783https://doi.org/10.1016/j.ijnurstu.2004.03.005
        • Gesin G.
        • Russell B.B.
        • Lin A.P.
        • Norton H.J.
        • Evans S.L.
        • Devlin J.W.
        Impact of a delirium screening tool and multifaceted education on nurses' knowledge of delirium and ability to evaluate it correctly.
        Am J Crit Care. 2012; 21: e1-11https://doi.org/10.4037/ajcc2012605
        • Rowley-Conwy G.
        Barriers to delirium assessment in the intensive care unit: a literature review.
        Intensive Crit Care Nurs. 2018; 44: 99-104https://doi.org/10.1016/j.iccn.2017.09.001
        • Nydahl P.
        • Dewes M.
        • Dubb R.
        • Hermes C.
        • Kaltwasser A.
        • Krotsetis S.
        • et al.
        Survey among critical care nurses and physicians about delirium management.
        Nurs Crit Care. 2018; 23: 23-29https://doi.org/10.1111/nicc.12299
        • Costa D.K.
        • White M.R.
        • Ginier E.
        • Manojlovich M.
        • Govindan S.
        • Iwashyna T.J.
        • et al.
        Identifying barriers to delivering the awakening and breathing coordination, delirium, and early exercise/mobility bundle to minimize adverse outcomes for mechanically ventilated patients: a systematic review.
        Chest. 2017; 152: 304-311https://doi.org/10.1016/j.chest.2017.03.054
        • Sasaki Y.
        • Hayashi M.
        • Egawa K.
        • Koga Y.
        • Kato E.
        • Kinoshita Y.
        • et al.
        For development of a guideline for post-operative delirium care; the current status of post-operative delirium and nursing care of ICU and Surgery Unit Patients.
        Journal of Japan Academy of Critical Care Nursing. 2014; 10 (in Japanese): 51-62
        • Matsuda K.
        • Hamamoto Y.
        • Watanuki S.
        The status of nurse's difficulty in administering pro re nata (PRN) psychotropic medications for delirious patients: a survey in acute hospitals nationwide in Japan.
        Journal of the Japan Society for Healthcare Administration. 2017; 54 (in Japanese): 95-105
        • Pun B.T.
        • Gordon S.M.
        • Peterson J.F.
        • Shintani A.K.
        • Jackson J.C.
        • Foss J.
        • et al.
        Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers.
        Crit Care Med. 2005; 33: 1199-1205https://doi.org/10.1097/01.ccm.0000166867.78320.ac
        • Law T.J.
        • Leistikow N.A.
        • Hoofring L.
        • Krumm S.K.
        • Neufeld K.J.
        • Needham D.M.
        A survey of nurses' perceptions of the intensive care delirium screening checklist.
        Dynamics. 2012; 23: 18-24
        • Mokkink L.B.
        • Terwee C.B.
        • Knol D.L.
        • Stratford P.W.
        • Alonso J.
        • Patrick D.L.
        • et al.
        The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content.
        BMC Med Res Methodol. 2010; 10: 22https://doi.org/10.1186/1471-2288-10-22
        • Owaki N.
        • Tanaka M.
        • Kawakami A.
        Development of the Japanese version of the strain of care for delirium index among intensive care nurses: a validation study.
        J Ochanomizu Assoc Acad Nursing. 2021; 16
        • Toriya M.
        • Hasegawa M.
        • Aohda T.
        • Sugawara M.
        • Taki T.
        The characteristics of the needs of hospital nurse administrators and nurses involved in delirium care.
        Journal of Japan Academy of Gerontological Nursing. 2012; 17 (in Japanese): 66-73
        • Ohki T.
        • Matsushita T.
        A study of the nursing judgment processes for postoperative delirium (2): judgment, certainty, and behaviors.
        The Showa University Journal of Nursing and Rehabilitation Sciences. 2014; 12 (in Japanese): 108-116
        • Koike Y.
        • Kobayashi M.
        • Kitamura M.
        • Miyasita K.
        “Senmou kanzya ni kakawaru kangoshi no konnankan”[Difficulty of nurses involved in delirium patients].
        Medical Journal of Nagano Red Cross Hospital. 2016; 29 (in Japanese): 56-59
        • Tahara K.
        • Morita K.
        Delirium-specific care provided by experienced nurses to patients with delirium in a general acute ward.
        Journal of Nursing Research Colloquium of Tokyo Women's Medical University. 2017; 12 (in Japanese): 12-18
        • Tahara K.
        Concept analysis of delirium care on a general ward.
        J Jpn Assoc Rural Med. 2017; 65 (in Japanese): 1148-1156https://doi.org/10.2185/jjrm.65.1148
        • Devlin J.W.
        • Fong J.J.
        • Howard E.P.
        • Skrobik Y.
        • McCoy N.
        • Yasuda C.
        • et al.
        Assessment of delirium in the intensive care unit: nursing practices and perceptions.
        Am J Crit Care. 2008; 17 (quiz 566): 555-565
        • Riekerk B.
        • Pen E.J.
        • Hofhuis J.G.
        • Rommes J.H.
        • Schultz M.J.
        • Spronk P.E.
        Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit.
        Intensive Crit Care Nurs. 2009; 25: 242-249https://doi.org/10.1016/j.iccn.2009.04.001
        • Balas M.C.
        • Burke W.J.
        • Gannon D.
        • Cohen M.Z.
        • Colburn L.
        • Bevil C.
        • et al.
        Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines.
        Crit Care Med. 2013; 41: S116-S127https://doi.org/10.1097/ccm.0b013e3182a17064
        • Elliott S.R.
        ICU delirium: a survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit.
        Intensive Crit Care Nurs. 2014; 30: 333-338https://doi.org/10.1016/j.iccn.2014.06.004
        • Andrews L.
        • Silva S.G.
        • Kaplan S.
        • Zimbro K.
        Delirium monitoring and patient outcomes in a general intensive care unit.
        Am J Crit Care. 2015; 24: 48-56https://doi.org/10.4037/ajcc2015740
        • Boehm L.M.
        • Vasilevskis E.E.
        • Mion L.C.
        Interprofessional perspectives on ABCDE bundle implementation: a focus group study.
        Dimens Crit Care Nurs. 2016; 35: 339-347https://doi.org/10.1097/DCC.0000000000000208
        • Pinto F.
        • Biancofiore G.
        The ABCDE Bundle: a survey of nurses knowledge and attitudes in the Intensive Care Units of a national teaching hospital in Italy.
        Dimens Crit Care Nurs. 2016; 35: 309-314https://doi.org/10.1097/DCC.0000000000000210
        • Oosterhouse K.J.
        • Vincent C.
        • Foreman M.D.
        • Gruss V.A.
        • Corte C.
        • Berger B.
        Intensive Care Unit nurses' beliefs about delirium assessment and management.
        AACN Adv Crit Care. 2016; 27: 379-393https://doi.org/10.4037/aacnacc2016535
        • Boehm L.M.
        • Dietrich M.S.
        • Vasilevskis E.E.
        • Wells N.
        • Pandharipande P.
        • Ely E.W.
        • et al.
        Perceptions of workload burden and adherence to ABCDE Bundle among intensive care providers.
        Am J Crit Care. 2017; 26: e38-e47https://doi.org/10.4037/ajcc2017544
        • Hickin S.L.
        • White S.
        • Knopp-Sihota J.
        Delirium in the intensive care unit—a nursing refresher.
        Can J Crit Care Nurs. 2017; 28: 19-23
        • Rowley-Conwy G.
        Critical care nurses' knowledge and practice of delirium assessment.
        Br J Nurs. 2017; 26: 412-417https://doi.org/10.12968/bjon.2017.26.7.412
        • Trogrlić Z.
        • Ista E.
        • Ponssen H.H.
        • Schoonderbeek J.F.
        • Schreiner F.
        • Verbrugge S.J.
        • et al.
        Attitudes, knowledge and practices concerning delirium: a survey among intensive care unit professionals.
        Nurs Crit Care. 2017; 22: 133-140https://doi.org/10.1111/nicc.12239
        • Xing J.
        • Sun Y.
        • Jie Y.
        • Yuan Z.
        • Liu W.
        Perceptions, attitudes, and current practices regards delirium in China: a survey of 917 critical care nurses and physicians in China.
        Medicine (Baltim). 2017; 96e8028https://doi.org/10.1097/MD.0000000000008028
        • Fraser V.
        • Cossette S.
        • Mailhot T.
        • Brisebois A.
        • Dubé V.
        Evaluation of an intervention with nurses for delirium detection after cardiac surgery.
        Worldviews Evidence-Based Nurs. 2018; 15: 38-44https://doi.org/10.1111/wvn.12266
        • Oxenbøll-Collet M.
        • Egerod I.
        • Christensen V.
        • Jensen J.
        • Thomsen T.
        Nurses' and physicians' perceptions of Confusion Assessment Method for the intensive care unit for delirium detection: focus group study.
        Nurs Crit Care. 2018; 23: 16-22https://doi.org/10.1111/nicc.12254
        • De Vet Henrica C.W.
        • Terwee C.B.
        • Lidwine B.M.
        • Knol D.L.
        Measurement in medicine: a practical Guide.
        Cambridge University Press, New York2011
        • Guttman L.
        Some necessary conditions for common-factor analysis.
        Psychometrika. 1954; 19: 149-161https://doi.org/10.1007/BF02289162
        • Kaiser H.F.
        An index of factorial simplicity.
        Psychometrika. 1974; 39: 31-36
        • Hair J.F.
        • Black W.C.
        • Babin B.J.
        • Anderson R.E.
        Multivariate data analysis.
        8th ed. Annabel Ainscow, United Kingdom2019
        • Japan Nursing Association
        Guidance on examination: certified nurse specialist.
        ([in Japanese]. Available from:) (cited 2021 May 1)
        • IBM Corp
        IBM SPSS statistics for Windows.
        (Released) IBM Corp, Armonk, NY2016 (Version 24)
        • Penuela M.C.
        • Law M.
        • Chung H.O.
        • Faught B.E.
        • Tsang J.L.Y.
        Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in a Canadian community intensive care unit: a quality improvement study protocol.
        CMAJ Open. 2019; 7: E430-E434https://doi.org/10.9778/cmajo.20190015
        • LeBlanc A.
        • Bourbonnais F.F.
        • Harrison D.
        • Tousignant K.
        The experience of intensive care nurses caring for patients with delirium: a phenomenological study.
        Intensive Crit Care Nurs. 2018; 44: 92-98https://doi.org/10.1016/j.iccn.2017.09.002
        • Kydonaki K.
        • Hanley J.
        • Huby G.
        • Antonelli J.
        • Walsh T.S.
        Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units.
        BMJ Open. 2019; 9e024549https://doi.org/10.1136/bmjopen-2018-024549
        • Dammeyer J.A.
        • Mapili C.D.
        • Palleschi M.T.
        • Eagle S.
        • Browning L.
        • Heck K.
        • et al.
        Nurse-led change: a statewide multidisciplinary collaboration targeting intensive care unit delirium.
        Crit Care Nurs Q. 2012; 35: 2-14https://doi.org/10.1097/CNQ.0b013e31823b1fec
        • Pronovost P.J.
        • Berenholtz S.M.
        • Needham D.M.
        Translating evidence into practice: a model for large scale knowledge translation.
        BMJ. 2008; 337: a1714https://doi.org/10.1136/bmj.a1714
        • Teece A.
        • Baker J.
        • Smith H.
        Identifying determinants for the application of physical or chemical restraint in the management of psychomotor agitation on the critical care unit.
        J Clin Nurs. 2020; 29: 5-19https://doi.org/10.1111/jocn.15052
        • Inouye S.K.
        • Foreman M.D.
        • Mion L.C.
        • Katz K.H.
        • Cooney Jr., L.M.
        Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings.
        Arch Intern Med. 2001; 161: 2467-2473https://doi.org/10.1001/archinte.161.20.2467
        • Terwee C.B.
        • Bot S.D.
        • de Boer M.R.
        • van der Windt D.A.
        • Knol D.L.
        • Dekker J.
        • et al.
        Quality criteria were proposed for measurement properties of health status questionnaires.
        J Clin Epidemiol. 2007; 60: 34-42https://doi.org/10.1016/j.jclinepi.2006.03.012