Delirium is a brain dysfunction exhibited by an acute onset and vacillating course of impaired cognitive function. Additional hallmark features include altered levels of consciousness, inattention, and disorganized thinking (American Psychiatric Association, 2013; Ely et al., 2001). Perceptual changes, such as hallucinations, disorientation, impaired memory, and altered speech, are also seen in delirium (Waszynski & Petrovic, 2008). Delirium is reversible and is often caused by a medical condition, a substance, or a combination of factors (Rice et al., 2011). Patients developing delirium are at risk for long-term cognitive impairment (Balas et al., 2012; Barr et al., 2013; Tate & Happ, 2012).
Delirium is associated with increased length of hospital stay, higher cost of care, and increased morbidity and mortality (Balas et al., 2012). Patients with delirium are more likely to require discharge to another level of care, such as a rehabilitation center or extended care facility (Pauley et al., 2015). In the intensive care unit (ICU), delirium is a common problem, occurring in up to 87% of patients receiving mechanical ventilation (Balas et al., 2012; Devlin et al., 2008; Ely et al., 2001). This vulnerable population is challenging to assess, as patients are frequently unable to communicate due to artificial airway maintenance or the effects of sedation (Zaal & Slooter, 2012).
Critical care nurses routinely perform comprehensive assessments of all body systems, including neurological status. Despite the fact that nursing assessment of delirium is part of a neurological assessment, the literature reports a nursing knowledge gap in performing delirium-specific assessment in the ICU (Devlin et al., 2008; Olson, 2012). Although delirium is common in ICU patients, studies reveal that it is often overlooked and underreported (Balas et al., 2012; Devlin et al., 2008; Zaal & Slooter, 2012). Critical care nurses have an important role to play in the prevention, detection, and management of delirium. The literature reveals that more research is needed to identify effective methods to improve critical care nurses' knowledge of delirium and confidence when assessing for it.
The purpose of this study was to use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument (Inouye et al., 1990) to evaluate a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) as an effective method to improve critical care nurses' knowledge of delirium and confidence in assessing for it. The three aims of this study were to (a) increase critical care nurses' knowledge of delirium, including the use of the CAM-ICU; (b) increase the confidence levels of critical care nurses in using the CAM-ICU to detect delirium and implement early management; and (c) evaluate the critical care nurses' satisfaction with the educational strategy.
Background and Significance
Consistent with the literature, it was identified that a knowledge gap existed in performing delirium-specific assessments by critical care nurses in the ICU of a large community medical center. A previous project at this medical center substantiated that educating nurses about delirium and the CAM-ICU through classroom instruction alone was ineffective (J. Smith & R. Edelman, personal communication, April 10, 2013). Feedback from the nurses indicated that didactic instruction did not allow them an opportunity to practice using the instrument. Additional comments reported a preference for online education. With the nurses' feedback in mind, the investigators postulated that a multimodal educational strategy would provide the nurses with their preference for online education, along with the ability to practice the CAM-ICU, through a simulation experience.
Online learning includes content that is presented on a computer either via the Internet or an Intranet (i.e., an online system available only to workers in the organization). Benefits to learners include accessibility, time flexibility, and a self-paced structure (Benson, 2004). The online learning module for the current study was created by the investigators after a review of the delirium literature and was delivered via the medical center Intranet.
Simulation offers the ability to gain experience with a skill, such as the use of the CAM-ICU, before using it in clinical practice. Simulation uses guided experiences to replicate aspects of the real world in an interactive fashion (Gaba, 2004; Leigh, 2011). Expertise and confidence are gained through practice in the simulated setting. Simulation experiences may use low- or high-fidelity manikins or standardized patients. For the current study, standardized patients were chosen as the most appropriate simulation modality with the rationale that live actors better represent behavioral symptoms of delirium. A standardized patient is a person who has been trained to represent an actual patient, often for the purpose of learning assessment or communication skills (Association of Standardized Patient Educators, 2013).
The current study was guided by both the American Association of Critical Care Nurses (2014) Synergy Model for Patient Care (Hardin, 2009) and Bandura's (1977) theory of self-efficacy. The American Association of Critical Care Nurses Synergy Model posits that patient characteristics and nurse competencies are interconnected; when they are matched, synergy is created and patient outcomes are optimized. As its core concepts, the model includes both nurse competencies and patient characteristics. Patients experiencing delirium have clinical characteristics that require the application of specific nurse competencies that, if absent, may result in poor patient outcomes. The Synergy Model suggests that if nurses are taught to assess for delirium, their competency will increase; nurses will appropriately detect delirium and implement early management.
Self-efficacy is central to Bandura's theory that describes human behavior as a continuous reciprocal interaction among cognitive, behavioral, and social exchanges. Self-efficacy is frequently used interchangeably with confidence and refers to a belief in one's ability to succeed. The nurse's sense of self-efficacy plays a major role in how he or she approaches goals, tasks, and challenges. Nurses with high self-efficacy are more likely to view difficult tasks as something to be mastered rather than something to be avoided (Bandura, 1977).
This study used a pretest–posttest design to evaluate the effect of a multimodal educational strategy on critical care nurses' knowledge of delirium, ability to assess and manage delirium, and their confidence in using the CAM-ICU.
Sample and Participants
A convenience sample of (N = 34) critical care nurses working in an adult medical–surgical ICU was recruited in a large community medical center. This study was part of a larger initiative in the ICU to train all nurses on the importance of prevention, detection, and management of delirium, along with the use of the CAM-ICU. It was mandatory that all critical care nurses completed the training, which consisted of a pretest, the online learning module, and a posttest. A second posttest was required 6 weeks after the online learning module to evaluate the retention of the content. For those critical care nurses interested in participating in the research study, a voluntary simulation experience was added as a supplement to the mandatory online learning module. This study was approved by the medical center's institutional review board.
The instrument used to screen for delirium was the CAM-ICU. The literature reports that nurses are more accurate in their assessments when using a screening instrument rather than relying on a subjective description in the patient assessment (Svenningsen, 2015). In a study by Ely (2001), interrater reliability of the CAM-ICU was k = 0.79 to 0.96 (95% confidence interval [CI], 0.92 to 0.99) and criterion validity was 98.4% (95% CI, 92% to 100%; p < .001). This instrument identifies delirium in terms of four diagnostic features, including an acute onset or fluctuating course of mental status, inattention, disorganized thinking, and altered level of consciousness (Tate & Happ, 2012). It is designed for rapid administration (i.e., less than 2 minutes to use) and is relevant for ICU patients who are unable to verbally communicate. The CAM-ICU can be adapted for use in patients with sensory alterations, such as impaired hearing or visual disturbances, and has been translated into 20 different languages (Vanderbilt University Medical Center, 2013).
The online learning module created by the investigators included content on the signs and symptoms of delirium, how to assess for it using the CAM-ICU, and strategies for early management. The average time for completion of the module was 45 minutes, and it was required for all nurses in the ICU as part of their education on delirium.
Simulation scenarios were created for the study based on two types of delirium seen in patients: hyperactive, which is manifested by agitation, and hypoactive, depicted by a withdrawn quiet state (Scott, McIlveney, & Mallice, 2013). Both scenarios, which lasted an average of 15 minutes, required nurses to assess the standardized patients using the CAM-ICU. Technology that was incorporated in the scenarios included medical supplies and equipment that replicated the ICU environment.
Data Collection Tools
The Demographic tool collected data on critical care nurses, including age, gender, years of experience, education, and employment status.
The Knowledge of Delirium tool was a 10-item, multiple choice, investigator-developed test created from identified gaps in critical care nurses' knowledge of delirium. A comprehensive review of the delirium literature was performed to write the test items which included risk factors, signs and symptoms, consequences, and management of delirium. The test was administered before and immediately after the online learning module, and then again 6 weeks following the simulation. This test was used for ease of use; no content validity was established.
The Confidence Scale (Grundy, 1993) was a five-item Likert scale used to measure nurses' confidence in delirium assessment before and 6 weeks following the simulation. This scale is used to measure confidence in the skill of physical assessment, and is not delirium specific. Scores on each item of the Confidence Scale are reported as 1 to 5, with 5 being a higher score pertaining to confidence. The scoring on each item can be added to report an overall level of confidence, or the scores can be reported separately for each item. Based on the findings of Grundy (1993), validity and reliability has been established for this tool. Construct validity was established through use of the tool with nursing students (N = 35) in comparison with experienced nurses (N = 22). Concurrent validity compared this scale with two other measures of confidence and reported correlation coefficients from .58 to .80. Reliability was reported through Cronbach's alpha scores of .84 to .93.
The Educational Methodology Satisfaction tool was a nine-item investigator-developed evaluation tool that was used after the simulation to obtain participants' ratings of satisfaction with the method of educational preparation to assess and manage ICU patients with delirium and their use of the information in the clinical area. This was administered 6 weeks following the simulation.
The investigators explained the purpose of the study, and then obtained written informed consent from nurses interested in participating in the research. Participants completed the Demographic tool and the first administration of The Confidence Scale. All participants had previously completed the online learning module, along with the pretest Knowledge of Delirium tool.
Two-hour sessions were scheduled for groups of six to eight nurses to complete their scenarios. Scheduling of these sessions facilitated an enriched experience for the participants as a group due to the sharing that occurs during the prebriefing and debriefing of the simulations. A prebriefing occurred at the beginning of each session with the purpose of reviewing the objectives focused on the CAM-ICU. Participants were randomly assigned to one of the two created scenarios: hyperactive delirium or hypoactive delirium. In the actual scenario, a project leader (representing a nurse completing her shift) interacted with a single nurse participant who portrayed the oncoming nurse assessing the patient using the CAM-ICU. After all nurses in the session completed their scenario, a debriefing was held. The debriefing, led by the project leader, included a guided reflection on whether the learning objectives were achieved. Six weeks following the simulation experience, the nurses who participated in the study completed the second posttest and the additional data collection tools: The Confidence Scale and the Educational Methodology Satisfaction tool. The time frame of 6 weeks was chosen to give participants time to apply the educational content into clinical practice.
Summary measures were created for the demographic data. To address aims 1 and 2, a series of McNemar tests were used to examine change in the Knowledge of Delirium items and Confidence Scale items following the multimodal educational intervention. To address aim 3, summary measures were created for the Educational Methodology Satisfaction tool. Alpha was preset at 5% for all testing of significance. All analyses were performed using IBM® SPSS® Statistics version 21.0 for Windows®.
Demographic data reported that most participants were women (91.2%), held a bachelor's degree or higher in nursing (76.5%), had 1 to 10 years of experience (58.8%), and worked full time (73.5%). Participants were evenly distributed by age (50.0% were younger than 40 years and 50% were older than 40 years) and by shift (47.1 % work 12-hour days and 52.9% work 12-hour nights or rotating schedules).
Aim 1 was to increase critical care nurses' knowledge about delirium, including the use of the CAM-ICU. Responses to the Knowledge of Delirium tool that was used for the pre-and posttest demonstrated that each participant either improved (i.e., incorrect to correct), retained (i.e., correct to correct), remained (i.e., incorrect to incorrect), or regressed (i.e., correct to incorrect). As indicated in Figure 1, the majority of the participants (65.4%) were in the retained response category, indicating that knowledge was high in the pretest and was unchanged. Analysis using McNemar tests showed no statistical change in knowledge of delirium following the simulation.
Change in delirium items following intervention (N = 34); Q = question.
Aim 2 was to increase the confidence levels of critical care nurses in using the CAM-ICU to detect delirium and implement early management. For each of the five items on the Confidence Scale, each participant improved, retained, or remained; no participants regressed following the simulation (Figure 2). Participants reported more confidence following the simulation. Analysis using McNemar tests comparing each of the five items pre-and postsimulation showed statistical significance for improvement in confidence on items 1, 2, 4, and 5 (p < .001).
Change in confidence instrument items following intervention (N = 34).
Aim 3 addressed satisfaction with the multimodal educational strategy. Data from the Educational Methodology Satisfaction tool indicated that participants felt very satisfied (91.1% agree or strongly agree) and prepared (85.3% agree or strongly agree) following the use of simulation to learn about delirium and how to assess for it using the CAM-ICU. Most participants felt that additional education beyond the simulation was not needed (58.8%). Participants felt educated (76.5% agree or strongly agree) and consistently employed (85.3% agree or strongly agree) delirium nursing management with patients after completing the education.
Although there was no significant change from pre- to posttest scores on the Knowledge of Delirium tool, the Educational Methodology Satisfaction tool revealed that the simulation helped participants feel educated about delirium. Participants reported that no further education beyond the simulation was needed. The majority of nurses participating in the study reported they now routinely assess for delirium using the CAM-ICU and use nursing management measures with patients as needed.
As reported through analysis of the Confidence Scale, this study significantly increased the confidence levels of these critical care nurses. The majority of nurses felt confident in their correct use of the CAM-ICU postsimulation, reinforcing that simulation in nursing education is an effective teaching strategy. The simulation provided nurses with the ability to practice assessment skills using the instrument, thereby acquiring expertise and confidence.
This study had a few limitations. The limitations included a small sample size, as only 50% of the eligible nurses agreed to participate in the simulation. Another limitation was the Knowledge of Delirium test. Although based on a comprehensive review of the literature, no content validity was established.
A multimodal educational strategy, which included simulation, was a successful teaching method that engaged critical care nurses in interactive learning. Many of the nurses in the study reported a genuine enjoyment related to participating in the study. Although no change in the knowledge scores of delirium existed, anecdotal comments from the participants revealed an enhanced awareness of the concept of delirium and the importance of early detection. Follow up with the nurses revealed that they recognized the value in using the CAM-ICU, and it has been incorporated into daily practice every shift and as appropriate. More research is needed to measure accuracy of nurses' assessment of patients at risk for developing delirium and validation that treatment was initiated as a result of these assessments.
- American Association of Critical Care Nurses. (2014). Synergy model: Basic information about the AACN Synergy Model for patient care. Retrieved from https://www.aacn.org/nursing-excellence/aacn-standards/synergy-model
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
- Association of Standardized Patient Educators. (2013). Transforming professionals through the power of human interaction. Retrieved from http://aspeducators.org/node/48
- Balas, M.C., Rice, M., Chaperon, C., Smith, H., Disbot, M. & Fuchs, B. (2012). Management of delirium in critically ill older adults. Critical Care Nurse, 32(4), 15–22. doi:10.4037/ccn2012480 [CrossRef]
- Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215. doi:10.1037/0033-295X.84.2.191 [CrossRef]
- Barr, J., Fraser, G.L., Puntillo, K., Ely, E.W., Gelinas, C. & Dasta, J.F.American College of Critical Care Medicine. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit: Executive summary. American Journal of Health-System Pharmacy, 70, 53–58.
- Benson, E.P. (2004). Online learning: A means to enhance professional development. Critical Care Nurse, 24, 60–63.
- Devlin, J.W., Fong, J.J., Howard, E.P., Skrobik, Y., McCoy, N., Yasuda, C. & Marshall, J. (2008). Assessment of delirium in the intensive care unit: Nursing practices and perceptions. American Journal of Critical Care, 17, 555–565.
- Ely, E.W., Inouye, S.K., Bernard, G.R., Gordon, S., Francis, J., May, L. & Dittus, R. (2001). Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit. JAMA, 286, 2703–2710. doi:10.1001/jama.286.21.2703 [CrossRef]
- Gaba, D.M. (2004). The future vision of simulation in health care. Quality and Safety in Health Care, 13(Suppl.), 2–10. doi:10.1136/qshc.2004.009878 [CrossRef]
- Grundy, S.E. (1993). The confidence scale: Development and psychometric characteristics. Nurse Educator, 18, 6–9. doi:10.1097/00006223-199301000-00004 [CrossRef]
- Hardin, S.R. (2009). The AACN Synergy Model. In Peterson, S.J. & Bredow, T.S. (Eds.), Middle range theories: Application to nursing research (2nd ed., pp. 99–114). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.
- Inouye, S.K., van Dyck, C.H., Alessi, C.A., Balkin, S., Siegel, A.P. & Horwitz, R.I. (1990). Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941–948. doi:10.7326/0003-4819-113-12-941 [CrossRef]
- Leigh, G. (2011). The simulation revolution: What are the implications for nurses in staff development?Journal for Nurses in Staff Development, 27, 54–57. doi:10.1097/NND.0b013e31820eecea [CrossRef]
- Olson, T. (2012). Delirium in the intensive care unit: Role of the critical care nurse in early detection and treatment. Dynamics, 23(4), 32–36.
- Pauley, E., Lishmanov, A., Schumann, S., Gala, G.J., van Diepen, S. & Katz, J.N. (2015). Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. American Heart Journal, 170, 79–86. http://dx.doi.org/10.1016/j.ahj.2015.04.013 doi:10.1016/j.ahj.2015.04.013 [CrossRef]
- Rice, K.L., Bennett, M., Gomez, M., Theall, K.P., Knight, M. & Foreman, M.D. (2011). Nurses' recognition of delirium in the hospitalized older adult. Clinical Nurse Specialist, 25, 299–311. doi:10.1097/NUR.0b013e318234897b [CrossRef]
- Scott, P., McIlveney, F. & Mallice, M. (2013). Implementation of a validated delirium assessment tool in critically ill adults. Intensive and Critical Care Nursing, 29, 96–102. http://dx.doi.org/10.1016/j.iccn.2012.09.001 doi:10.1016/j.iccn.2012.09.001 [CrossRef]
- Svenningsen, H. (2015). A shared language regarding sedation and delirium in critically ill patients. Nursing in Critical Care, 20, 204–209. doi:10.1111/nicc.12187 [CrossRef]
- Tate, J.A. & Happ, M.B. (2012). The Confusion Assessment Method for the ICU (CAM-ICU). Retrieved from https://consultgeri.org/try-this/general-assessment/issue-25.pdf
- Vanderbilt University Medical Center, Center for Health Sciences Research. (2013). CAM-ICU resources in additional language translations. Retrieved from http://www.icudelirium.org/delirium/languages.html
- Waszynski, C. & Petrovic, K. (2008). Nurses' evaluation of the Confusion Assessment Method: A pilot study. Journal of Gerontological Nursing, 34(4), 49–56. doi:10.3928/00989134-20080401-06 [CrossRef]
- Zaal, I.J. & Slooter, A.J. (2012). Delirium in critically ill patients: Epidemiology, pathophysiology, diagnosis and management. Drugs, 72, 1457–1471. doi:10.2165/11635520-000000000-00000 [CrossRef]