Journal of Gerontological Nursing

Feature Article 

Institutionalizing Clinical Reasoning: A Grounded Theory of the Clinical Reasoning Processes RNs Use to Recognize Delirium

Mohamed El Hussein, PhD, RN; Sandra Hirst, PhD, RN

Abstract

Delirium is a common disorder among hospitalized older adults often leading to prolonged hospitalization, increased health care costs, and sometimes death. The goal of the current study was to construct a grounded theory that explains the clinical reasoning processes that RNs use to recognize delirium in older adults in acute care settings. Seventeen participants in three hospitals were interviewed. The core category that emerged from the data was institutionalizing clinical reasoning. Findings from the current study can be a starting point for RNs to bring self-awareness to variables that influence their reasoning processes. [Journal of Gerontological Nursing, 41(10), 38–44.]

Abstract

Delirium is a common disorder among hospitalized older adults often leading to prolonged hospitalization, increased health care costs, and sometimes death. The goal of the current study was to construct a grounded theory that explains the clinical reasoning processes that RNs use to recognize delirium in older adults in acute care settings. Seventeen participants in three hospitals were interviewed. The core category that emerged from the data was institutionalizing clinical reasoning. Findings from the current study can be a starting point for RNs to bring self-awareness to variables that influence their reasoning processes. [Journal of Gerontological Nursing, 41(10), 38–44.]

Delirium is primarily a disorder of cognition characterized by confusion and lack of attention (Meagher, Maclullich, & Laurila, 2008; Neufeld & Thomas, 2013). It is associated with functional decline, institutionalization, and mortality (Scott, Mathias, & Kneebone, 2015). Delirium symptoms can persist beyond discharge in up to 78% of individuals (Cole, 2010; Dasgupta & Hillier, 2010; Inouye et al., 2007; Witlox et al., 2013). Ongoing symptoms are associated with functional and cognitive impairment in 50% of patients, two to three times increased risk of death, and lack of decision making (Inouye, Westendorp, & Saczynski, 2014). Delirium also increases risk of dementia (Kiely et al., 2006; McCusker, Cole, Dendukuri, Han, & Belzile, 2003; Speciale, Bellelli, Lucchi, & Trabucchi, 2007). Its early recognition and prevention should be care priorities for gerontological nurses.

Background

Life expectancy has increased by more than 30 years since the beginning of the 20th century (Howse, 2006). The number of older adults admitted to acute care settings has also increased (Health and Social Care Information Centre, 2014). Older adults are at high risk of adverse hospital outcomes, such as delirium, due to their reduced functional ability and mobility, alterations in nutrition, possible polypharmacy, and other comorbidities (Scott et al., 2015). Tadd et al. (2011) conducted an ethnographic study in four acute care hospitals, where the majority of participants agreed that acute care hospitals are not the right place for older adults or a good fit for their management. Tadd et al. (2011) focused on the culture of acute care settings and disregarded the individual, personal, and cognitive perspectives of the participants.

Neville and Gilmour (2007) established that determining the cause of the confusion (i.e., delirium) requires careful assessment. Neville (2008) added that the complex nature of working with older adults in general and those with delirium in particular demand highly skilled and knowledgeable nurses to respond promptly to changes in older adults’ cognitive status in addition to effectively factor in the personal and contextual variables that influence their hospitalization experience.

Delirium in older adults is featured by alterations in various personal and contextual dimensions that must be considered by health care staff to capture its occurrence. Nurses’ competence to deliver care for older adults with delirium is negatively impacted by their underrecognition of delirium (Rice et al., 2011; Steis & Fick, 2008; Voyer et al., 2012). Underrecognition of delirium can be attributed to nurses’ indifferent approach to older adults and their negative attitudes and stereotypes about older adults, which affect their ability to understand their needs (Samter & Voss 1992; Treharne, 1990). Payne, Hardey, and Coleman (2000) maintained that the organizational structure of nursing work and activities with older adults tend to focus on meeting patients’ physical needs rather than the delivery of competent care. Moreover, nursing care of older adults is historically delegated to inexperienced and unqualified staff (Cormack, 1985), ignoring the fact that the complexities of providing competent care for older adults require well-developed clinical reasoning skills (Payne et al., 2000). The aforementioned variables can convince nurses to accept a patient’s abnormal behavior as part of the aging process before delirium has been fully verified, thus leading to underdevelopment of their clinical reasoning processes and failure to adjust their impression in light of later information.

Clinical reasoning was not conceptualized as an exclusively cognitive function because it also includes significant social, psychological, cultural, and contextual influences (Rashotte & Carnevale, 2004). As such, it is an ideal approach to be used in the process of delirium recognition in older adults. Rice, Bennett, Clesi, and Linville (2014) added that well-developed clinical reasoning skills are antecedent for delirium recognition. RNs must practice their cognitive and metacognitive skills to engage in effective clinical reasoning to recognize delirium (Sedgwick, Dersch, & Grigg, 2014).

Research Question

The research question that guided the current study was: What are the processes and strategies that RNs use to recognize delirium in older adults in acute care settings?

Grounded theory (Glaser, 1978) was used because it is uniquely suited for field work to explore the activities that reflect what participants actually do while interacting with older adults. The problem of delirium underrecognition needed a theoretical grasp of its processes within its data to understand what is occurring during the interaction between RNs and older adults with delirium. As such, grounded theory is a research method that is methodologically congruent with this research question. Grounded theory is ideational, leading to creation of ideas that explain the problematic nature of delirium underrecognition. Understanding these processes leads to better interpretation of the ideas and makes them more relevant as core problems and processes emerge. The use of grounded theory provides additional emphasis on “thinking as opposed to learning” (Glaser, 1978, p. 7), which makes it an ideal tool to uncover the thinking processes of the participants in the current study.

Method

Data Collection

The authors of the current study recruited participants from three tertiary hospitals in Canada. The recruitment process started after the study received ethical approval from the respective board. The researchers (M.E.H., S.H.) posted flyers inviting the participation of RNs with a minimum of 2 years’ experience working full-time with older adults in acute care settings. Initially, a convenience sampling method was used to select candidates followed by theoretical sampling. Theoretical sampling continued and was guided by the emerging concepts and categories. After the 12th interview, pertinent empirical data were sought to fill theoretical gaps in the emerging theory. Five additional interviews were conducted that enriched the conceptual density of the subcategories and further supported them by indicators grounded in the empirical data.

Seventeen participants from 15 different units contacted the researchers and consented to be interviewed. Consents to be interviewed and audiotaped were signed by participants and researchers before the interview; each interview lasted between 45 and 60 minutes and was transcribed verbatim immediately after the interview by a transcriptionist hired for this purpose. An interview guide was used, which evolved after each interview, and questions were modified based on the concurrent collection and analyses of the data and emerging theory. The interview questions focused on the meaning of delirium, processes and approaches to patients with delirium, associated contextual circumstances, and any circumferential variables that may have impacted RNs’ approach to patients with delirium.

Data Analysis

Grounded theory differs from other qualitative research methods in that it not only provides meaning, understanding, and description of the phenomenon under study, but also provides theory-generation (Glaser, 1978). One of the core principles of performing grounded theory research is constant comparison, which leads to the generation of concepts and ultimately categories that result in the emerging theory.

The grounded theory method prompts interaction with the data from the beginning of collection and throughout the process of analysis. Interviews were transcribed and analysis began with line-by-line coding where each line of data was labeled. Facts (i.e., indicators) in the data were located, coded, and collapsed into concepts until a pattern emerged. These concepts were converted into subcategories and continuously checked against and verified by the original data. A clear connection that highlights the properties of these subcategories in the data was drawn so as to stay grounded in the participants’ experiences. Line-by-line coding was continued until codes were found for further exploration; these codes were captured and questions were developed around them to focus the data construction and analysis. On several occasions, conventional norms and the authors’ own assumptions were challenged. Emerging concepts and subcategories guided further data collection and theoretical sampling. This process was continued in an attempt to find indicators in the data that constantly support and corroborate the subcategories and achieve a good fit with the core category. Further properties were sought until the concepts were verified and saturated. Categories grouped many indicators under one idea and denoted the underlying pattern. Memo writing was the cornerstone in the process of data analysis, as it helped raise data to a conceptual level and developed properties for each category. Once no new properties of the pattern emerged, saturation was reached and data became conceptually dense to explain the pattern.

Results

Institutionalizing clinical reasoning was the grounded theory that emerged from the data (Figure). Institutionalizing describes the submergence of RNs into the organizational and political structure of the acute care hospital. This core category has two subcategories: politicking and tasking.

The grounded theory: institutionalizing clinical reasoning.

Figure.

The grounded theory: institutionalizing clinical reasoning.

Politicking

Politicking is the process of integrating hospital policy and unit norms by RNs’ into their everyday practice (Antal-Mokos, 1997). Politicking incorporated the pressure that acute care units exerted on participants’ clinical reasoning processes and subsequent actions. This submergence was a barrier to RNs’ familiarity with patients. It is represented in RNs who work casual shifts on different units and in their shift rotations. Both factors decreased the time needed to gather enough cues to understand the pattern of behavior of their patients, leading to underrecognition of delirium. Participants voiced that assigning them to the same patient would provide the opportunity to recognize subtle changes in behavior and cognition. This quest for familiarity was captured in the statement by one participant, “Especially on days, our assignments get moved a lot because, depending on how many staff.... One day we might have four and then five, they keep shifting our load.” Another participant expressed:

If you work with a patient daily, there is a higher chance to be recognizing a delirium.… If you come on shift you work with a patient one day, you’ve never seen this person in your life, and he’s old so you think “he’s probably a bit senile.”

Delirium recognition tools are integrated into hospital procedures and influence RNs’ clinical reasoning process. A lack of consistency in using these tools was captured by one participant:

They’re specific to different units and to different programs…if we go here we have a set that we use, which is nursing care for the older adult… go to the orthopedic unit…and the physicians would have an order set for delirium with hip fracture.... They were all created in isolation.

What emerged from participants was that they did not formally assess for cognition while interacting with older adults, yet delirium is an alteration in cognition. Mental status was usually assessed by occupational therapists with tests not used by RNs.

Lack of documentation of cognitive status also leads to dysfunctional (i.e., unworkable) clinical reasoning to recognize delirium. The following statement illustrates this observation: “I’ve worked in long-term care. Charting by exception is what we used to do. In the hospital? They do it every shift. If there’s a change in status.” Clinical reasoning in this context was situated in the context of self-protection. There was an atmosphere of being held liable and documentation was used as protection.

According to hospital policy, using physical restraints requires a physician’s order. However, some RNs used what the organization called the “geri-chair.” This labeling raised concerns because according to them the “geri-chair” is a physical restraint. Relabeling changed the legal consequences of the intervention and steered the clinical reasoning process into self-protection. This tension is demonstrated in the following statement:

If that chart had gone to court that nurse would be liable for not getting an order for the restraints….a nurse doesn’t consider a geri-chair, a restraint, and…will not get an order if she sticks her patient into a chair restraint with a table.

As shown in the above examples and quotes, politicking is integral to the clinical reasoning processes used by RNs to recognize delirium.

Tasking

The race to get tasks done reflects the second subcategory of the grounded theory developed to explain the recognition of delirium in older patients. Participants’ main concern was often getting tasks done as quickly as they could. A criterion that guided tasking was a stable patient condition. RNs felt obligated to attend to unstable patients rather than patients who were shouting or agitated. RNs’ definition of stability excluded behavioral manifestations and focused on vital signs, numbers, and tracings. One participant’s response captured this notion: “Once they’re stable, they’re gone... whether they’re delirious or not.”

Participants voiced that acute care settings, where patient management is disease-oriented and efficiency-driven, lacked the flexibility and freedom for them to effectively assess delirium. Consequently, changes in patients’ cognitive status were not noticed until they interrupted the organizational flow on the unit. One example is patients with hypoactive delirium (Irwin, Pirrello, Hirst, Buckholz, & Ferris, 2013), who were sometimes perceived as being “lighter load.” This instance is illustrated by one participant who stated, “They tend to be the easier patients that get ignored, right? Versus the ones that are really active and draw your attention.” Or as another participant said, patients with hypoactive delirium who were “pleasantly confused” posed no threat to themselves or to staff, and did not disrupt the norm of the unit. Thus, RNs did not feel obligated to perform any further assessment; their clinical reasoning process was halted.

Overwhelming workload was the most cited cause for failure to recognize delirium. Some RNs dealt with delirium in terms of work-related consequences rather than patient care outcomes. They regarded the hyperactive form of delirium (Irwin et al., 2013) to be challenging because it interfered with their work or disrupted the order of the unit. Their comments attest to their focus on performing tasks:

If you had an acutely confused patient, you would want to be checking on that patient more often. A lot of your other things might be sacrificed because you might continually be checking.... I think because nurses are so busy that when you have those days that your patient never rings the bell or you only have to check on them every hour or two and they’re fine, you get that sense of relief.

For some participants, the acute care settings’ schedules for meals and bedding change, for example, guided their clinical reasoning process. One participant captured this notion, stating:

So, number 1 is report, number 2 is walking in and looking at the room. If it looks like this…okay well, what’s going on, he’s moving around, life is busy, right. If things don’t look touched....like us, on our unit we give water twice a day on my shift. If the water is not touched...[this patient may be experiencing hypoactive delirium characterized by detachment and lethargy].

Tasking was supported by the computer record software—one of the icons was “task manager.” Some participants believed that their role was reduced to checking boxes and clinical reasoning became a choice but not a requirement, as one stated, “Get my 9 o’clock meds done, my 10 o’clock procedures done, my 11 o’clock referrals done.” Delirium recognition tools were computerized and integrated into the computer record system. Once the diagnosis of delirium was confirmed, it was entered and an order set appeared. However, the software has more than five sets of task interventions related to delirium, which created confusion for RNs as to which intervention to use. This challenge influenced the RNs’ clinical reasoning.

Discussion

Previous studies inferred that RNs failed to recognize delirium due to faulty clinical reasoning (Benner, Tanner, & Chesla, 1992; Rice et al., 2014; Tanner, Benner, Chesla, & Gordon, 1993). Rice et al. (2011) asserted that nurses underrecognized delirium because they “failed to demonstrate the reasoning activities consistent with critical thinking” (p. 309). In the current study, RNs’ underrecognition was not solely related to clinical reasoning process, but was also context-dependent upon the organization, the acute care hospital. This finding is in disagreement with McCarthy (2003), who indicated that nurses’ ability to recognize delirium was independent of the clinical setting and totally dependent on their philosophical perspective on aging. Although the perception of ageism may have influenced the clinical reasoning process for some participants in the current study, it was not the overarching theme. The influence of aging on recognition was also supported by Agar et al. (2012).

Stetler, Ritchie, Rycroft-Malone, Schultz, and Charns (2009) defined institutionalization as the integration and adoption of a specific perspective into the fabric of a clinical organization until it becomes the norm. In the current study, RNs were preoccupied with managing their required tasks. Managing these tasks was part of their normative routine. The focus on performing a task was a distinct influence on the RNs’ clinical reasoning process in recognizing delirium. This focus on tasks may relate to what Stebbins (2012) described as performing a role versus engaging with an activity. The former is task oriented, where deep thinking and reasoning are not prerequisite, whereas engaging with an activity is a mental and physical process triggered by the objective of achieving an outcome. Participants in the current study were task-oriented.

Congruent with other studies where RNs in acute care settings identify work complexity patterns (Ebright, Patterson, Chalko, & Render, 2003), RNs in the current study continuously addressed tasks and interrupted their care with one patient to attend to an urgent need by another patient. These interruptions resulted in disjointed interactions, which did not help them assess patients for delirium. RNs’ main concern was identified as their ability to timely and competently handle patients’ load during shifts so as not to lose credibility among their peers. Competency and efficiency were perceived as performing the tasks on time and not getting behind in work. This observation matches the findings of Nilsson, Rasmussen, and Edvardsson (2013), where “falling behind” (p. 1682) was the substantive grounded theory that facilitated/hindered care in older adults with cognitive impairment. The pace in acute care settings in the current study did not provide the opportunity of waiting to access resources or finish one process and then move to another, as has been reported previously (Ebright et al., 2003). RNs were often engaged with several activities simultaneously and down time was not an option. Other studies have validated these observations where the rapid pace of activities, the competing tasks, acquainting oneself with new policies and procedures, and mastering new equipment added layers of distraction to RNs’ clinical reasoning processes (Ebright et al., 2003; Potter et al., 2005). The culture of acute care settings directed the clinical reasoning process, which focused on multiple task accomplishment, diminishing time available for attention to older patients.

Implications for Gerontological Nursing Practice

RNs can reexamine their practices and reflect on the organizational factors that influence their reasoning processes. Nurses need to explore their own views of aging and ask themselves what perceptions about older adults do they hold? Do these views negatively impact the assessment of older adults under their care? Have they let task accomplishment take priority over holistic care? Most nursing jurisdictions promote continuing competency, and answers to these questions by RNs may establish learning objectives for the next year. RNs should perform regular cognitive assessment and be specific and proactive about uncovering delirium. RNs in acute care settings should collaborate with gerontological nurses and geromental health nurses to develop deeper understanding of clinical challenges common in older adults, such as delirium.

Unit managers and policy makers are advised to consider implementation of programs such as the Hospital Elder Life Program (Inouye, 2004), a multicomponent intervention strategy designed to prevent delirium by targeting six delirium risk factors, and the Acute Care for Elders Model (Tinetti, 2013), which focuses on patient-centered care, frequent medical review, early rehabilitation, early discharge planning, or prepared environment.

Institutionalizing clinical reasoning may be useful to administrators who develop policies on standards of practice for older patients. If task accomplishment is ingrained in acute care facilities, should assessment of delirium be integrated as an expected task into unit routines by nurse managers? Should it be a separate check box on computerized record keeping? The integration of delirium as a routine and expected nursing task is a potential point of debate. It may ensure that nurses include delirium assessment into their daily practice, but it may also standardize tasks and detract from holistic nursing care.

The findings from the current study highlight the need for nurse researchers to further investigate the causes of underrecognition of delirium to develop interventions to facilitate its recognition. It will be the responsibility of undergraduate nurse educators to integrate these strategies into their programs and hospital-based educators to incorporate them into orientation and periodic education sessions with staff.

Conclusion

The core category of institutionalizing clinical reasoning provides an overarching explanation of the clinical reasoning processes that RNs used to recognize delirium. It explains how participants described their individual clinical reasoning processes and comprises two subcategories, politicking and tasking. Through the consideration of the findings from the current study, the incidence and duration of delirium can be reduced and better patient outcomes realized. Sensitivity to issues that emerged in the current study may result in more effective clinical reasoning processes and better recognition rates. Recognition of the complexity and difficulty of clinical reasoning processes in acute care settings may lead to the development of alternative programs and approaches to older adults with cognitive impairments such as delirium.

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Keypoints

El Hussein, M. & Hirst, S. (2015). Institutionalizing Clinical Reasoning: A Grounded Theory of the Clinical Reasoning Processes that RNs Use to Recognize Delirium. Journal of Gerontological Nursing, 41(10), 38–44.

  1. Nurses’ clinical reasoning is partly shaped by the respective hospital and unit policies and norms.

  2. Hospital policies should promote nurses’ longer interaction with patients to develop familiarity and uncover subtle cues of delirium.

  3. Nurse educators should ensure that bedside nurses are competent in using the available delirium recognition tools.

  4. Nurses’ should not allow the value of the interaction with patients to depreciate due to patients’ aging and should perform regular cognitive assessment and be proactive about uncovering delirium.

Authors

Dr. El Hussein is Associate Professor, Faculty of Health and Community Studies, School of Nursing, Mount Royal University; and Dr. Hirst is Associate Professor, Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Mohamed El Hussein, PhD, RN, Associate Professor, Faculty of Health and Community Studies, School of Nursing, Mount Royal University, 4825 Mount Royal Gate SW, Calgary, Alberta, Canada T3E 6K6; e-mail: melhussein@mtroyal.ca.

Received: March 20, 2015
Accepted: July 07, 2015

10.3928/00989134-20150728-12

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