Clinical Education Focused on Providing Care for Clients Experiencing Delirium: Enhancing Nurses' Knowledge, Self-Efficacy, and Application to Practice

Monday, 9 November 2015: 1:45 PM

Sherida Ingram, BScN, RN1
Yolanda B. Babenko-Mould, PhD, MScN, BScN, RN2
Richard Booth, RN, BScN, MScN2
(1)Arthur Labatt School of Nursing, Western University, London, ON, Canada
(2)Arthur Labatt Family School of Nursing, Western University, London, ON, Canada

Background:  Delirium is an urgent health condition that requires treatment without delay to lessen the chance of increased morbidity and mortality.  Despite the seriousness of delirium, it is reported that both nurses and other healthcare professionals fail to detect the presence of delirium in 60% of clients in acute care settings (Mitstarz, Eliott, Whitfield, & Ernest, 2011).  A primary reason why delirium is poorly recognized is due to a lack of education (Gordon, Melillo, Nannini, & Lakatos, 2013; McCrow, Sullivan, & Beattie, 2014; Tabet, Hudson, Sweeney, Sauer, Bryant, Macdonald, & Howard, 2005).  It was proposed that if education can support nurses’ abilities to provide more effective and safer client care, then it was prudent and timely to generate deeper insights related to how nurses’ knowledge and self-efficacy would be influenced as a result of participating in a clinical education session.  In addition, given that knowledge translation is pivotal factor in nursing education and practice, it was important to explore how nurses’  knowledge was applied to their practice after participation in an education session.   

Purpose and Design:  The purpose of this mixed methods study was two-fold:  a) to assess nurses’ knowledge and self-efficacy prior to and immediately after involvement in a clinical education session about how to provide care for the client at risk for delirium and for the acutely delirious client in a hospital setting, and b) to explore nurses’ experiences of applying knowledge from the education session to the practice setting.  The education session focused on objectives related to the risks, signs and symptoms of delirium, standardized screening tools available for delirium and management strategies of the client at risk for delirium and the acutely delirious client.  

Methods:  Upon receipt of ethics review board approval, unit coordinators and educators of two participating acute care hospital facilities were provided with a Letter of Information about the study, which was sent via email.  The study information was distributed by unit coordinators and educators to nursing staff.  Thus, all eligible RNs at the acute care facilities involved in point-of-care-nursing practice were invited to volunteer to participate in the education sessions.  Recruitment posters were also distributed throughout the two facilities.  At each education session, a package was distributed to attendees containing the Letter of Information, the Consent Form, and the Demographic Questionnaire.  In order to address part ‘A’ of the study, the pre-test knowledge instrument and pre-test self-efficacy instrument were distributed for completion immediately before the education session.  The post-test knowledge instrument and post-test self-efficacy instrument were distributed for completion immediately following the education session.  

A total of six education sessions were held; four sessions at the first facility and two at the second facility.  Fifty-six participants took part in the education sessions and completed the pre and post-test instruments.  Each education session was held as a face-to-face 60 minute 'lunch and learn' session lead by the primary researcher.  A pre-prepared slide presentation and the same case study were utilized in each session to ensure consistency of presented material.

Instruments:  Two researcher-designed instruments were utilized for the quantitative methods part of the study: the Knowledge Instrument to Care for a Client at Risk for Delirium and of the Acutely Delirious Client and the Self-Efficacy Instrument to Care for a Client at Risk for Delirium and of the Acutely Delirious Client Instrument.  Both instruments were completed prior to and immediately after the education session.  In part ‘B’ of the study, seven nurses volunteered to participate in the individual audio-recorded interviews at least two weeks after the education session to explore their experiences of translating the knowledge developed from the clinical education session into practice.  Individual interviews were conducted using a semi-structured interview guide and interviews were subsequently transcribed verbatim.  Descriptive content analysis was conducted on the transcribed data in order to develop categories and themes related to nurses’ experience of knowledge translation regarding the topic of delirium.

Outcomes:  The results of the quantitative portion of the study indicated that nurses had a higher level of knowledge and self-efficacy about the care of clients at risk for or experiencing delirium as it relates to assessment, screening and management of delirium after participating in the education session.  The qualitative findings highlighted participants’ rich experiences and revealed the categories of:  empathy, knowledge acquisition, competence, leadership, and confidence.  Themes, which served to capture the essence of participants’ experience included: enhancing emotional intelligence, strengthening clinical judgment to enhance quality of care, and increasing leadership competency.  

Implications:  Nurses’ were found to have gained knowledge of the risks, signs, symptoms and management of the delirious client and for those at risk for delirium after attending the education sessions.  This may allow for recognition of delirium and increase nurses’ abilities to prevent exacerbation of delirium.  Nurses’ overall higher ratings of self-efficacy, as a result of involvement in the clinical education session, suggest that nurses who believe they can assess for and manage clients’ delirium may decrease the overall incidence of delirium.  

As a result of increased knowledge,  nurses may be able to provide more comprehensive screening, and seek treatment modalities earlier, preventing further decline in the clients overall status.  Providing a more timely diagnosis and early treatment may decrease the clients’ length of stay, potential risk of institutionalization following discharge, loss of function and decrease the use of restraint.  Further, increased self-efficacy for caring of this population may enable the nurse to manage clients experiencing delirium, while providing support the client and family with more confidence.  

Recommendations:  Delirium education is recommended to strengthen nurses’ knowledge and self-efficacy of caring for this high risk population.  Education programs for nurses should be based on evidenced-based practices.  In this way, education being received should be consistent and the management of these clients will become a standard of care.  Collaboration between academic faculties and hospitals is recommended to increase the awareness of delirium with both students and professional nurses. 

Conclusion:  Education sessions to prevent delirium increased nurses’ competence and confidence.  Delirium is one of the most common conditions found in the acute clinical setting, yet it remains one of the least recognized and understood conditions.  Studies, such as this, have shown that simple and inexpensive clinical education programs have the potential to significantly decrease the prevalence of delirium (Tabet et al., 2005).  Therefore, an investment and valuing of ongoing continuing professional development in education can ultimately positively impact quality and safe client care.    

Keywords:  nurses, delirium, education, clients, acute care, knowledge, self-efficacy, quantitative, qualitative