Changing Registered Nurses’ Attitudes Regarding Delirium Assessment in a Military Community Hospital

Purpose

The purpose of this presentation is to discuss the attitudes of registered nurses to the application of a standardized delirium assessment tool in a rural community hospital serving a large military veteran population.

Background

Delirium in the hospitalized patient can be a life-changing and highly stressful experience for the patient, the family, and for the nurse resulting in long-term life changes for the patient and family.  It is estimated that a majority of patients hospitalized in medical/surgical units and ICUs experience symptoms of agitation and delirium during their hospital stay.  The military combat veteran has a 10-20% higher risk of delirium events during acute hospitalization.  Delirium is commonly undetected by nurses in upwards of 80% of all ICU patients and this rate may be significantly higher across all hospital nursing units.  The attitudes of nurses towards use of detection tools may be one factor in the under-recognition of delirium.  There is evidence that standardized assessment tools can assist nurses to identify patients at risk and identify early symptoms for delirium.

Project Description

The project utilized a pre- and post-survey design. The project was completed between October-December 2014.  IRB approval was granted.  A convenience sampling method was used to recruit participants who were registered nurses, employed by the rural community hospital, had a minimum of 1 year work experience, demonstrated the ability to read and write the English language.  A total of 58/154 community hospital nurses were recruited with only 29 fitting the inclusion criteria that included completion of both the pre- and post-intervention survey.  The project setting involved a small rural community hospital in Alabama with a maximum bed capacity of 120.  The hospital provides a full service, 24-hour, 12-bed Emergency Department, an 8-bed Intensive Care Unit, one 29-bed surgical floor, one 29-bed medical floor, a 6-bed Labor unit, and a 12-bed Post-partum unit.  Hospital admissions average 284/month.  This facility is located near a large active-duty military instillation and serves a diverse military and veteran population.  Approximately 78% of the nurse employees had personal connections to a current or former military service member.

Methods

A nurse attitudes survey was adapted for this project.  Data collection included completion of pre- and post-intervention surveys.  The survey instrument included self-report measures through Likert scales, choice completions, and narrative comments.  The internet-based program, Survey Monkey®, captured participant responses. The project provided an educational-training intervention (ETI) session with embedded video-scenario examples of patients experiencing delirium events during acute hospitalization.  Participants, who attended the training session, utilized the delirium assessment tools (B-CAM or CAM-ICU) to practice scoring patients seen in the video-scenarios. 

Results

Descriptive statistics were used to describe data related to the specific goals of this study.  Three open-ended questions were analyzed to identify themes signifying other knowledge gaps related to delirium assessment. Inferential statistics were used for both paired samples t-tests and Chi-square calculations in order to examine for significant differences in study outcomes prior to and post intervention.  While there were modest clinical differences in study outcomes, there were no statistically significant results.  These results could be attributed to the small sample size. 

Conclusion

Participants reported a positive attitude when given the opportunity for education and clinical application of standardized delirium assessment tools.   Participants reported feeling more confident in completing delirium assessments. They indicated increased recognition of the risk factors for and symptomatology of delirium in hospitalized patients age 65 and older.  A strong willingness to continue to utilize the standardized tools to perform delirium assessments on their patients was reported.  Anecdotally, the nurses felt delirium assessment should be added to their electronic health record (EHR) system as part of the nursing assessment records.  Specifically, the participants recognized that their high military veteran population was at great risk for delirium events.  Many nurses indicated that they did not previously investigate their patient’s military background during their admission nursing assessment and now see the need to include that information in the EHR.