NURSES ATTITUDES TOWARDS OLDER PATIENTS WITH DELIRIUM

NURSES ATTITUDES TOWARDS OLDER PATIENTS WITH DELIRIUM

Abstract

The population of the elderly is increasing. Hence the number of people with delirium condition is also rising. The attitude of nurses towards the elderly is a question of concern over many years. This research study focused on studying the attitudes of nurses towards elderly patients with delirium. The objective of the paper was to determine the nursing skills and knowledge required for effective interaction with delirium patients, how knowledge on delirium assessment tool and protocol enables nurses to develop positive attitudes and how age, work experience and education are related to nursing attitudes.  The research used a literature review research methodology. Data was collected from authors qualitatively. Scientific journals, books and web-based sources will also be used in data collection. From the analysis of the data, knowledge and nursing skills required for effective interaction with delirium patients include; calculation, communication techniques, providing information, self-management, working disciplinary as well as knowledge about delirium patients, self-management and competency.  Adequate knowledge of delirium assessment tool and protocol, age. Work experience and education influence nurses’ attitudes.

            Introduction

According to Blevins (2018), delirium is an acute confusional condition which is usually characterized by fluctuating mental status and inattention; it constitutes an acute organ failure of the brain. Delirium increased the risk for mobility and mortality for hospitalized patients and under-recognized by healthcare practitioners has contributed to poor outcomes for patients. Delirium happens to be an acute medical emergency that if not treated immediately will have a direct impact which might negatively influence a patient’s rate of recovery and in turn increases the length of stay in the hospital and likelihood of being admitted into a care home and risk of mortality (Brooke, 2018).

Delirium is under-recognized and usually not documented by nurses in over 80% of patients who have been delirious. Nurse play critical roles in assessing the risk for delirium because they provide around the clock care and see these patients in a variety of circumstances (Swan B A. et al. 2011). Some variables are known to determine delirium, which is usually age (65 and above) and dementia. With up to 5-85% of patients with delirium usually detected if adequate risk assessment and a preventive care procedure, the emergence of delirium could be prevented (Laurila 2006).

The consequences and challenges of not addressing delirium in patients admitted in the hospitals have been linked and shown to have numerous adverse effects which include:  a protracted stay in the hospital, functional and capacity decline, morbidity and mortality, increased need for nursing care institutions and placements and an increased cost of healthcare (Dahlke and Phinney 2008). Need not to say that delirium is and represent one of the preventable adverse effects amongst elderly patients during their stay at the hospital.

2          Background

At least more than half of the hospitalized older adults will likely experience delirium, which if left untreated can and will eventually lead to detrimental outcomes. Despite the severity and prevalence of delirium, less than one-third of these cases have been recognized by nurses. For the fact that little is known on how nurses manage this problem. (Dahlke and Phinney 2008).

In Finland, for example, the proportion of persons aged 65 or over in the population is estimated to rise from the present 19.9 to 26 per cent by 2030 and to 29 per cent by 2060. The demographic dependency ration that is the number of children and pensioners per one hundred persons of working age will go up in the near future. (Statistics Finland retrieved 16.05.19, as published in 2018). The size of the old population is expected to be doubled at the end of 2030. As the ageing population in Finland and the rest of the world keeps increasing so will the need for expanded hospital care for older adult grow.

During hospital admission older patients who are vulnerable to factors that predispose them to failure in their body mechanisms are further exposed to certain precipitating factors such as medication, surgeries, and sleep disruptions, thereby overwhelming them and delirium sets in (Day Higgins and Koch, 2008).

Delirium is often seen as an acute, sometimes fluctuating distortion in the mental status, including inattention, an altered level of consciousness and disorganized thinking. This may last as long as few hours to a few months or even longer. Delirium, at times, may present itself as the first or only underlying medical problem (Hare et al., 2009).

According to DSM-V Diagnostic and statistical manual of mental disorders(2013), delirium usually presents with signs and symptoms such as (a) disturbances that have to do with consciousness with a reduced ability to focus, shift, or sustain attention;(b) a cognitive change(language, disorientation, memory) or perpetual disturbance developments that cannot be accounted for by any pre-existing confirmation or evolving dementia; (c) development of disturbances over a very short period of time ( hours -days) and likely to fluctuate during the course of the day; and (d) a laboratory or physical findings that tend to show that, the disturbance is a direct cause of physiological consequences of a general condition, substance intoxication, medications or withdrawal or medications side effects. The manifestation of delirium may be often confused with dementia or mental illness. Identification also may be very difficult as delirium can come in forms or may exhibit as one of its three main types: hyperactive, hyperactive and the mixed form.

The hyperactive form is exhibited as a hyper-vigilance and is usually associated with hallucinations and agitations. The condition is further characterized by restlessness and aggressive behaviour. Hypoactive delirium is characterized by motor retardation, apathy, slowness in speech as well as sedation. Hospitalized patients with this form of delirium are most likely to have the condition easily recognized and will tend to receive early intervention. Additionally, this form of delirium can be more challenging physically and emotionally for the nurses on duty than other forms and could require much more resources, energy and time (Hare et al.,2009). The mixed form of delirium on the other is a combination of both conditions. It implies that the patient is showing hyperactive and hypoactive delirium.  When a patient has delirium with no symptoms of motor retardation has cognitive challenges related to delirium.  Hypoactive delirium is the most common among people. However, it is also less likely to be realized, discovered or reported. However, such hypoactive subtype patients are said to be more cooperative.

Research studies have been done on the effects of the different types of delirium. However, their study findings have remained inconclusive. For instance, some of the research studies have shown that patient prognosis is worse after the patient has undergone hyperactive delirium. Other research studies have shown that prognosis is more poor and ineffective after there are hypoactive delirium symptoms.  This result tends to shown inconclusiveness.  In addition to that, the way both types of delirium are managed is also different.  When patients display motor agitation and behavioural challenges, physicians tend to use antipsychotic medication and physical restraints.  Such type of medication, however, is avoided at all costs for the case of hypoactive delirium (British Geriatrics Society and Royal College of Physicians, 2006).

The hypoactive form often exhibits as drowsiness, lethargy and most times difficulty in focusing attention. Hospitalized patients of these forms of delirium are usually less disruptive to nurses, and consequently, this form of delirium is more likely than hyperactive delirium to go undetected and unrecognized. Delirium is an acute state of confusion, in contrast to dementia, which is a chronic state of confusion (Hare et al., 2009).

Besides being caused by more than one element or factors, delirium usually complicates an intricate interrelationship of a vulnerable patient with an existing factor and exposed to further challenges in the hospital environment (Inouye, 2006). Hospitalized patients who are already vulnerable to delirium due to dementia and/or coexisting conditions can easily get delirium as a result of a relatively affable or a harmless offence as a dose of a sleeping pill. While for those hospitalized patients who originally do not have vulnerability may develop delirium just only after being exposed to factors such as general anaesthesia, major surgery, stressful impact and psychoactive medications. A simple interaction between the factors within an individual and factors in the environment of the hospital can set up the development of delirium (Inouye, 2006).

Yet hospital caregivers (which includes registered nurses, certified caregivers and physicians) may not be adequately trained or experience to identify or notice the signs and symptoms of delirium so as to effectively initiate an appropriate intervention and treatment in order to reduce the unexpected effects of delirium. It is therefore important to understand how nurse’s attitudes towards caring for an older patient with delirium will influence the emergence of delirium in elderly or older adults of the population.

Because delirium arises as a complicating result of many interactions between the hospitalized individual and the hospital environment, a multicomponent approach to care will be more effective. Every factor contributing to the development of delirium should be addressed by professional caregivers so as to resolve delirium in older patients. It is pertinent to note that, untreated delirium will have long-term detrimental consequences for families and individuals involved as well as the hospitals and the healthcare system.

Many of the previous research studies have focused on the use of prospective study design. This is a method where patients adhere to specified inclusion criteria to be screened for delirium. Data is collected and analyzed to give the conclusions of the research. From the many previous research studies, approximately two of them used a retrospective study design hence studying events that have already occurred.  For instance, a research study on the outcomes of the delirium patients after the discharge was one in the Netherlands.  This has helped, for instance, in the Netherlands, as the Dutch hospitals have been able to come up and publish new guidelines on how to diagnose and manage delirium among hospitalized adults.

            Theoretical Framework

A theoretical framework is the ideas or theories that will guide this research. Change theory, as proposed by Lewin in 1974 (Kitson is 2005), and the theory of situated clinical reasoning by McCarthy (2003) contributed to the theoretical framework that will guide this study. The integration of these two theories will provide us with a multidimensional approach in investigating nurse’s current knowledge, philosophy and attitudes towards ageing and to identify changes in these attributes after an education or training intervention.

Change theory, according to (Lewin 1974), is premised on two main concepts guiding change in a working environment. The first concept, which is, unfreezing centres on awareness of current attitudes, behaviours and beliefs. For example, what is a nurse’s belief regarding older patient’s health, and what are their attitudes regarding taking care of older patients with delirium and how do these attitudes and behaviours affect the care of this patient with delirium? The second concept is recognizing; and it includes: putting education into practice, implementing a support mechanism and using available tools. The final concept, which is about refreezing, addresses improved assessments of delirium care and an obvious institutional change. This can be perceived by the obvious change in nurse´s competence, knowledge, and confidence in administering care, beliefs about the ageing patient, ability to utilize available tools and recognition of increased support for administering effective care.

The theory of change by Lewin has been renewed and modified as a template and framework for hospitals to implement organizational change within the hospital environment (Suc, 2009). The change theory has been used to understand and explain human behaviour as it relates to patterns and changes of resistance to change. It has been used to guide and identify factors that might hinder change as well as those that drive and be a catalyst to change. Nurse’s participation to change is an integral aspect of any process of change. An introspective look into nurse’s attitudes, before and after initiating change is an essential step towards understanding what aids or helps successful participation. This review will help in looking at how developing an awareness of a current culture about delirium care and as well as assessing change in attitudes following a delirium intervention.

Additionally, the qualitative analysis study of nurse’s interview concerning the nurse’s views and philosophies of ageing, which was grounded in McCarthy’s (2003) theory of situated clinical reasoning will be applied to this study. The theory implies that behaviours flow from philosophical beliefs or perspective about how life functions. Her hypothesis was that the wide discrepancy nurse’s ability to identify delirium could be characterized by a difference in philosophy on ageing. For example, in a small study, she conducted found that nurses who believed in healthful ageing looked to be more consistent and competent in differentiating between an acute confusion and dementia in older patients than their other colleagues. Subsequently, the theory of change by Lewin and McCarthy’s theory of situated reasoning will serve as a framework for considering nurses’ behaviours and attitudes in the administration of care for older patients with delirium before and after an educational intervention.

Aim and research questions

The primary aim of this study is to describe how nurses understand delirium with older patients and nurses’ attitudes towards interacting and caring for old people with delirium.

Despite the numerous literature about delirium, less is known about the actual events in the clinical and practice settings. In order for the application of best practice guidelines, it is, therefore, necessary to know and understand the everyday realities of caring and nursing delivery. For these reasons, I also intend to explore how nurses take care of these hospitalized older adults at risk of delirium and the challenges, and nurses face in trying to deliver this care.

            Research Questions

The research questions include;

1. What are the fundamental nursing skills and knowledge required for effective interaction with patients with delirium?
2. How does an adequate knowledge about delirium assessment tool and treatment protocol lead to a better nursing attitude and care for delirium patients?
3. Are nurse’s age, work experience, and education related to attitudes and attitudinal change

            METHODOLOGY

In this chapter, the methodological process for this study is being discussed; this process includes data collection and data analysis. This is a systematic literature review comprising of qualitative and quantitative contentment analysis.

The research design, according to Fisher (2019) in the case of either quantitative or qualitative methods are described as the various procedures that a researcher will follow in order to undertake the research. In a simple analogy, it is the recipe or process that a researcher will follow to conduct the study, which is referred to as the method.

6.1       LITERATURE REVIEW

A literature review encompasses comprehensive research and adoption of articles of studies that have been written previously. The main focus of a literature review is to carefully summaries various professionally written articles with the primary aim of identifying a specific area of study in order to critically analyze these articles in a professional way. It is important to know therefore that, the main work of a researcher is to be able to bring about the relationship of different works that a relevant to the research to create a masterpiece (Aveyard H, 2010).

During a research process, the most important aspect of putting into consideration based on a literature review is its structure. The various information obtained during this process should be systematic and should correlate to the subject in discussion. There should be an orderly presentation of information considering the importance of making it easy for the readers to follow. Bearing in mind that, arguments that are presented should be based on academic research works and not of personal thoughts and opinions (Oliver 2012)

According to (Aveyard H, 2010) in the usage of primary sources, in this case, research articles, it is recommended that the usage of non- research materials should have avoided. As the integrity of such review is reflected on how thorough the review was and the kind of references used for the review.

6.2   Data collection

Collection of data for this research work will be achieved by thorough research of scientific sources. I intend to successfully extract scientific sources of the school database which have various directories as regarding scientific data. I intend to collect data from authors qualitatively. Scientific journals, books and web-based sources will also be used in data collection. This articles will, in turn, provide the background about my topic and also throw more light on the research questions

Although there are many approaches to data collection in qualitative research. Example, interview, participant observation, case study. This thesis is focused on obtaining data from existing peer review, healthcare articles, and pre-existing articles. These articles will provide background information about the topic and answer the research questions.

Keywords derived from the research topic will be used in search and exploring databases. The search “nursing and delirium“, “and “communication”, delirium and interaction” and knowledge” and “roles”. In databases like EBSCO and CINAHL, search fields are designed in sentence formants. Keywords from such a search will be categorized and used in a structured manner to search for relevant articles. For example, “nurses’ role towards the older patient with delirium”, caring for an older patient with delirium”, “nurses’ knowledge about delirium” some of these articles will provide answers to the research questions.

• Data Analysis

According to Holloway (2013), data analysis is a comprehensive means of collecting data, merging, organizing and sorting this data in a way that such data will be relevant to the research conducted. Knowledge plays a pivotal role for researchers when analyzing data in order to refine all sources data was obtained into meaningful information to be used during research. Due to the complexity in data analysis, it is crucial for researchers to interpret information correctly so as to avoid distortions of information during data collection.

Content analysis is a method used in classifying data into categories and subcategories which share the same content. It is a technique used for analyzing a collection of text. It usually contains oral text, written text, sentences, phrases and audio-visual text presented in data content (Holloway, 2013).

6.4 Inclusion and exclusion criteria

The inclusion and exclusion were implored to enhance the acquisition of reliable, up to date and valid information from previously scientifically studied sources. According to (Griffiths 2009) who in his explanation, agreed that it is of essence that a researcher implores criteria which are strictly tied to their research topic.

TABLE 1. Inclusive and exclusive criteria as given by Griffiths (2009).

• Ethical Considerations

According to Resnick (2015), ethics are professional codes of conduct that defines right or wrong. Norms for conduct that distinguishes between acceptable and unacceptable behaviours.

Ethics in nursing research is the act of moral principle which a researcher has to follow to follow during the process of conducting research in order to ensure that, absolute care is taken regarding how the subjects of the study are being protected. According to (Holloway and Kathleen 2017), researches on health should be strictly guided by the professionalism that entails following rules and codes of conduct during research.  In this context, the researcher intends to abide by ethical norms and values in the course of the research process in order to ensure knowledge, truth and avoidance of error (e.g. usage of real names or wards where events might have occurred). In furtherance of ethical considerations, my process of data collection and processes will ensure the avoidance of vices such as distortions and fabrication of information, plagiarism, misinterpretation and falsification of data which is guided by the Finnish national board on research integrity (TENK.)

RESEARCH FINDINGS AND DISCUSSION

The data for the research was obtained from existing peer review, healthcare articles, and pre-existing articles.  Through the analysis of various past research studies, we found out various aspect of knowledge and skills required for nurses to handle the patients with delirium.  One of the important aspects is the is having basic knowledge on the diagnostic of the delirium condition.  Hence, having knowledge of diagnostic criteria and standard screening is very important when handling delirium patients. According to a research study done by Daniel Davis, the U.K. doctors lack the knowledge of diagnostic criteria. This is proving to be a challenge to them when it comes to interacting and treating patients with delirium (Davis & MacLullich, 2009).

According to Bélanger & Ducharme, in their research study, knowledge on the disease, competence as well as confidence is required among nurses to effectively interact with delirium patients. Nurses need to understand what delirium is, the diagnostic criteria, as well as the treatments methods of the condition. With such knowledge, they can be able to display competency in their work as well as confidence.  There are other skills, such as sensitivity, compassion, as well as empathy.  Compassion is very important due to the burden of care associated with delirium patients. These are the core qualities needed when interacting with people with delirium.  Besides, communication skills are also very important (Bélanger & Ducharme, 2011).  As a nurse, when communicating with delirium patient, you need to show belief, creativity, understanding as well as patience.

Furthermore, patient cantered care knowledge is another required knowledge and skills from nurses. In such cases, previous articles assert that nurses need to be very well versed with such patient-centred knowledge and skills. For instance, they need to know ways they can use to identify a delirium patient in a unique way.  They need to know ways through which they can focus on delirium patient feelings.  Cultural competency is also another skill required for nurses. Nurses deal with patients from different cultural background. Hence, having cultural competency knowledge enables the nurses to interact well with such patients and offer medical services regardless of their ethnic and social-cultural backgrounds and colour (van Velthuijsen et al. 2018).

In another research study conducted, it was proved that patients with delirium may be subjected to neglection and sometimes abuse. As a nurse, care interaction skills are very important.  Care interaction skills are based on how you interact with patients to assist him physically, mentally, as well as emotionally.  In summary, intervention techniques are very important. They include the calculation, communication techniques, providing information, self-management, working disciplinary as well as knowledge about delirium patients is very important skills.

Adequate knowledge about delirium assessment toll and treatment protocol is very important. From the various past research studies, the poor attitudes among the patients’ issue to lack of knowledge and skills on handling delirium patients.   The common assessment tool is the screening method.  One of the ways through adequate knowledge on delirium assessment protocol lead to better nursing attitude is through the acquisition of knowledge on multilevel delirium. This, in turn, helps in changing the attitude of nurses towards their delirium patients.  According to King et al., when nurses acquire multilevel knowledge, they are able to recognize particular constellations of factors in the patient situation that made them think about the delirium. With such multilevel knowledge alongside the clinical presentation, sensitized professionals as well as observational cues, they tend to construct a positive image of the delirium (King, Roberts & Bowers, 2013).  In addition, the use of an easy-to-use screening tool, according to research, has been proved to increasing awareness of delirium among people (Steis & Fick, 2008). As a result, this helps in changing the attitude of the nurses towards such patients.

In another research done by van Velthuijsen and her colleagues, they found out that the use of DOS (Delirium observational screening) screening particularly influences the attitudes of nurses towards the delirium patients in the clinical practice (van Velthuijsen, 2018).  This method proved to be very effective when diagnosing early and even late-stage delirium, both the hypoactive and hyperactive delirium.  In the previous research studies, it was found that nurses lack knowledge on how to diagnose delirium. With the screening assessment tool, they are able to know the condition they are dealing with. This changes their attitudes since delirium is mainly associated with dementia (Swan et al. 2011). Although there are certain similarities, there are still some differences that make its clinical diagnosis, treatment and management different from that of dementia. With screening method, nurses tend to know what they are dealing within a patient and hence can dedicate their efforts in managing such patients’ conditions.  For instance, with lack of such assessment tools, there have been approximately 30% of the delirium patients are have been dragonized incorrectly in the past before the introduction of screening methods such as the DOS (Eastwood et al.  2012).

Nurses’ age, work experience as well as education are clearly related to their attitude according to the previous literature reviewed.  King, Roberts and Bowers in their research found out that the head nurses had more positive attitudes towards the delirium patients than the junior nurses. This is a clear implication that work experience is an influence on nurse attitudes.  Education and age are other factors also linked with the nurse attitudes towards delirium patients (King, Robert & Bowers, 2013).  The young nurses, according to research, are said to lack the sophisticated knowledge and experience to deal with such condition among the patients. In terms of education; training and intervention have been mainly considered by many previous research studies.

Day, Higgins and Koch, 2008   in their Research study showed that nurses who have undergone a specialized form of training develop a more positive attitude approach towards the delirium patients than those with lack of education and training.  The reason behind this is the fact that training and education enable nurses to seek to move away from the factor of deficits hence pushing them towards the positive aspect of their caring and health condition of delirium related illness. Besides, training enables the nurses to realize their abilities and appreciate them by providing medical care to delirium patients.  This is contrary to the nurse philosophies of aging which states that the healthcare system was designed for the younger people and the elderly delirium patients are a burden to the healthcare system (Mehrdad et al. 2012). This is due to their holistic approach required in their treatment which becomes challenging to nurses irrespective of their experience, skills and education

Implications for Future Research

This research study indeed provides a clear insight into three main aspects of nurse attitudes towards delirium patients. They include how delirium assessment tool influence attitudes of nurses, the influence of nurse knowledge and skills on their attitudes and also the influence of age, work experience and education on nurse attitudes. It is important to know that the population of the elderly is increasing world.  According to world data, there are approximately 900 million elderly people in the world, especially people over the age of 60 years. On the other hand, the population of delirium patients is also rising. This is coming along with various challenges to the nurses and the healthcare system, generally.

The aspects of providing medical and nursing care to the delirium patients is one of the burdens to the nurses considered to be time-consuming and one that requires a holistic approach.  This is an area that is of considerable concern to the healthcare system.  However, there is still a need for further research studies to h contribute in exploring more workplace dynamics that also contributes to the negative attitude, which makes the healthcare professionals feel the process as a burden and hectic. Besides, there is a need for further research studies on how we need to improve the support we accord in dealing with this issue from the perspective of time and physician.  Most importantly, there is a need to analyze the negative impacts of the nurses’ negative attitudes towards delirium patients.

Limitation of The Study

This research study contributes to a broad range of knowledge on nurses’ care of delirium patients, especially the elderly.  It touches on knowledge, competency, nursing education and skills, work experience, age and delirium screening methods influence on nurse attitudes. However, the study results of this are restricted to the findings of the general society. There is no specific target population that was aimed, for instance, the community or a certain hospital. The research took a general approach to elderly patients in society.  Indeed, there is a lack of direction towards a specific population target. The population has several communities. The behaviour of people in communities is different.  You might find that there are some communities where nurses have a unique and different attitude. Although the factors that contribute to nurse attitudes towards the elderly are quite similar, there is still limited information on how different communities have specific and unique nurse attitude causes the elderly delirium patients.

 Conclusion

Delirium patients are continuing to rise in the world population. However, caring for these patients are indeed a challenge due to the attitudes of the nurses towards them. From this research studies, it is indeed clear of some of the factors that contribute to poor and negative attitudes of nurses towards patients with delirium.  Caring for delirium patients also has been a challenging factor due to several reasons. They include increased workload, challenging patients, lack of knowledge, education, training and support, lack of adequate time to spend assessing and caring for elderly delirium patients.

From this research studies, lack of knowledge and education indeed negatively influence the attitudes of nurses. Nurses require knowledge, competency and confidence in their work. Their nursing skills need to be displayed in compassion and empathy; they show the delirium patients.  In addition, the use of a delirium assessment tool influences their attitudes. They tend to have a tool they can easily identify the condition a patient is suffering; in this case, delirium and hence know what they are handling.  Age, work experience and education also influence the attitudes of nurses.

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Appendix

Time Plan