Barriers to delirium screening and management during hospital admission: a qualitative analysis of inpatient nursing perspectives

Abstract

Background: Delirium in hospitalized patients is a major public health issue, yet delirium is often unrecognized and missed during inpatient admission. The objective of this study was to identify barriers to delirium screening, identification, and management from a nursing perspective on inpatient, acute care units.

Methods: This was a pre-implementation, diagnostic evaluation study to determine current practice patterns and potential barriers to optimizing delirium care at a major university hospital. A qualitative approach was used, which included focus groups of inpatient nurses working on major medical and surgical acute care units. Focus groups were conducted until signs of thematic saturation were present, and data were analyzed via inductive thematic analysis, without predetermined theories or structures. A consensus approach was utilized for transcript coding, and final themes were generated after multiple reviews of initial themes against transcript datasets.

Results: Focus group sessions (n = 3) were held with 18 nurses across two major inpatient units. Nurses reported several barriers to successful delirium screening and management. Specific challenges included difficulty with using delirium screening tools, an organizational culture not conducive to delirium prevention, and competing clinical priorities. Proposed solutions were also discussed, including decision-support systems with automated pager alerts and associated delirium order sets, which may help improve delirium care coordination and standardization.

Conclusion: At a major university hospital, nurses affirm the difficulty experienced with delirium screening and identification, particularly due to screening tool challenges, cultural barriers, and clinical workload. These impediments may serve as targets for a future implementation trial to improve delirium screening and management.

Keywords: Decision support (clinical); Evaluation methodology; Implementation science; Quality Improvement.

Fig. 1

Qualitative Study Design Study flow diagram presented. Three focus groups were conducted with 18 inpatient nurses from the medical-surgical units chosen for study participation. After focus group completion, transcripts were generated and reviewed. Codes were generated and incorporated into a main codebook, after which codes were applied to the text to generate major study themes. Themes were then incorporated into an analytical narrative, for which findings were compared to similar, related studies (see Discussion section)