Development of effective guideline for delirium management is still seeking nowadays. As nurses are in the first confrontation line for delirium, their prospective in identifying barriers are essential in developing integrated strategies and clinical guidelines.
Objective
To explore the barriers focusing on intensive care unit (ICU) nurses’ point of views to provide an evidence-based support for effective nurse-led delirium management in ICU settings.
Methods
Whittemore and Knafl framework was recruited to build up this integrative review. PRISMA guidelines were followed to search about barriers of nurse-led delirium management. Articles published up to June 2024 in five databases; Web of Science, Scopus, PubMed, CINAHL and EMBASE using related keywords were involved. Mixed Methods Appraisal Tool (MMAT) was used to evaluate the quality of articles included in this review and then reported nurse-led delirium barriers were mapped according to COM-B model.
Results
Twenty-three articles out of 1,020 research articles were included in this review after carefully checked according to the exclusion and inclusion criteria. based on MMAT, 7 articles achieved 100%, 11 articles were achieved 80%, and 5 articles achieved 60%. Nurses’ knowledge deficit is the most common psychological capability barriers of nurse-led delirium management, while complexity of delirium screening tools was found to be a physical capability barriers. High workload, lack of staff, lack of time, lack of documentation and lack/ shortage of guidelines were barriers mapped to physical opportunity, while communication barriers in particular patient’s intubation and sedation were mapped to social opportunity barriers. Motivation was represented by addressing delirium as a major problem, self-confidence, psychological support and considering nurse’s views.
Conclusions
Nurse’s knowledge deficit, complexity of delirium screening tools, high workload, lack of time, lack of documentation, lack/ shortage of guideline, and impaired communication were barriers of nurse led delirium management. This study is promising in ease of application in clinical practice since delirium barriers in ICU settings were well-presented in a COM-B framework that may facilitate therapeutic strategies and related decision making.
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Introduction
Delirium is defined, by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and International Classification of Diseases (ICD), as a state of disturbance in consciousness, awareness and cognitive function that has fluctuating course and short-lasting symptoms [1, 2]. As a multifactorial neuropsychiatric syndrome with a complex clinical syndrome, three types of delirium have been described based on patient’s level of agitation; hypoactive delirium is characterized by a state of withdrawal and sedation, although this type is the more frequent, it is the more dangerous one that its detection is difficult, hyperactive delirium that’s hallucination and aggression are the hallmarks and mixed delirium with fluctuation symptoms of hypoactive and hyperactive delirium [3, 4].
Prevalence of delirium has been reported as a common disorder among ICU patients; with variable rate of about 45.9% in Saudi Arabia [5], and to a less prevalence was reported in several countries ranging from 16.4% to 31.5% [6‐10]. In 2018, a systematic review reported that prevalence of delirium was 31% [11], and a comparable prevalence 33% was reported in a more recent systematic review [12]. Regarding the delirium’s risk factors; a meta-analysis [12] identified 28 delirium risk factors including modifiable risk factors such as multiple-system dysfunctions, cardiac catheterization, immobilization, multiple medications, sepsis, mechanical ventilation, cardiac surgery, metabolic acidosis, pain, use of physical restraints, respiratory diseases, and sleep deprivation. In the other side; non-modifiable risk factors such as elderly age and female gender, in addition to dementia, hypertension, pre-ICU emergency surgery or trauma, and prolonged sedative use [13‐17].
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The negative burden of delirium extended beyond personal health to society and health systems as a cascade of increasing mortality and morbidity, prolonged hospital stay and increased costs [17‐19]. Recently, a cohort study of adults undergoing major elective surgery in Harvard-affiliated hospitals reported that the cost associated with delirium was $44 291 per patient over 1 year and this cost increases significantly with delirium severity [20]. There are numerous studies indicating that delirium and its consequences could be minimized and even prevented through implementing effective delirium management such as integrating multicomponent interventions, providing more accurate screening tools and lowering delirium risk factors [17, 21‐26]. Unfortunately, delirium in ICUs is underrecognized and underestimated [27, 28], and this is referred to many barriers; patient-level barriers, organizational-level barriers and nurse-level barriers [29, 30]. Thus, the identification of barriers is one of the most important factors that play a role in effective delirium management.
This systematic review shed light on the barriers to ICU nurse-led delirium management using the Capability, Opportunity, Motivation, Behavior (COM-B) model, the heart of Behavior Change Wheel (BCW), as a guiding framework to organize the relevant findings. Based on target behaviors, BCW is a behavior change intervention framework that can be utilized to determine intervention processes and strategies [31, 32]. The integrated intervention among COM-B components is presented in Fig. 1; as the individuals’ motivation (automatic and reflective) toward the target behavior (delirium assessment in this case) is proportionally influenced by opportunity (physical and social) and capability (physical and psychological). As logic gates; capability and opportunity should be opened for motivation to conduct the behavior. From the other side, behavior generate a positive or negative feedback to the capability, opportunity and motivation [33‐35]. This integrative review aims to explore and synthesize outcomes on the barriers to nurse led delirium management in ICU settings.
Fig. 1
Integration of capability, motivation, and opportunity components of behavior model of behavior, (COM-B) model. Adopted from [35]
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Methods
The framework addressed by [36] was recruited to build up this integrative review through performing five stages; 1) identifying the review problem and objective, 1) searching the literature and selecting the relevant articles, 3) evaluating and extracting the data involved in the selected articles, 4) analyzing their data, and 5) presenting the review outcomes. This protocol facilitates the synthesis of the studies outcomes and provide a comprehensive insight about the barriers to nurse-led delirium management in ICU setting.
Stage 1: problem and objective identification
Recent reports indicated to the exacerbated of delirium status and its burden in ICU setting. Nursing stuff is the first line responsible to seriously tackle this issue and definitely a list of barriers will be intercepted, accordingly, the identification of such barriers is a crucial to help the nursing staff to overcome and getting the chance to care delirious patient effectively. The researcher classified these barriers into three categories; patient-level barriers, organizational-level barriers and nurse-level barriers, but, up to our knowledge, all these have not yet collectively mapped in accordance to the COM-B model and so a review, based on this concept, is necessary to organize the behavior and to improve the professional competence of ICU nurses while managing the delirium. The purpose of this integrative review was to explore the barriers to nurse-led delirium management in ICU setting. The research question was: What is the barriers nature faced by ICU nurses during managing delirium?
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Stage 2: literature search
Search strategy and eligibility criteria
The search in the databases; Web of Science, Scopus, PubMed, CINAHL and EMBASE was carried out using the keywords: barrier OR challenge OR difficult OR limit OR obstacle AND delirium management OR delirium assessment OR delirium control OR delirium treatment AND nurse AND intensive care unit OR ICU. These keywords were the best appropriate terms and strongly related to this review. The obtained articles from these databases weren’t limited regarding publication date. Studies that were written in English and focused on nurses’ barrier while delirium management in ICU setting were included. If studies had different health provider participants, only nurses’ point of views were considered. studies that investigated delirium assessment by health providers other than nurses, and delirium assessment in non-ICU settings were excluded. Case reports, abstracts, reviews, letters and editorials were also excluded.
Study selection
A systematic search of the literature was carried out in June 2024. A total of 1020 research articles were obtained from the initial search. 755 articles were identified after removal of duplicates and then were assessed by screening their title and abstract; accordingly, 642 articles were excluded while 113 articles were subjected to full-text reviewing; 90 were excluded because either they focused on delirium management in different settings other than ICU or nurses’ point of views weren’t clearly addressed, as well the articles that have no significant information were excluded. Finally, 23 articles were carefully discussed in this review as they met the inclusion criteria. The guidelines of the PRISMA were adopted (Fig. 2.)
Fig. 2
A representative diagram of study process (PRISMA flowchart)
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Stage 3: data evaluation and extraction
Data evaluation
The quality of studies included in this review was assessed by Mixed Methods Appraisal Tool (MMAT). MMAT has been widely accepted as a critical appraisal tool to assess the quality of 5 types of research based on study design (qualitative, quantitative descriptive studies, quantitative randomized controlled trial, quantitative non-randomized studies, and mixed methods studies) [37]. MAS and MA independently appraised the included articles and the minor disagreements were resolved through discussion.
Data extraction
Paper title, author(s), year of publication, study design, variables/confounders, data collection tool, study location, population, sampling, sample size, and study outcomes were the extracted data from the included articles in this review.
Stage 4: data analysis
Data analysis was conducted through several steps as reported by [38]. Starting from data reduction and organization via Excel and via concept mapping up to synthesis integrated conclusion the barriers faced by ICU nurse during delirium in accordance with the COM-B model. Data analysis of the articles, included in this review, has been led to present and discuss them under three major headlines capability, opportunity, motivation, each with two sub-headlines as in the “Results” section.
Stage 5: presentation of the study outcomes
This review provided a new a comprehensive insight into the barriers against effective delirium management form point of views of ICU nurses working in tweleve contries. COM-B model was a hub to organize these barriers and help us in the synthesis of integrated understanding of delirium.
Results
Twenty-three articles were in accordance to the inclusion criteria, and so these articles were in-depth discussed in this review. All of these articles were subjected to the critical appraisal using MMAT (Supplementary File 1). Briefly; 7 articles fulfilled 100% of the MMAT criteria (5 qualitative and 2 quantitative cross-section), 11 articles fulfilled 80% of the MMAT criteria (5 qualitative, 3 quantitative cross-section, 2 quantitative pre- and post-experiment and 1 mixed method), and 5 articles fulfilled 60% of the MMAT criteria (1 quantitative non-randomized, 3 quantitative cross-section and 1 mixed methods). Of all the included articles; 6 were conducted in USA, 3 in both of China and UK, 2 in both of Korea and Netherlands, and 1 in each of Saudi Arabia, Iran, Turkey, Canada, Spain, Republic of Ireland and Denmark (Table 1). COM-B model was recruited to analyze the results of the included articles to be broadly themed into capability, opportunity, and motivation and each of them included two subthemes [33].
- Nurses reported that patient’s intubation/sedation is a barrier to delirium management.
- Study proved that delivery of a comprehensive educational intervention didn’t make a significant change in point of view of nurses regarding addressing intubation as a barrier.
- Study described that lack of staff, heavy workload, inability of patient’s communication with nursing staff and disturbance in documentation are among of the barriers to delirium management.
- Nurses preferred the implementation of nonpharmacological interventions for delirium management.
20 nurses and 14 physicians/ 4 mixed medical–surgical ICUs at 4 university hospitals
Qualitative
*****
- Nurses stated that the physicians’ indifference and not considering nurse assessments led to nurse frustration.
- Nurses described CAM-ICU assessment as embarrassing to them, patients and their families and ICU nurses felt that the beneficial of using delirium assessment tool in improving outcome couldn’t be achieved.
- Patient’s intubation and sedation were identified as communication barriers to effective assessment.
- Nurses reported that knowledge deficit about delirium, heavy workload, patient’s intubation and sedation, and lack of time were among of the barriers to delirium management.
- Nursing education is essential for preventing and managing delirium.
- Having no specific protocol, unmatching assessment tools to the nurse's assessment and busy department are organizational level barriers reported by nurses.
25 nurses/ PICU in a large midwestern tertiary academic medical center
Quantitative non-randomized
***
- Intubation and sedation are the most patient level barriers reported by nurses.
- Nursing education is essential for preventing and managing delirium
- Training strengthen the physical capability and psychological capability of nurses to perform delirium assessment.
aStudy location didn’t specify in the article, this is affiliation of correspondence
***** fulfilled 100% of the MMAT criteria, **** fulfilled 80 % of the MMAT criteria, and *** fulfilled 60% of the MMAT criteria
Capability
Capability is an attribute of the individual that together with opportunity makes a behavior possible or facilitate it. It generally concerned to the psychological and physical capacity of the individual to engage in the target behavior [33, 35].
Psychological capability
Psychological capability is the capability of that involves an individual’s mental functioning (e.g. understanding and memory), it includes a person’s capacity to engage in the thought and comprehension processes through education in order to perform the target activity [35, 61]. Education by the definition is increasing understanding and knowledge as in case of providing information to promote positive practice while training is focused on imparting skills [34, 62]. Nursing education is essential for preventing and managing delirium [52, 57, 58, 60].
Three knowledge types were identified to psychological capability in the included studies firstly, basic knowledge is considered what is related to the understanding and knowledge about the symptoms, associated risk factors, pathophysiology, assessment and treatment of delirium. Nurses reported a list of barriers to delirium management, knowledge deficit about delirium was one of the most barriers that reported in seven of the included studies [30, 44‐46, 49, 52, 56, 57] and this is my attributed to fluctuating nature of delirium and its symptoms, as a results, delirium is prone to under-recognition, underestimation and misdiagnosis as well as to misapply the delirium guidelines [43, 45, 58, 63, 64]. The prevalence of knowledge deficits among nurses was varied; as reported 37% in [63], 42% in [46], 100% in [52]. Difficulty to assess the delirium symptoms was reported among 75.6% of nurses [49]. Physicians indicated that the nurses had limited knowledge or unaware the pathophysiology of delirium and hence couldn’t determine the treatment of choice, consequently their communication was negatively affected [42]. Limited knowledge about delirium assessment tools, delirium diagnosis, nursing measures and delirium risk factors [30, 56, 64] were considered other drawbacks that play a critical role against the effective delirium management.
Secondly, pharmacological knowledge is considered what is related to the understanding and knowledge of delirium from the pharmacy point of view including; drugs of choice, mechanism of action, dosage, contraindications and side effects). As more pharmacological knowledge, more interventions should be targeted in order to improve delirium management. Only one study [42] indirectly addressed the pharmacological knowledge, where most nurses reported that physicians prescribe a wide range of drugs with dosage below the therapeutic index and also without adherence to the guideline, consequently different treatments will be provided to the delirious patients. It has been reported that delirium could be induced by lorazepam and diazepam drugs, which are frequently prescribed when haloperidol exerted no benefit [41]. Haloperidol and Dexmedetomidine appeared to be the most widely accepted in pharmacological management of delirium [65], however, the effectiveness of Dexmedetomidine was controversially was reported [65, 66].
Thirdly, Nonpharmacological Knowledge where the nonpharmacological intervention was recommended to manage delirium, however more clinical investigations are needed [67]. Nurses preferred the implementation of nonpharmacological interventions for delirium management [48, 51]. In the study [51] nurses identified 12 barrier and 9 facilitator themes to cognitive stimulation as one of the nonpharmacological therapies for delirium. This deficient knowledge may refer to the low level of education [44], in addition, a Danish study suggested a necessity for continuous education and training on usage CAM-ICU that definitely help nurses to get rid of barriers faced in their work environment [53].
Physical capability
Physical capability is the capability of that related to an individual’s physique and musculoskeletal functioning, it involves having the relevant skill, strength and stamina to conduct the target behavior. Many reports [52‐54, 57, 60, 68] indicated that training strengthen the physical capability and psychological capability of nurses to perform delirium assessment.
It has been determined that complexity of delirium screening tools is an obstacle to delirium diagnosis and prevents providing the optimal care [47, 58]. 65⋅8% of nurses indicated that complexity trouble the diagnosis process, hence majority of them asking psychiatric consultation while conducting delirium assessment [47]. This complexity is inversely correlated to the nurse’s experience in ICU [49].
Devlin et al. found that bedside teaching of delirium was recognized as the most popular method as it enhance professionalism and communication between healthcare providers and delirious patients [43]. A well- designed training course, aimed at investigating ICU nurses’ awareness about the impact of burden of delirium on society and healthcare system, demonstrated to be helpful in improving nurses’ awareness of the importance of delirium screening tools [54].
Opportunity
Opportunity is an attribute of the environmental system involves all the individual’s motivation factors to enact the target behavior. It has been subcategorized into two types; physical opportunity which influenced by an environment and social opportunity which is affected by language and culture [34, 35].
Physical opportunity
Physical opportunity is represented by the materials and financial resources of the surrounding system [35]. The delirium management barriers related to physical opportunity to could be divided into organizational level and patient level [30]. Heavy workload as an organizational level barrier was reported in six of the included study [30, 40, 41, 51, 54, 57]. This heavy workload, as a result of an inadequate patient-to-nurse ratio, is negatively associated with quality of care, where the opportunity to manage delirium effectively will be reduced, as nurses couldn’t provide the emotional support for patient contributing to poor delirium management. This is an alarming for nursing managers to adjust patient-to-nurse ratio and workload of nursing staff [30, 54].
Medical staff and their collaboration are critical to delirium assessment [40, 59]. Medical staff may help nurses in decreasing their workload, improving their knowledge and consulting. A physician consultation for delirium assessment was requested by 89⋅3% of the delirium-assessed nurses [47], however, this requesting was useless as the patient check by physician is usually done after recovery and getting normal [41]. Furthermore, have no receiving feedback and expert advice was stated by 81.4% of nurses as one of the difficulties of delirium management [49]. Lack of staff, lack of effective collaboration, staff turnover and their underestimation to the delirium assessment results are another organizational level barriers reported in the literatures [39, 43, 46, 51, 53, 59, 69].
Five of the included studies [39, 51, 52, 57, 60] described that disturbance in documentation is one of the barriers to delirium management and to overcome this, electronic nursing process records should be involved in the process of delirium management [60, 64].
Lack of time, either due to high workload or tools time consuming, is one of the most common organizational-level barriers reported among ICU nurses in [30, 39, 41, 43, 45‐47, 52, 54‐56, 70]. With different ratios; where 61% of nurses stated that in [39], 25% [52] and to a less extent 7% in [46]. As a result of time constrains; the performing timely and repeated delirium assessments would be difficult and the providing detailed nursing care to every delirious patient is significantly limited, resulting in aggravate the delirium situation.
Absence of delirium educational resource [49], having no specific protocol [30, 42], unmatching assessment tools to the nurse’s assessment [30, 49], having no enough tools [42] and busy department [30] are also organizational level barriers reported by nurses.
It has been determined that the training improved nurses’ delirium knowledge and imparted them the capability to effectively care ICU delirious patients [52, 53].
Social opportunity
The ability to manage delirium for unstable patient, in particular who hasn’t ability to communicate, is one of the important skills required in ICU nurse. The inability of communication, due to has no common language with nursing staff or has visual or hearing defect, is one of the patient level barriers resulting to inadequate management [40, 48, 49, 51, 57].
Patient’s intubation and sedation were identified as communication barriers to effective assessment. Difficulties in delirium assessment for intubated/ sedated patients are commonly reported in twelve included studies [30, 39, 43, 46, 47, 49, 50, 53, 55, 56, 60, 71]. According to a cross sectional study, 99% of Irish nurses faced difficulties when assessed delirium in intubated and sedated patients [55]. Intubation and sedation are the most patient level barriers reported by nurses but with a variation in responses rate among them; where 27% and 38% of USA nurses reported that as in [43, 60]. A higher percentage (58%) reported among UK nurses [46], 72.8% and 69.4% among China nurses in case of intubation and sedation respectively [49] and similarly among Saudi nurses, 44.1% and 34.6% in case of intubation and sedation respectively [39].
Motivation
The mental processes that stimulate and direct behavior is called motivation. These motivation processes are subdivided into two types; reflective motivation and automatic motivation [34, 35, 61]. It has been demonstrated that nurse’s thoughts and emotions are potentially reflected in their behavior [47].
Reflective motivation
A better understanding of nurses’ beliefs and attitudes toward delirium is necessary to success in managing delirium effectively [43, 48]. Addressing delirium as a major problem and appreciation for the importance of preventing and treating delirium were reported among ICU nurses [39, 44, 45, 47, 51].
Reflective motivation involves conscious thought process, such as person’s beliefs, plans and evaluation [34, 35, 61]. Dechant et. al. suggest that staff should perfectly trust their ability to manage delirium [58]. Nurses felt energized when they effectively manage the agitation and see patients getting better. This motivates them to work with these patients lovely and promotes their professional feeling [40]. Believing that delirium isn’t preventable and lack of trust in reliability of physician-described delirium management, are important barriers among ICU nurses [45]. Jung et al. indicated that using CAM-ICU assessment promoted nurse motivation toward delirium care, as well indicated that providing information and frequent orientation made patients more calm and delirium care more easier [41]. Clearly, 80% of nurses agreed that the providing a standardized instrument would increase their confidence and ability to detect delirium [59]. On the other hand, ICU nurses felt that the beneficial of using delirium assessment tool in improving outcome couldn’t be achieved and these tools are unreliable as different results were obtained by different evaluators even in case of similar patient’s situation [39, 42, 45, 49, 53].
Nurses’ thought about their significant role in delirium management should be enhanced as it motivate nurse’s behavior toward conducting assessment, while Nurses’ thought that their limited role in ICU is one of the delirium management barriers; since nurses perceived that delirium detection isn’t their job [72], and their role is supportive, in contrast, delirium screening is confrontational [53]. Believing that only elderly are suffering from delirium is widely prevalent among nurses and this lead to deprive adults, who may be at more risk, from optimal care [42], so assessment of all patients regardless of age is suggested by nurse to get rid of delirium assessment barriers [60].
Automatic motivation
Nurse’s enabling, as one of the interventions for automatic motivation, is represented by education, training and providing delirium-related facilities and facilitators including team collaboration, experience sharing, guidelines, high reliability of these tools, process checklist, documentation system and reminders [45‐51, 73].
Automatic motivation involves habitual, instinctive and affective processes such as desires and emotion [34, 35, 61]. Lee and Roh described the emotional burden of delirium in five items including emotionally exhaustion, physically exhaustion, stressfulness, problematic in its nature and requirement of urgent care when onset of delirium symptoms [57]. Physicians should consider nurse’s assessment during making therapeutic plan and decision-making as respecting is highly recommended to motivate nurse, in contrast, physicians’ indifference and not considering nurse assessments in their plan of care lead to nurse frustration [39, 43, 53, 55].
According to a cross-sectional study among China nurses, 81.7% of them reported the difficulty in getting support for their stress and 68.1% of them agreed that the control of their emotions is also difficult [49]. Zamoscik et. al indicated that nurses are in need to receive psychological support to overcome the negative emotions resulting from long-term dealing with delirious patients and to strength their attitudes in order to provide optimal health care [48].
Discussion
Despite the existing research on the barriers to manage delirium in ICU settings, these etiologically-varied barriers haven’t been integratory investigated in line with the relevant behavior model. To our knowledge, this is the first integrative review attempted to conceptualize barriers to nurse-led delirium management in ICU setting in accordance with the COM-B model.
Our analysis suggests that nurse’s knowledge deficit is the most common among psychological capability barriers to manage delirium in ICU settings [44‐46, 49, 52, 56, 57]. This analysis also highlights three kinds of delirium-related knowledge; basic knowledge, pharmacological knowledge and nonpharmacological knowledge. To addressing this barrier, education and training are the suitable interventions according to the BCW approach [33, 34]. The importance of education in improving nurse’s psychological capability (understanding and knowledge) toward effective delirium management has been demonstrated [52, 53, 57, 58, 60, 74]. Another study reported a significant improving in nurses’ knowledge about delirium through implementing multifaceted education program [75]. A pre-post quality project reported that implementing a multifaceted nursing education program alongside with nonpharmacologic delirium interventions led to reduce delirium duration significantly and to reduce the risk of delirium development [76, 77]. In the same line, an integrative review indicated that implementing nonpharmacologic delirium interventions resulted in decreasing incidence and duration of delirium [78]. Complexity of delirium screening tools is what is related to the physical capability barrier to manage delirium [47, 49, 58]. Health institutes should provide training courses to the nurses, as training is accounted the most effective interventions proposed by BCW approach [33, 34].
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High workload, as a physical opportunity-related barrier, prevents nurse’s engagement in face-to-face educational programs and makes nurses more susceptible to subjective burden and nurses’ burnout, consequently, providing care and patient outcomes are negatively affected [79‐82]. In line with the findings of this review regarding the barriers related to physical opportunity; lack of staff, lack of time, lack of documentation and lack/ shortage of guideline, a mixed-methods systematic review considered them as organizational-level barriers [83]. Furthermore, nurses were frustrated due to lack of effective evidence-based treatment [84‐86]. On the other hand, Elliot, 2014 reported that nurses didn’t consider time to be an issue [87]. To overcome physical opportunity-related barriers, health institutes should conducting restructuring environmental, as it is the most effective intervention in such condition [33, 34]. A multi-center quality improvement project concluded that delirium screening has been improved in the presence of delirium specialist team [88]. The incidence and duration of delirium was significantly reduced through implementing a nonpharmacologic delirium interventions alongside with a multifaceted nursing education program [76]. Restriction is one of the interventions suggested by BCW [34], hence after providing the delirium guideline, using specific rules may reduce the opportunity of managing delirium using instincts.
Regarding barriers related to social opportunity, patient’s intubation and sedation were identified among of the most communication barriers. In a similar integrative review, Alotni et al. suggested that enablement is the intervention in case of lack of communication [61]. Enabling a patient’s family in managing pain, delirium in this case, help nurses not only in overcoming the communication barrier but also in making nurse and administrative decisions [89, 90]. In addition, Devlin demonstrated that bedside teaching reinforced communication between patients and nurses [43]. Oppositely, Scott et al. proved that delivery of a comprehensive educational intervention didn’t make a significant change in point of view of nurses regarding addressing intubation as a barrier [50].
A better understanding of nurses’ beliefs and attitudes toward delirium and addressing delirium as major problem may evoke nurse’s behavior and motivate their efforts to tackle with delirium. Our analysis revealed that nurses have reflective motivation-related barriers that negatively effect on delirium management. Such barriers, nurses’ thought regarding their limited role just a supportive and delirium detection isn’t their task [72]. However, their role is fundamental in delirium interventions including prevention, diagnosis, and management [65, 78]. Nurse’s believing that delirium affects only elderly person and couldn’t be prevented, and their doubting about reliability and beneficiary of delirium assessment tools are another reflective motivation-related barrier reported in limited research.
Study limitations
The time constraints as proposed in the project has presented a challenge for this study. another limitation of this review is that it only included English-language studies, which might have left out important studies. the absence of randomized clinical trials within the included studies in this review may consider another weakness.
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Conclusion
This review is a promising in ease application in clinical practice, since delirium barriers in ICU settings were well-presented in a COM-B framework that may facilitate therapeutic strategies and related decision making. In addition, as reported that a well-conducted integrative review can stimulate further research, so this review suggested to classify barriers under 3 different themes; professional perspective on delirium, implementing pharmacological and non-pharmacological treatment for delirium and work organization in the ICU. The considering delirium barriers based on COM-B model are recommended, that’s focus on the person and organization responsibility and facilitate the handling the barriers and thus enhance the clinical interventions.
Acknowledgements
The authors are indebted to the Deanship of Scientific Research and Hail University for their endless support and cooperation during this study. Also, the researcher would like to thank all staff nurses and supervisors at the related setting who participated in this study.
Declarations
Ethics approval and consent to participate
NA
Competing interests
The authors declare no competing interests.
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