Crit Care Nurs Q

Vol. 44, No. 4, pp. 393–402

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Delirium in Intensive Care Units

Perceptions of Physicians and Nurses
Basma Salameh, PhD, RN;
Daifallah M. Al Razeeni, PhD, MS, EMT-P, SCEMS, KSU;
Khulud Mansor, MS, RN; Jihad M. Abdallah, PhD;
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Ahmad Ayed, PhD, RN; Hiba Salem, BSN, RN

Delirium is an indicator of morbidity and mortality in intensive care unit (ICU) patients. It can lead
to negative outcomes and longer hospital stays, thus increasing hospital costs. Despite national
recommendations for daily assessment of delirium, it remains underdiagnosed. Many studies point
to a lack of knowledge among health care professionals to accurately detect and manage ICU
delirium. The aim of our study was to assess the knowledge, attitudes, and practices of Palestinian
health care professionals regarding ICU delirium. The results of a cross-section observational study
revealed that delirium appears to be often underrecognized or misdiagnosed in ICUs in Palestine.
Therefore, it is critical to further educate the medical and nursing teams and to promote the use of
validated tools that can aid in the assessment of this condition. In this way, the length of hospital
stays and related health care costs can be reduced. Key words: delirium, delirium assessment
tool, intensive care unit

D ELIRIUM is defined by the Ameri-

can Psychiatric Association’s Diagnos-
tic and Statistical Manual of Mental Dis-
orders (DSM-5) as a condition characterized
by a disturbance of the consciousness and
cognition that occurs over a short period of
time.1 Intensive care unit (ICU) delirium is
subdivided into 3 categories: hyperactive, hy-
poactive, and mixed delirium. Hyperactive
delirium involves hallucination, whereas hy-
Author Affiliations: Department of Nursing, Arab
American University, Jenin, Palestine (Drs Salameh
and Ayed); Palestinian Ministry of Health—ICU
Department, Rafedia Hospital, Nablus, Palestine
(Dr Razeeni and Mr Mansor); An-najah National
University, Nablus, Palestine (Dr Abdallah); and
Kindred Hospital, Denver, Colorado (Ms Salem).
The authors have disclosed that they have no signif-
icant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Basma Salameh, PhD, RN,
Department of Nursing, Arab American Univer-
sity, PO Box 240, Jenin, 13 Zababdeh, Palestine
(basma.salameh@aaup.edu).
DOI: 10.1097/CNQ.0000000000000376
poactive delirium is characterized by a state
of withdrawal. The third category, mixed
delirium, is a state alternating between hyper-
active and hypoactive delirium.2
Delirium is a common and serious disor-
der that is present in 80% of critically ill ICU
patients.3,4 It is associated with longer ICU
stays, extended deployment of ICU equip-
ment, higher hospitalization costs, increased
chance of long-duration disability in terms
of daily activity, and long term posttraumatic
stress disorder.5-9 Moreover, undetected and
untreated delirium is related to increased
mortality rates during the 6-month period
post-ICU stays. Despite its proven impor-
tance, ICU delirium remains underdiagnosed
by interdisciplinary teams.10
Many factors lead to the development
of delirium among critically ill patients.
Cavallazzi et al11 suggested that advanced
age, cardiac surgery, cardiac catheterization,
multiple-system dysfunctions, comorbidities,
and the severity of illness were all risk fac-
tors for ICU delirium. Delirium is found to
be preventable by integrating multicompo-
nent interventions, risk factor recognition,
393

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394 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2021
and acute intervention to several conditions
such as hypovolemia.12-15 Integrating multi-
component interventions has good evidence,
indicating that it can minimize the probability
of delirium. This approach is recommended
in the 2019 Scottish Intercollegiate Guide-
lines Network (SIGN) guidelines.16
Considering the plethora of previous and
ongoing studies related to ICU delirium, it
is somewhat troubling that this condition re-
mains underrecognized and underdiagnosed.
This is explained by previous studies as,
due to inadequate knowledge regarding the
cognitive baseline in elderly people,17 symp-
toms similar to antidepressant discontinua-
tion syndrome18 and psychiatric causes and
illness-related mental changes.19 Despite new
evidence, advances in practice guidelines and
recommendations for daily screening of ICU
delirium from the Intensive Care Society,
as well as a number of other assessment
tools that have been developed, often the
process of assessing delirium is done solely
based on the definition in the DSM-5 and
not on validated guidance tools.12 According
to Xing et al,20 many nurses and physicians
do not possess adequate training and knowl-
edge regarding delirium screening. They also
suggest that there are barriers to assessing
delirium, including intubated and sedated pa-
tients, time constraints, and work overload.
With appropriate inclusion, planning, and
communication, nurses and other health care
providers can contribute positively to imple-
mentation processes and actions that may
improve patient outcomes. Further education
for medical and nursing teams in health care
facilities is critical, as is the promotion of vali-
dated tools that can improve and simplify the
assessment of delirium.
No previous or current studies have fo-
cused on ICU delirium in the Palestinian
context in order to understand the context-
specific knowledge, attitudes, and practices
of nurses and physicians related to delir-
ium detection and management. Health care
professionals and hospital administrators in
Palestine will benefit from the results and
recommendations generated by this study.
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Underrecognizing and misdiagnosing delir-
ium increase negative outcomes, whereas
improved assessment and monitoring of ICU
delirium can result in effective prevention
and multicomponent management.
METHODS
Design, setting, and sample
A cross-sectional, descriptive study design
was used for this research using a survey
questionnaire as the data collection tool.
The study was conducted in hospitals in the
northern region of Palestine between January
and April 2018. All participants were associ-
ated with the Palestinian Ministry of Health
and were selected to represent disparate
geographic areas throughout Palestine. Ap-
proximately 25% of the health care providers
were physicians, 75% were nurses, and the
average number of beds was 62. To increase
the response rate by the participants, the tool
was administered in person as a hard copy.
The sample size depended on the response
rate of nurses and physicians working in the
ICU department. A total of 285 participants
were selected for the study, including nurses
and physicians with a minimum of 1 year
of experience working in an ICU or surgi-
cal coronary care unit (SCCU) that engage in
cardiothoracic surgery. The number of com-
pleted questionnaires received was 200, 158
(79%) nurses and 42 (21%) physicians, for an
overall response rate of 70.2%.
Data collection tool
A structured questionnaire developed by
researchers in accordance with existing lit-
erature was used to collect data.21,22 The
nurses and physicians who agreed to partici-
pate completed a self-reporting questionnaire
that targeted 4 areas of study: (1) demo-
graphics and participant characteristics (such
as age, type of specialty [physician/nurse],
years of practice in the ICU, and other fac-
tors); (2) delirium knowledge and education;
(3) attitudes, perceptions, and current prac-
tices regarding delirium; and (4) obstacles to

delirium assessment. The survey included 12
questions that addressed delirium knowledge
and attitude and was measured using a Lik-
ert scale, with 1 as “strongly disagree” and
5 as “strongly agree.” Questions regarding
the importance of risk factors and obstacles
to assessing delirium as well as all other
questions were addressed as either yes/no
or as multiple-choice questions. Scores mea-
suring degree of agreement and importance
of items were obtained using a 1- to 5-point
Likert scale (from 1 = strongly disagree or
not important to 5 = strongly agree or very
important). Practices and frequency of inter-
ventions were also scored on a scale from 1
(never) to 5 (always); yes/no questions were
coded as follows: 1 = yes; 2 = no.
Reliability and validity
The research tool was assessed for relia-
bility and validity using the following steps:
the initial version of the questionnaire was
evaluated by 3 experts in the medical field
(1 physician from the Ministry of Health and 2
university academics), and the questionnaire
was adjusted on the basis of their comments
and suggestions. Then the tool was applied
to a pilot sample of 5 physicians and 5 nurses,
and some modifications were made on the ba-
sis of the obtained feedback. Reliability was
assessed using the Cronbach α, which ranged
from 0.71 for the knowledge scale to 0.90
for the scale measuring importance of risk
factors.
Data analysis
The data were coded and analyzed using
the Statistical Package for Social Sciences
(SPSS) v21.0. Variables measuring the degree
of agreement or the importance of items
were obtained using a 5-point Likert scale
(from 1 = strongly disagree or not impor-
tant to 5 = strongly agree or very important).
Basic descriptive statistics (averages and fre-
quencies) were obtained. The differences
in frequencies between levels of categori-
cal variables were tested using Fisher’s exact
test. The differences in mean scores of agree-
ments or the importance of items between
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Delirium in Intensive Care Units 395
nurses and physicians were tested using uni-
variate analysis of variance with a model
that also included work experience as a
factor in the analysis. Significance was de-
clared when the P value was less than .05
(P < .05).
Ethical considerations
The researchers obtained the required eth-
ical approval by the ethical committee in
charge. In addition, formal consent forms
were signed by all participants included
in the study after providing them with in-
formation regarding the study. Finally, the
participants were informed that they had the
right to refuse to participate or withdraw
at any time without any consequences. The
study was approved by the Palestinian Min-
istry of Health and the Helsinki Committee
under approval number PHRC/HC/319/18.
RESULTS
The number of completed questionnaires
received was 200, 158 (79%) nurses and 42
(21%) physicians, for an overall response rate
of 70.2%. The sample was made up of 75%
males and 25% females. Moreover, approxi-
mately half of participants (55%) were aged
25 to 34 years. And, one-third of them (38.5%)
had work assignment more than 75% of the
time. Years of working were mostly from 2 to
5 years (48.8%) and 6 to 10 years (28%).
About one-third of the nurses (32.9%) be-
lieved that alternating delirium was the most
prevalent type that occurred in the ICU
where they worked, whereas 31.0% of the
physicians believed that hypoactive delirium
occurred most frequently. In addition, 42.4%
of the nurses reported that delirium can
be detected by identifying periods of fluc-
tuating consciousness. Conversely, 45.2% of
the physicians reported that attention deficit
was characteristic of delirium. Most health
care team members (nurses and physicians)
agreed that delirium leads to increased health
care costs and prolonged mechanical ventila-
tion. Significance was observed in this cate-
gory (P < .01). In addition, a consensus was
396 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2021
Table 1. Characteristics of Delirium Based on Nurse and Physician Knowledge

Group

Nurse Physician All Pa

According to you, which form of delirium is the .099
most prevalent in the ICU?
Hyperactive delirium 29.7% 21.4% 28.0%
Hypoactive delirium 13.9% 31.0% 17.5%
Alternating hyperactive/hypoactive 32.9% 26.2% 31.5%
All forms are almost equally present 23.4% 21.4% 23.0%
Features of delirium are: .071a
Gradually occurring 22.8% 9.5% 20.0%
Attention deficit 29.1% 45.2% 32.5%
Fluctuating consciousness 42.4% 35.7% 41.0%
Unorganized thinking 5.7% 9.5% 6.5%
Delirium leads to: .008
Increased health care costs 10.1% 7.1% 9.5%
Increased morbidity and mortality in the ICU 12.7% 23.8% 15.0%
Prolonged mechanical ventilation 13.3% 31.0% 17.0%
All of the above 63.9% 38.1% 58.5%
Which patient is delirious? .754a
A patient who may have trouble keeping 50.0% 54.8% 51.0%
attention and cannot organize his/her thoughts
A patient who has some trouble with memory 24.7% 21.4% 24.0%
but is not confused
A patient who is cooperative and calm, but 17.1% 16.7% 17.0%
hyper-alert
A patient who is plucking and picking but can 8.2% 7.1% 8.0%
focus his/her attention

Abbreviation: ICU, intensive care unit.

a
Not significant.

reached that delirium is defined as a situation
where patients struggle to maintain attention
and organize their thoughts. Table 1 displays
nurse and physician knowledge related to the
characteristics of delirium.
In regard to attitudes and general knowl-
edge questions, the mean score of physicians
was 3.76, whereas nurses scored 3.53 on a
scale of 1 to 5, with 5 representing the high-
est level of knowledge or positive attitude.
Table 2 displays the average mean scores of
nurse and physician knowledge regarding
ICU delirium. Significant differences were
not found (P > .05) between nurses and
physicians in all items of the scale except for
one attitude statement: Delirium is a prob-
lem that requires adequate treatment. The
mean score for this item for nurses was 3.53
and 3.76 for physicians, with a significant
difference (P < .05).
Attitudes, perceptions, and current prac-
tices related to ICU delirium were also
assessed for both health care provider groups.
A statistically significant difference was ob-
served between them when questioned
about the number of times they had read ma-
terial about delirium within the past year. The
majority of nurses (70.3%) reported not hav-
ing read anything about delirium during that
period. Only 54.8% of physicians reported
the same, whereas 28.6% had read material
about delirium 2 or 3 times over the past
year. Approximately one-third of the nurses
and one-third of the physicians reported
that delirium-related events occurred during
less than 10% of their shifts, with statistical

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 Delirium in Intensive Care Units 397

Table 2. Average Scores of Knowledge and Attitudes Toward Delirium by Group (Nurses and
Physicians)

Group

Statement Nurses Physicians P

Delirium is underdiagnosed 3.13 3.31 .297
Delirium is a problem that requires adequate 3.53 3.76 .105
treatment
Delirium is associated with long-term 3.24 3.29 .646
neuropsychological damage
Delirium prolongs the weaning of the patient from 3.56 3.52 .669
mechanical ventilation
Delirium assessment is needed in patients who 3.01 3.10 .642
seem alert and oriented
Delirium is associated with an increased risk of 3.41 3.07 .120
dementia
Delirium occurs only in the elderly 2.96 3.10 .343
I can identify delirium in an ICU patient 3.25 3.00 .290
I can explain delirium to the family of a patient 3.35 3.43 .649
Delirium is preventable 3.17 2.88 .115
Early mobilization and physical therapy can 3.34 3.12 .268
prevent delirium
Delirium, like acute renal failure, is a form of organ 2.89 2.81 .665
failure
Mean score of all items 38.83 38.38 .992

Abbreviation: ICU, intensive care unit.

significance (P < .05). A high percentage of
physicians found that delirium occurred in
10% to 25% of ventilated patients, whereas
the majority of nurses observed delirium
in 26% to 50% of ventilated patients, with
significant differences (P < .01).
Another significant observation was the
frequency of delirium assessment. The ma-
jority of both physicians (69%) and nurses
(88%) reported that they were not perform-
ing routine assessments, with a statistically
significant difference (P < .01). Haloperidol
was reported as the main drug prescribed
for ICU delirium; however, most respondents
in both groups did not know which side
effects should be monitored after administra-
tion of the drug. Significance was observed
(P < .01). Table 3 provides statistical informa-
tion regarding the attitudes, perceptions, and
current practices of nurses and physicians
related to ICU delirium.
In terms of nurse and physician percep-
tions regarding the extent to which certain
factors contribute to delirium, significance
was observed for sepsis, acute respiratory
distress syndrome (ARDS), liver failure, and
renal failure. In all these cases, physicians
had higher mean scores (3.79, 3.69, 3.79, and
3.69, respectively) than nurses (3.32, 3.16,
3.39, and 3.32, respectively). Table 4 displays
the difference between nurse and physi-
cian perceptions regarding the risk factors of
delirium.
A majority of nurses and physicians stated
that the following were obstacles to assess-
ing delirium: sedation of patients (89.0%),
intubation of patients (80.0%), workload
(78.5%), time consumed by delirium assess-
ment (71.5%), and complexity of the tool
itself (71.0%). Table 5 presents the obstacles
to assessing delirium as perceived by nurses
and physicians.

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398 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2021

Table 3. Attitudes, Perceptions, and Current Practices Regarding Delirium

Group

Nurses Physicians Pa
I have read something about ICU delirium in the .267
past year
Yes 29.1% 38.1%
No 70.9% 61.9%
How many times have you read about delirium in .013
the past year?
0 70.3% 54.8%
1 19.0% 14.3%
2-3 8.9% 28.6%
>3 1.9% 2.4%
In the past 3 y, I have participated in training .611
course on delirium in the ICU
Yes 14.6% 9.5%
No 85.4% 90.5%
What percentage of all your shifts do you have to .048
deal with delirious patients at the ICU?
Never 3.2% 2.4%
<10% of shifts 38.6% 33.3%
10%-30% of shifts 24.7% 47.6%
30%-50% of shifts 23.4% 16.7%
50%-70% of shifts 8.2% 0%
>70% of shifts 1.9% 0%
What percentage of ventilated patients develop .003
delirium according to you?
<10% 18.4% 26.2%
10%-25% 31.0% 54.8%
26%-50% 32.9% 16.7%
51%-75% 13.9% 2.4%
76%-100% 3.8% 0%
Do you routinely assess patients for delirium? .008
Yes 12.0% 31.0%
No 88.0% 69.0%
How often? .003
Not done 88.0% 69.0%
At admission 2.5% 16.7%
Daily 7.0% 11.9%
At discharge 2.5% 2.4%
What is your first-choice drug for delirium in the .001
ICU?
I don’t know 41.1% 16.7%
Haloperidol 47.5% 59.5%
Diazepam 3.2% 2.4%
Propofol 0% 4.8%
Chlorpromazine 2.5% 0%
Midazolam 3.2% 9.5%
Morphine 1.3% 0%
Fentanyl 0.6% 7.1%
Chlorpheniramine maleate 0.6% 0%
(continues )

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 Delirium in Intensive Care Units 399

Table 3. Attitudes, Perceptions, and Current Practices Regarding Delirium (Continued )

Group

Nurses Physicians Pa
What side effects do you know or have observed? .004
Respiratory depression 5.7% 19.0%
Decrease level of consciousness 13.3% 21.4%
Sleepy and hypoactive 8.9% 19.0%
Hallucination 13.9% 9.5%
Hypotension 3.2% 2.4%
Don’t know 55.1% 28.6%
According to you, can the routine screening of .754
delirium in the ICU be helpful in improving the
prognosis of critically ill patients?
Yes 53.2% 59.5%
No 46.8% 40.5%
In managing delirium, do you follow a protocol NA
or guidelines?
Yes 0% 0%
No 100% 100%

Abbreviations: ICU, intensive care unit; NA, not applicable.

a
P values are based on Fisher’s exact test.

DISCUSSION providers regarding ICU delirium. The nurses

and physicians who served as participants
This was the first study conducted in Pales- were aware of the concept “ICU delirium”
tine to assess the knowledge of health care and acknowledged the increase in health care

Table 4. Importance of Risk Factors for Delirium According to Nurses and Physicians

Risk Factor Nurses Physicians Overall Score P

Sepsis 3.32 3.69 3.39 .048
ARDS 3.16 3.79 3.30 .002
Surgery before the ICU admission 3.12 3.40 3.18 .260
Primary neurological disorder 3.41 3.67 3.47 .255
Administration of sedatives and analgesics 3.46 3.64 3.50 .312
Liver failure 3.39 3.79 3.47 .026
Renal failure 3.32 3.69 3.40 .031
Heart failure 3.27 3.57 3.34 .098
Hypoxia 3.46 3.83 3.54 .066
Anemia 3.20 3.38 3.24 .384
Shock 3.35 3.43 3.37 .556
Visual impairment 2.98 3.17 3.02 .455
Hearing impairment 2.98 2.81 2.94 .362
Gender 2.92 3.02 2.95 .652
Age >70 y 3.28 3.57 3.34 .154
Cognitive impairment 2.99 3.381 3.08 .106

Abbreviation: ARDS, adult respiratory distress syndrome.

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400 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2021
Table 5. Obstacles to Assessing Delirium
Obstacle
Patient being under sedation
Patient being intubated
Workload
The time it takes to perform the assessment
The complexity of the diagnostic tools
No tool
Lack of information about the subject
The problem is not as important as other
problems in the ICU and the CCU (myocardial
infarction, pressure ulcer)
Abbreviations: CCU, cardiac care unit; ICU, intensive care unit.
costs as one of its results. It is expected that
this awareness is derived from their constant
contact with patients, many of whom exhibit
signs and symptoms of at least one form of
delirium.
It was also found that physicians acknowl-
edged the need for adequate treatment when
delirium occurs to a larger extent than nurses.
It is possible that physicians view ICU delir-
ium as a more serious problem than nurses
do. As shown by Arend and Christensen,23
ICU delirium is a problem requiring treatment
to prevent constant increases in health care
costs.
Pursuing knowledge and finding methods
to manage delirium were low among both
groups of health care providers, with the
majority of participants indicating that they
had not read anything about delirium over
the past year. Furthermore, they had only
dealt with delirium cases in less than 10%
of their shifts. In addition, the majority of
nurses in our study reported that they had not
performed any delirium assessments. There-
fore, delirium might not have been detected
in the first place to be even considered for
treatment. This might be a result of circum-
stances where the majority of the participants
in our study have not performed routine delir-
ium assessments. This is due to the lack of
use of a validated tool to assess delirium in
Palestinian hospitals, leaving assessment de-
pendent on health care provider experience
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Percentage of Nurses and Physicians
Declaring the Obstacle
89.0%
80.0%
78.5%
71.5%
71.0%
23.5%
11.5%
7.5%
and personal diligence. Clearly, if assessments
are not performed, delirium is bound to be
underreported. According to Forsgren and
Eriksson,24 59% of nurses in their sample
had performed routine assessments. In addi-
tion, participants reported delirium in 10% to
25% of all ventilated patients. This proportion
may have been miscalculated because many
evaluators state that ventilation serves as an
obstacle to assessment.17,25
Haloperidol is the first choice of drug used
to mitigate delirium in all Palestinian hos-
pitals included in this study. Unfortunately,
most participants did not know the poten-
tial side effects of this drug. Girard et al3
concluded that haloperidol (Haldol) does not
significantly affect the duration of ICU delir-
ium. In addition, many drugs may actually
cause delirium as a side effect. This was not
reported by participants as something to be
taken into consideration when assessing or
treating delirium.
Significance was observed with ARDS and
liver failure. In both cases, physicians scored
a higher mean score (3.79) than nurses (3.16
and 3.39, respectively). A systematic review
regarding the risk factors associated with ICU
delirium was conducted by Zaal et al.26 They
reported 11 putative risk factors identified
by strong or moderate levels of evidence.26
Organ (liver) failure was identified with a
moderate level of evidence. Acute respiratory
failure was supported by an inconclusive

level of evidence.26 In our study, nurses and
physicians reported liver failure and ARDS
as the most ominous risk factors, thereby
exhibiting either their lack of awareness
of the most important risk factors or their
misjudgment regarding the severity of liver
failure and ARDS.
Our study found that both the nurses and
physicians consider that several obstacles ex-
ist to delirium assessment, and these are sim-
ilar to those reported by other researchers.
Many have reported that the sedation or
intubation of patients serves as an obsta-
cle; however, there are studies that indicate
successful assessments regardless of these
factors.27 Similar to our study, Patel et al28
suggested that ICU delirium screening is time
intensive and Devlin et al29 stated that the
complexity of the tool is a barrier to assess-
ment. Therefore, identifying the factors that
obstruct delirium assessment may contribute
to a further understanding of the reasons why
ICU delirium is frequently underdiagnosed.
Limitations
The small sample size may be considered
a limitation in this study. Although the sam-
ple included health care professionals from
7 different hospitals, the number of ques-
tionnaires collected from each hospital was
unequal. In addition, the participants were
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Delirium in Intensive Care Units 401
predominantly nurses (158 of 200; 79%), with
only 42 (21%) physicians. In addition, the
self-reporting aspect of the questionnaire is a
limitation because it increases the potential
for bias. Also, questionnaire items might have
been interpreted differently between individ-
uals, and data recollected from prior events
might not have been equally accurate among
the participants.
CONCLUSION
Previous studies suggest a lack of knowl-
edge among health care professionals that
hinders accurate detection and management
of ICU delirium. Accordingly, accurate assess-
ment and diagnosis of ICU delirium are vital
for timely treatment. This study highlights in-
adequate knowledge and a lack of practice of
delirium assessment among Palestinian health
care professionals. The majority of health care
providers in our study reported that they had
not performed any previous delirium assess-
ments. As such, there is a pressing need to
promote accredited tools for ICU delirium
assessment in hospitals and conduct educa-
tional training of the medical and nursing
teams in health care facilities related to early
detection and management of ICU delirium
in order to improve and simplify the assess-
ment of delirium, hence improving patient
outcomes.
in the ICU during daily care. Intensive Care Med.
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