How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups.

Objectives: The aim of this study was to explore the experiences of doctors and nurses caring for patients with delirium in the intensive care unit (ICU) and to describe the process of delirium management. Setting: This study was performed in 5 ICUs located within 4 hospitals in Madrid (Spain). Participants: Purposeful sampling was performed which included (1) doctors and nurses working in ICUs, (2) with >1 year experience in the ICU and (3) clinical experience with delirium. 38 professionals participated (19 doctors, 19 nurses), including 22 women and 16 men. The total mean age was 39 years. Design: A qualitative study using focus groups. Methods: 7 focus groups were held to collect data: 3 nurse focus groups, 3 doctor focus groups and 1 mixed focus group. Each group comprised 6–10 participants. A semistructured questions guide was used. Thematic analysis methods were used to analyse the data. Results: 3 themes were identified: (1) the professional perspective on delirium; (2) implementing pharmacological and non-pharmacological treatment for delirium and (3) work organisation in the ICU. The professionals regarded patients with delirium with uncertainty, and felt they were often underdiagnosed and poorly managed. Doctors displayed discrepancies regarding pharmacological prescriptions and decision-making. The choice of medication was determined by experience. Nurses felt that, for many doctors, delirium was not considered a matter of urgency in the ICU. Nurses encountered difficulties when applying verbal restraint, managing sleep disorders and providing early mobilisation. The lack of a delirium protocol generates conflicts regarding what type of care management to apply, especially during the night shift. A degree of group pressure exists which, in turn, influences the decision-making process and patient care. Conclusions: Patients with delirium represent complex cases, requiring the implementation of specific protocols. These results serve to improve the process of care in patients with delirium.

研究目的：本研究旨在探索重症监护病房（Intensive Care Unit, ICU）医护人员照护谵妄（delirium）患者的经历，并描述谵妄的管理流程。研究场景：本研究在西班牙马德里4家医院下设的5个ICU内开展。研究对象：采用目的抽样法（purposeful sampling），纳入标准如下：（1）ICU在职医护人员；（2）拥有1年以上ICU工作经验；（3）具备谵妄临床照护经验。最终共有38名专业人员参与本研究，其中医生、护士各19名，女性22名，男性16名，平均年龄为39岁。研究设计：采用焦点小组（focus groups）法的质性研究。研究方法：共开展7场焦点小组访谈，其中护士组、医生组各3场，混合组1场，每组参与人数为6~10人。本研究采用半结构化访谈提纲（semistructured questions guide）进行数据收集，并运用主题分析法（thematic analysis）对采集的数据开展编码分析。研究结果：共提炼出3个核心主题：（1）医护人员对谵妄的专业认知视角；（2）谵妄药物与非药物治疗的实施现状；（3）ICU的工作组织模式。参与研究的专业人员对谵妄患者的照护存在诸多不确定性，普遍认为谵妄常存在漏诊及管理不佳的问题。医生群体在药物处方与决策制定方面存在分歧，药物选择多依据个人经验。护士群体反映，多数医生未将ICU内的谵妄问题视为紧急事项。护士在实施言语约束、管理睡眠障碍及开展早期活动时均面临诸多困难。缺乏谵妄照护规范会导致照护方案选择上的分歧，尤其在夜班时段更为突出。同时存在一定程度的群体压力，进而对临床决策制定与患者照护质量产生负面影响。研究结论：谵妄患者属于复杂照护群体，亟需建立针对性的照护规范。本研究结果可为优化谵妄患者的照护流程提供实践参考。