Managing agitation secondary to hyperactive delirium in deteriorating patients.

Delirium is an under-recognised condition which adversely affects deteriorating patients. Delirium can be an acute or long-term condition and is associated with increased morbidity and mortality, and extended length of hospital stay. The management of delirium is often reactive rather than proactive, which can lead to the inappropriate use of chemical and physical restraint to control agitation secondary to hyperactive delirium. Caring for patients with delirium presents physical and emotional challenges for nurses, who are sometimes inclined to use restraint, which should be a last resort. This article describes the challenges of caring for patients with delirium, presents the risk factors for and assessment of delirium, and describes the management of agitation secondary to hyperactive delirium. Support and education for nurses caring for patients with delirium is essential to ensure optimal patient care and avoid staff burnout.

Understanding the decision-making of critical care nurses when restraining a patient with psychomotor agitation secondary to hyperactive delirium: A 'Think Aloud' study.

AIMS & OBJECTIVES: This study aimed to explore the decision-making processes undertaken by critical care nurses when considering restraint to manage a patient with psychomotor agitation secondary to hyperactive delirium. BACKGROUND: Psychomotor agitation is frequently cited as clinical rationale for initiating chemical or physical restraint. Despite the presence of clinical guidance for restraint in critical care, wide variations in nursing and prescribing practice are evident. Nurses are the primary decision makers when initiating restraint, but little is known about this process and influencing factors. DESIGN: A pragmatic qualitative approach was used to explore critical care nurses' decision-making processes. METHODS: A 'think aloud' approach was undertaken. Audio-visual vignettes featuring simulated patients were used as stimulus to elicit decision-making processes from thirty critical care nurses and practitioners. The COREQ checklist was followed. RESULTS: Five themes relating to restraint were identified: Intrinsic beliefs and aptitudes; Handover and labelling; Failure to maintain a consistent approach; Restraint might be used to replace vigilance; The tyranny of the now. CONCLUSIONS: Restraint was more frequent when staffing ratios were reduced below 1:1 and opportunities for vigilance reduced. Participants described physical and psychological exhaustion when caring for a patient with delirium and how this might lead to restraint to create 'space' for respite. Variations in practice were evident and restraint use appears rooted in custom and culture rather than objective assessment. RELEVANCE TO CLINICAL PRACTICE: The lack of pre-emptive management for hyperactive delirium and reduced staffing ratios lead to the decision to restrain to preserve safety in acute agitation. The struggle to manage agitated behaviour is associated with nurse burnout and reduced engagement with therapeutic management methods, suggesting the need for psychological and educational support for clinical staff. Delirium is an important and debilitating form of organ dysfunction which should be collaboratively managed by the multi-disciplinary team.

Using audiovisual vignettes to collect data remotely on complex clinical care: a practical insight.

BACKGROUND: Vignettes are regularly used in nursing research and education to explore complex clinical situations. However, paper-based vignettes lack clinical realism and do not fully recreate the pressures, sights and sounds of clinical settings, limiting their usefulness when studying complex decision-making processes. AIM: To discuss the approach taken by the authors in developing and implementing audiovisual vignettes to collect data remotely in a qualitative study. DISCUSSION: The authors describe how they created audiovisual vignettes for a qualitative 'Think Aloud' study exploring how critical care nurses decide whether to restrain agitated patients with varying degrees of psychomotor agitation. They discuss the practicalities of filming, editing and hosting, as well as the theoretical and clinical background that informed the creation of the vignettes. CONCLUSION: Audiovisual vignettes are a cost- and time-effective way of remotely exploring decision-making in challenging environments. This innovative method assists in studying decision-making under simulated clinical pressures and captures data about how people make complex decisions. IMPLICATIONS FOR PRACTICE: Audiovisual vignettes are an innovative tool for collecting data and could also be used in educational settings and offer the opportunity to explore complex clinical decision making remotely. Clinical accuracy is essential for immersing participants and simulating an environment and its pressures. The method could be further enhanced by making vignettes responsive to participants' decisions.

Identifying determinants for the application of physical or chemical restraint in the management of psychomotor agitation on the critical care unit.

AIMS AND OBJECTIVES: To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit. BACKGROUND: Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old, and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence-based practice or custom and culture. STUDY DESIGN: Integrative review. METHOD: Seven health sciences databases were searched to identify published and grey literature (1995-2019), with additional hand-searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data were extracted, and thematic analysis undertaken. RESULTS: A total of 23 studies were included. Four main themes were identified: the lack of standardised practice, patient characteristics associated with restraint use, the struggle in practice and the decision to apply restraint. CONCLUSIONS: There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision-makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated. RELEVANCE TO CLINICAL PRACTICE: Delirium and agitation pose a potential threat to patient safety and the maintenance of life-preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence-based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.

Critical care nursing: caring for patients who are agitated.

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Thematic Analysis: How do patient diaries affect survivors' psychological recovery?

AIM: This review aims to use thematic analysis to explore and synthesise evidence of the actual or potential reported effects of diaries on the psychological rehabilitation and recovery of discharged critical care patients. BACKGROUND: Evidence suggests that whilst admission to critical care may save patient lives, the psychological aftermath can damage a patient's recovery and these needs must be met. Patient diaries are one potential intervention to aid patients understand their critical illness and fill memory gaps caused by sedation, thus reducing psychological distress post-discharge. Prospective patient diaries are increasing in popularity amongst critical care units in the United Kingdom, however there is little evidence base to support their use or understand their effects. METHOD: A literature review using systematic methods was undertaken of studies relating to the effects of diaries on discharged patients. Thematic analysis enabled the generation and synthesis of themes. RESULTS: Three themes arose from the generated codes: 1) Reclaiming ownership of lost time. 2) Emphasising personhood. 3) Fear and frustration. The diary intervention was shown to have a largely positive impact on survivors' psychological rehabilitation. However, caution should be exercised as recipients could find the contents painful and emotional. Diaries should be embedded within a robust critical care follow-up plan. CONCLUSION: This review suggests that diaries have the potential to form one aspect of rehabilitation and make a positive impact on patients' recovery. More research is indicated to fully evaluate the effects of diaries on their recipients.