Experience of nurses in identifying delirium among cancer patients: A qualitative study

Background:  Information about how nurses screen for delirium in cancer patients can provide insights into improving recognition. This study aimed to investigate the experiences of nurses while identifying delirium in cancer patients.

Methods: The study's design was qualitative, using thematic analysis. Data were gathered via a focus group discussion with ten nurses from two oncological wards of Nursing and Health Research Universitas Riau, Pekan Baru Riau, Indonesia. The focus group discussion lasted roughly 90 minutes. Participants provided feedback on their experiences with assessment in delirium through semi-structured and open-ended questions. Data collection occurred in September 2023 at two oncology wards. Data analysis in this phenomenological research used the Collaizzi method to describe the meaning of an experience identified through the important themes of a phenomenon consisting of seven stages.

Results: Categories, subcategories and themes were constructed. Experiences of nurses in identifying delirium among cancer patients were identified i) delirium, agitation and confusion are almost similar (the term delirium is not well known, and the type of delirium is not familiar); ii) tools for assessing delirium are needed (the tool does not exist and is unknown, used clinical experiences supported by laboratory testing); and iii) nurses can play an important role in identifying delirium (important role in assessing delirium, advising to prevent delirium among healthcare professionals).

Conclusion: Nurses who work in oncology wards need to know more about delirium screening since they play an important role in early detection and treatment. Therefore, appropriate knowledge and measurement tools are required to identify delirium earlier among cancer patients.

Nurses play an important role in identifying delirium. However, they need more knowledge and skills to identify and differentiate delirium from other levels of consciousness. This lack is mainly due to an absence of appropriate measurement tools. The training of nurses should focus on delirium identification using an appropriate tool.

Delirium could be the most common neurological symptom in cancer patients [1]. Delirium occurs when a person has extreme confusion due to a physical or mental ailment. This condition may impair their ability to focus, direct, maintain, and transfer attention [2, 3]. Patients who received therapy in a hospital setting typically have this syndrome. According to a comprehensive review study, the incidence of delirium varies from 3% to 29% per hospitalisation, with a prevalence of approximately 20% among newly admitted patients [4]. According to various studies, delirium affects 22–44% of cancer patients, which may rise up to 87% in their final days of life [5].

The management and treatment of patients with delirium in cancer care settings provide complex challenges. Despite being treatable with skilled nursing care, delirium is frequently misdiagnosed and, as a result, either ignored or improperly managed in cancer patients [4, 6, 7]. It can be difficult to determine if a given delirium episode is reversible, and doctors may find it difficult to make decisions about delirium care. Nearly 50% of cancer patients receiving palliative care had permanent delirium episodes, according to a prior study, which raised the death rate [8–10]. As a result, the symptoms are not recognised as indicators of a severe acute illness for which appropriate actions and treatment have not been started [1, 11, 12].

Nurses have an important role in providing nursing care to cancer patients [7, 8]. The nursing care to prevent delirium can begin by evaluating cognitive function. Observations are carried out on patients who experience changes in mental status and behaviour, such as observing orientation towards people, time and place, which must be carried out every 6 hours [13]. Nonetheless, there appears to be a deficiency in clinical practice regarding delirium, including inadequate knowledge regarding the treatment of delirium in patients, insufficient abilities to give patient care and a conflict in making judgments regarding patient care [7, 8]. Few studies have investigated nurses' experiences with delirium and its detection in cancer patients. Therefore, the purpose of this study was to investigate the experiences of nurses identifying delirium in cancer patients.

A qualitative study was done using thematic analysis through focus group discussion (FGD). The FGD method was chosen to explore in-depth information and understand participants' experiences identifying delirium among cancer patients. Through FGD, each respondent can express his opinion or add additional information if he recognises that other respondents still lack the information the researcher needs. The FGD took about 90 minutes to explore nurses' experiences to assess delirium in cancer patients. The guideline from the FGD has been piloted before being applied to the respondents. The pilot was conducted to ensure that the FGD steps had gone well and that everything was ready before the FGD sessions.

FGDs were conducted with ten nurses who worked in two oncology wards at the Nursing and Health Research referral hospital Universitas Riau, Pekan Baru Riau, Indonesia. The number of nurses in the two wards reached 30, but only 10 met the criteria to participate. Nurses who have worked for at least 1 year in the oncology ward and treated patients with delirium were included. Written informed content was obtained from the respondents. The participants were also explained that they would be protected confidentially and could withdraw from the study at any time without consequences. Data collection took place in September 2023. The nurses who were selected as respondents in this study, on average, had the similar length of service and did not have more positions than others to avoid not being open with each other in giving opinions during the FGD.

The FGD was digitally recorded. The researchers took brief notes on each participant's responses to semi-structured, open-ended questions about nurses' experiences doing delirium assessments in cancer patients. If everything has reached the same understanding, then data saturation was considered to be reached. Questions during FGD were: 1) How do you identify patient delirium?; 2) is there training about delirium provided by the hospital?; 3) are there special tools provided by the hospital to identify delirium?; and 4) the role taken by nurses in the care of delirium patients so far is limited to what actions?

Data analysis in this phenomenological research uses the Collaizzi method to describe the meaning of an experience identified through the important themes of a phenomenon consisting of seven stages [14]. Data analysis in this study was manual. Information was obtained using open coding. The discussion was verbatim transcribed, and the Indonesian transcripts underwent content analysis before translation. All transcripts were meticulously read several times, as were the participants' experiences. Categories, subcategories, and themes were then constructed. Data were verified by member checking, peer questioning, and cross-examination to ensure trustworthiness, reliability, and authenticity. We gave respondents the opportunity to see if there is still data they feel do not represent all the answers they provided.

A total of 10 nurses (1 men and nine women) had participated (Table 1). The emergent themes, however, clearly reflected similar experiences and were titled as follows: 1) more knowledge about delirium is essential; 2) lack of appropriate measurement tools; and 3) nurses play an important role in identifying delirium.

Table 1 Participant characteristics

The participants stated that they believe nurses in oncological wards should be more knowledgeable about delirium since they play an important role in therapy, particularly early screening.

The term delirium is not well known
Interviews revealed that the term "delirium" is rarely used. Instead, most nurses utilised perplexity when the patient's mental state changed without first conducting an assessment.
“…..nurses need to know about delirium; so far, delirium has only been identified based on suspicion and experience that nurses have gained while caring for patients in hospital ….” (P7)

The type of delirium is not familiar
It is pretty difficult for them to differentiate between delirium and confusion. Therefore, it makes nurses misdiagnosed.
“……cancer patients with delirium are difficult to study because they are calm…..” (P2)
“……another patient is different, they calmer instead of agitation and confusion…...”(P3)

The participants stated that techniques for diagnosing delirium do not exist and are unknown. Nurses will judge the patient’s condition based on their clinical experience and support the results by sending blood specimens for laboratory examination.

The tool does not exist and is unknown
Data obtained from participants found that they never used the assessment tool which focused on delirium. Instead, they used the Glasgow Coma Scale (GCS) to measure patients' condition if they showed mental status changes.
"... in the room used by GCS, then converted to apathetic, poor awareness status.....” (P2)
“…. from the beginning, we used GCS and then we assessed qualitative awareness…” (P4)
“….. if you assess consciousness using GCS, if consciousness decreases using EWS….” (P3)
"…..not studied, we only GCS is studied....." (P5)

Used clinical experiences supported by laboratory testing
When they are still not sure what happened to the patients, they will refer them to the doctor and ask for a laboratory examination, particularly for electrolyte imbalance.
“……we used our clinical judgment when we found any changes in patients……” ( P10)
“……just check their blood electrolytes, then see whether there are imbalances……” ( P5)

Since the nurse is the closest person in the ward, the nurse should know more about delirium and how to identify those cases.

An important role in assessing delirium
Nurses are always by the patient’s side for almost 24 hours. Therefore, they have an important role in the early screening of delirium symptoms and in preventing the worsening of delirium.
“…..I believe that we have a significant role, so we need to master delirium assessment because delirium in cancer patients is different from other patients.......” (P5)

Advising to prevent delirium among healthcare professionals
Nurses make many observations that other healthcare professionals do not. Based on their assessment, the nurse plays a vital role in giving advice and suggestions to other healthcare professionals regarding the patient’s condition. So the appropriate treatment will run smoothly.
“…….we then give some advice and suggestions to our colleagues based on our assessment…….”(P9)

From FGDs, nurses admitted that 1) more knowledge about delirium is essential, 2) a lack of appropriate measurement tools to assess delirium, and 3) nurses can play an important role in identifying delirium.

Knowledge about delirium is essential because delirium is a common occurrence when caring for cancer patients from the first diagnosis to the latter stages of the disease. Nevertheless, this condition is commonly disregarded. Because delirium can exacerbate a patient's condition and raise their risk of death, health professionals must be aware of the disorder's many features and be able to recognise common underlying causes [15]. It was the same with a study which mentioned that a neurological disorder called delirium makes people abruptly disoriented. Delirium patients may have difficulty in articulating their circumstances or suffer from hallucinations or delusions [16]. Other studies mention that every patient receiving cancer therapy who is admitted to the hospital should have their delirium levels evaluated [17]. The physician or nurse must determine and address reversible triggering factors after diagnosing delirium [18]. The research results from other studies support the theme found in this research, which is how important it is for a nurse to understand how to identify delirium. It will ensure patient safety because it can prevent patients from experiencing dangerous situations if they are misdiagnosed and mistreated [15].

Delirium goes undetected if structured detection measures are not used. When hypoactive delirium occurs in cancer patients, it is frequently misinterpreted as dementia, Wernicke's aphasia, anxiety disorders, or depression [19]. Several validated delirium detection or screening instruments have been created for various patient populations admitted to hospital wards, intensive care units, and emergency rooms [20]. A comprehensive evaluation of the patient's state of awareness should be carried out using a Sedation-Agitation Scale (SAS), such as the Richmond Agitation–Sedation Scale (RASS), before delirium screening. The level of consciousness is used to categorise patient assessments. Patients must be able to speak to be screened for delirium at the preferred level of consciousness. RASS-3 screening should start after the level of consciousness has been determined [21]. The ICU patients, in particular, require greater attention because they are frequently sedated, intubated, and physically weak, making them more likely to be diagnosed with delirium [17]. The results of existing studies show that instruments that detect delirium do not exist. Detection using existing instruments still allows for multiple interpretations, potentially leading to interpretation errors.

Nurses can play an important role in identifying delirium since they spend more time at the patient's bedside than physicians. Nurses interact with patients frequently and continuously; they are more able to notice changes in their attention, consciousness, and cognitive function. As a result, nurses' observations are crucial for the early identification of delirium symptoms and ongoing monitoring, which is necessary to track the patient's clinical progression. Nurses can effectively monitor delirium signs with supervision and training. A study mentions that monitoring and early detection of delirium in cancer patients is the nurse's responsibility to expedite treatment [17]. As a result, nurses' observations are crucial for the early identification of delirium symptoms and ongoing monitoring, which is necessary to track the patient's clinical progression[19]. The data supported the idea that nurses can effectively monitor delirium signs with supervision and training [16]. The overall experience of nurses in detecting delirium in cancer patients cannot be represented broadly. Perhaps this study only represents nurses in hospitals in the Riau region, Indonesia, so research with a stronger methodology, especially grounded theory, might be needed. Moreover, one FGD, with male and all female participants and different roles and designations of the participants, is a limitation of the study. The number of female nurses is greater in the ward than male nurses. This condition meant that only a few male nurses were included in the criteria for research respondents. Respondents have the similar work experience, so we don't think gender and position differences are problematic in this study.

The study shows nurses who work in oncology wards need to know more about delirium screening since they play an important role in early detection and treatment. Therefore, appropriate knowledge and measurement tools are required to identify delirium earlier among cancer patients.

We would like to thank all participants who participated in this study.

Conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: NH, SP, HD, SW, E, SW. Drafting the work or reviewing it critically for important intellectual content: NH, SP, HD, SW, E, SW. Final approval of the version to be published: NH, SP, HD, SW, E, SW. Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: NH.

We do not have any conflict of interest.

We confirm that the data supporting the findings of the study will be shared upon reasonable request. 

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