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Bedside coaching to improve nurses' recognition of delirium.


Delirium is a widespread complication of hospitalization and is frequently unrecognized by nurses and other healthcare professionals. Patients with neuroscience diagnoses are at increased risk for delirium as compared with other patients. The aims of this quality improvement project were to (1) increase neuroscience nurses' knowledge of delirium, (2) integrate coaching into evidence-based practice, and (3) evaluate the effectiveness of this combined approach to improve nurses' recognition of delirium on a neuroscience unit. Institutional review board approval was obtained. A retrospective chart review of randomly selected patients admitted before the intervention was completed. The (modified) Nurse's Knowledge of Delirium Tool was electronically administered to nursing staff (n = 47), followed within 2 weeks by a didactic presentation on delirium. Bedside coaching was performed over a period of 4 weeks. The (modified) Nurses Knowledge of Delirium Tool was electronically readministered to nurses 4 weeks later to determine the change in aggregate knowledge. A postintervention chart review was conducted. SPSS software was used to analyze descriptive statistics with regard to chart reviews, documentation, and change in questionnaire scores. Findings reveal that neuroscience nurses recognize the absence of delirium 94.4% of the time and the presence of delirium 100% of the time after a didactic session and coaching. The postintervention chart review showed a statistically significant increase (p = .000) in the documentation of delirium screening results. Expert coaching at the bedside may be a reliable method for teaching nurses to use evidence-based screening tools to detect delirium in patients with neuroscience diagnoses.

Keywords: bedside coaching, delirium, neuroscience nurses


More than half of all hospitalized adults in the United States are 65 years old or older. Yet, the acute care environment can be risky for this population. The potential to develop iatrogenic events such as falls, pressure ulcers, adverse drug events, or nosocomial infections is greater for older than younger adults because of the normal physiological changes of aging, the presence of multiple comorbidities, and polypharmacy (Capezuti, Zwicker, Mezey, & Fulmer, 2008). One of the most widespread, costly, and injurious complications of hospitalization for older adults is delirium (Akechi et al., 2010; Inouye, 2000; Young & Inouye, 2007).

Delirium is a complex neuropsychiatric disorder characterized by an acute change in consciousness, with inattention or perceptual disturbances, which fluctuates over a period of time. Once believed to be an expected outcome of illness in older adults, delirium is now viewed as a medical emergency because of the associated negative consequences (Evans & Kurlowicz, 2008; Inouye, 2006). Delirium frequently leads to poor outcomes for patients including increased morbidity, mortality, functional decline, and hospital length of stay; mental and physical disability; risk of institutionalization; and greater healthcare costs (Rigney, 2006; Siddiqi, Holt, Britton, & Holmes, 2009). Additional delirium-related expenses are estimated at $2,500 per patient or an additional of $6.9 billion Medicare dollars per year (Young & Inouye, 2007).

Nurses play a crucial role in delirium recognition because they spend more time at the bedside than physicians and other healthcare professionals (Akechi et al., 2010; Evans & Kurlowicz, 2008). Routine and systematic assessment is a key to the early recognition of delirium. However, research has shown that nurses and their physician colleagues frequently do not recognize delirium because of many factors including minimal emphasis on delirium during their formal education and lack of familiarity with the standardized tools (Akechi et al., 2010; Evans & Kurlowicz, 2008).

Research on patients with delirium coupled with a neuroscience diagnosis is limited (McManus et al., 2009; Oldenbeuving et al., 2007; Ramirez-Bermudez et al., 2006), despite the fact that stroke, epilepsy, dementia, central nervous system infections, dehydration, or neurosurgery have been identified as common etiologies of delirium in patients of all ages. The clinical picture of delirium in neuroscience patients is the same as it is in other conditions; yet, bedside nurses and non-psychiatric physicians frequently do not recognize the symptoms (Cerejeira & Mukaetova-Ladinska, 2011; Steis & Fick, 2008).

Research reveals that educational interventions for nurses, which focus on delirium prevention, recognition, and treatment, can significantly decrease the incidence of delirium in hospitalized older adults (Inouye, Foreman, Mion, Katz, & Cooney, 2001; Tabet et al., 2005). In addition, educational interventions have augmented the ability of nurses to detect delirium in patients to some extent (Akechi et al., 2010; Ramaswamy et al., 2010). Nevertheless, numerous studies have determined that nurses continue to have difficulty identifying delirium, particularly in the hypoactive form, even after educational interventions have been conducted (Akechi et al., 2010; Flag, Cox, McDowell, Wose, & Buelow, 2010).

Coaching, which is another intervention, may be a method to reinforce classroom learning for nurses and to help them to accurately recognize delirium in their patients. A relatively new concept for the nursing profession, the goal of the coaching process is to build skills based on clear expectations and provide structured learning at the bedside (Habel & Yoder, 2011). Coaching is a collaborative relationship between an individual and a skilled facilitator, the coach. The role of the coach is to support, encourage, and help the client through a learning process (Donner & Wheeler, 2008). Coaching is a short-term process to develop and improve practice (Davis, Middaugh, & Davis, 2008). No research was identified that described the use of a coaching intervention to improve nursing knowledge of delirium. Combining education and a coaching intervention may be useful in improving recognition and outcomes for patients at risk for delirium on a neuroscience unit. Therefore, the aims of this project were to (1) increase neuroscience nurses' knowledge of delirium by providing delirium education, (2) integrate coaching into evidence-based practice using screening tools for delirium as the standard of care for all patients on the neuroscience unit, and (3) evaluate the effectiveness of this combined approach to improve nurses' recognition of delirium on a neuroscience unit.


Human Subjects Protection approval to conduct this pretest/posttest quality improvement project was obtained from the University of Massachusetts Lowell and the Partners Healthcare System Institutional Review Boards. To assess the nurses' preintervention practice and documentation related to delirium, a retrospective chart review of 25 randomly selected adult patients was conducted. Evidence of common delirium symptoms and documentation of delirium screening were recorded along with patient demographics. Simultaneously, a measure of the nurses' preintervention knowledge of delirium was conducted using a modified version of the Fremantle Hospital & Health Service Nurse's Knowledge of Delirium Tool (Modified Fremantle Questionnaire; Hare, Wynaden, & McGowan, 2008); permission to adapt the original questionnaire for the neuroscience patient population was received from the primary author. The Modified Fremantle Questionnaire consists of two parts: demographic data and questions related to delirium and risk factors for delirium. The demographic questions were modified to reflect present practice in the United States, as several categories in the original version of the questionnaire did not accurately reflect current U.S. practice. For example, "position designation," "ward assignment," and "work hours per fortnight" were replaced with "highest level of education," "number of years in nursing practice," and "specialty certification."

In addition, there are 28 questions related to delirium or its risk factors that require nurses to reply "agree," "disagree," or "unsure" to a series of statements. The original questionnaire was created for use on an orthopedic unit, and 1 of the 28 statements was based on a clinical scenario with a patient who fell and fractured his or her hip. This question was modified to describe a patient who fell and sustained a subdural hematoma to more accurately reflect the neuroscience population. The score on the questionnaire can range from 0 (low knowledge) to 28 (high knowledge). The questionnaire was electronically mailed via a secure Web application (REDCap), to the entire nursing staff of the 31-bed neuroscience unit, and remained available for self-administration for a period of 2 weeks.

In preparation for educating staff nurses on using the Brigham and Women's Hospital (BWH) Delirium Screening Tool, the first author and the unit-based clinical educator independently but simultaneously screened 24 neuroscience patients for delirium and were in 100% agreement with the results. Uncertainties related to findings in two patients with neuroscience diagnosis were discussed with and clarified by the psychiatric clinical specialist.

Sample and Setting

All registered nurses (RNs; n = 47) who work on the 31-bed neuroscience intermediate care unit at a large academic medical center in Boston, Massachusetts, were included in the sample.


Delirium education was provided in person by the first author and consisted of "Delirium Prevention and Treatment: A Multidisciplinary Approach," a Power Point curriculum written by the BWH Delirium Task Force (2011) and augmented by a handout "Points to Ponder about Delirium in Neuroscience Patients," prepared by the first author. In addition to the delirium education, the BWH Delirium Screening Tool (BWH Delirium Task Force, 2011), an unpublished modification of the CAM-ICU (Elye et al., 2001), was reviewed step-by-step during the education process. The length of the teaching session ranged from 30 to 40 minutes and was delivered in small groups of 2-4 nurses in the conference room or at the nurses station at varied times of the day but always during the nurses' regular working hours.

Once every nurse on staff had received the education, bedside coaching by the first author, an expert clinician, was initiated. Bedside coaching consisted of individual collaboration with each nurse; a detailed review of the BWH Delirium Screening Tool; guidance, support, and encouragement in using the delirium screening tool at the bedside; and the proper documentation of results. Every nurse was asked to provide a return demonstration of delirium screening to the coach on two of his or her patients at the bedside. The coach provided support, explanation, and feedback and independently but simultaneously screened the patients for delirium. The findings of the coach and the staff nurse were then compared and discussed immediately after the patient assessment.

One month after the intervention was completed, the Modified Freemantle Questionnaire was read-ministered electronically to all nurses to assess the change in aggregate scores regarding the knowledge of delirium after the intervention. A postintervention chart review was simultaneously conducted to show changes in documentation related to delirium symptoms and interventions.


Data were analyzed with IBM Statistical Package for the Social Sciences (SPSS) version 20 (SPSS, Inc.). Descriptive analyses were conducted to identify the demographic and employment characteristics of the nursing staff that participated in the preintervention and postintervention survey. Aggregate pretest and posttest scores from the Modified Fremantle Questionnaire were evaluated using descriptive measures. A two-sample t test was conducted to determine whether the increase in the mean survey scores after the educational intervention and coaching was statistically significant. Calculation of frequencies and percentages were conducted to evaluate the results of the preintervention and postintervention chart review and the coaching results. Agreement between the coach and the RN on delirium screening as well as the documentation of delirium screening and symptoms were measured.


Most of the nurses who responded to the questionnaire were less than 40 years old, and most had a bachelors degree in nursing (preintervention group, 70.4%; postintervention group, 77.3%), yet their years of experience varied widely (Table 1). The preintervention questionnaire produced 27 responses and a mean score of 17.7 correct answers, whereas the postintervention questionnaire yielded 22 responses and a mean score of 20.7 correct answers (Table 2). This did not represent a significant improvement in aggregate scores from pretest to posttest (p = .1366).

The preintervention chart review revealed no evidence of nursing documentation related to delirium screening, behaviors, or interventions other than benzodiazepine use (n = 16) for restlessness, sleeplessness, or agitation. After the educational intervention and coaching, the postintervention chart review showed a statistically significant increase (p = .000) in the documentation of delirium screening results and associated behaviors or cognition (Table 3). Coaching data were analyzed to determine the frequency of agreement in delirium screening results between the coach and the staff nurse (Table 4). Of the 71 patient encounters, the coach and the RN were in agreement in 94% of the time. Of note, there was a cohort of patient encounters (n = 5) for whom the BWH Delirium Screening Tool was not effective because of the patient's global aphasia.


The results of this study show that, for this group of neuroscience nurses, an educational program on delirium coupled with bedside coaching in the use of a standardized delirium screening tool significantly improved practice and process of care. This was evidenced by the consistent use of the BWH Delirium Screening Tool and enhanced documentation of delirium screening results after the intervention. The dramatic change from no evidence of delirium screening and associated behavior documentation to a nearly universal practice is encouraging but should be viewed with caution. This may have been a "placebo effect" related to the novelty of the program; and the influence of the intervention has not been evaluated long term. Regardless, monthly chart reviews and intermittent coaching will continue to be conducted to support this practice change.

Although the results of the Modified Fremantle Questionnaire did not reveal a significant change in the nurses' level of knowledge, there was a 20.5% increase in the nurses reporting that they felt confident that they are able to quickly and accurately recognize delirium in patients after the intervention. This may be attributed in part to the coaching that took place at the bedside because coaching is designed to improve skills rather than just to provide information (Ervin, 2005). The fact that the Modified Freemantle Questionnaire has face validity but does not have established content validity may also have affected these results. Yet, at the time of this study, it was the only tool available to measure nurses' knowledge of delirium. The practice change suggests that coaching at the bedside in addition to didactic education may be an effective means of changing practice related to delirium screening, intervention, and documentation. This mirrors the finding of Lemiengre et al. (2006) who reported that education alone is not sufficient to improve the recognition and treatment of delirium by nurses; it is the teaching strategy that seems to be important. Clinical coaching at the bedside has been found to be successful in incorporating evidence-based practice in home care, critical care, and several other nursing specialties (Ervin, 2005.). More research is indicated to determine if bedside coaching by an expert nurse is a reliable method to improve nurses' recognition of delirium.

There were two additional findings of interest that stemmed from this project. The most notable finding was that the neuroscience nurses, when comparing their delirium screening with that of the coach, were in agreement in 94.4% of the time for patients without delirium and 100% of the time for patients with delirium. This finding is unlike the results of Steis and Fick (2008) who published a systematic review and found that nurses recognized delirium in patients only 26%-83% of the time. An earlier study by Inouye et al. (2001) found that nurses recognized delirium only 19% of the time, even after education. This may be attributed to the unique skill set and assessment skills that neuroscience nurses possess. Neuroscience nurses routinely and systematically assess for changes in the level of consciousness and mental status in their patients as a part of their neurological examination (Bader & Littlejohns, 2004). This specialized skill set may make delirium assessment easier for them than for nurses from other specialties. Of the four patients who screened positive for delirium during this study, three had symptoms of mixed delirium and one had hyperactive delirium. None of the patients with delirium had the hypoactive type at the time of the study. This is important to note because hypoactive delirium has been identified as the most difficult type for nurses to identify in practice (Cerejeira & Mukaetova-Ladinska, 2011; Inouye et al., 2001).

The second finding was related to patients with global aphasia. Patients with global aphasia who could not understand or process language or communicate by any means were not able to be assessed using the BWH Delirium Screening Tool because it required them to respond in some way, either verbally, in writing, or by pointing to a communication board. When a patient is unable to understand directions or questions, it is not possible to fully assess cognition. Further research in the area of behaviors indicative of delirium for patients with global aphasia would be useful to help this at-risk population in the future.


There are a few limitations associated with this project. The sample was from one specialty unit, without randomization or a control group. Therefore, generalization of results to other units is not possible. The small sample size of survey respondents and the limited number of patients with delirium made it impossible to show statistical significance related to the education or coaching. The patients on the unit at the time of the intervention were atypical in that they were generally younger and healthier than the usual population. The first author was the nursing director on the unit where the project was conducted, and some may argue that there may have been some coercion for nurses to participate. However, quality improvement projects are well within the role of the nursing director. The change in practice from this study has led to other units inquiring about how we were able to motivate nurses to conduct a delirium assessment on all patients every 8 hours. Evidence suggests that one-on-one coaching may change nursing practice in relation to delirium screening and documentation, but further research is indicated.


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Questions or comments about this article may be directed to Susan Jean Gordon, DNP ACNP-BC GNP-BC, at She is the NICHE Program Leader and Nursing Director of the Neuroscience Intermediate Care Unit, Brigham and Women's Hospital, Boston, MA.

Karen Devereaux Melillo, PhD GNP ANP-BC FAANP FGSA, is the Professor, Director and Chair, School of Nursing at the University of Massachusetts Lowell.

Angela Nannini, PhD FNP, is an Associate Professor of Nursing at the University of Massachusetts Lowell.

Barbara E. Lakatos, DNP PMHCNS-BC APRN, is the Program Director, Psychiatric Nurse Resource Service at the Brigham and Women's Hospital, Boston, MA.

The authors declare no conflicts of interest.

DOI: 10.1097/JNN.0b013e31829d8c8b
TABLE 1. Demographic Information on Nurses Who
Participated in the Survey

                              Preintervention     intervention

                               n        %        n        %

Participants                     27      --        22      --
  20-29                           8     29.6        9     47.3
  30-39                           9     33.3        7     31.8
  40-49                           8     29.6        6     27.2
  50-59                           2      7.4        0      0.0
  Diploma                         2      7.4        0      0.0
  Associate degree                5     18.5        4     18.2
  BSN                            19     70.4       17     77.3
  MSN                             1      3.7        1      4.5
Years in practice
  2 or less                       4     14.8        3     13.6
  3-5                             8     29.6        7     31.8
  6-10                            4     14.8        6     27.3
  11-20                           8     29.6        5     22.7
  >20                             3     11.1        1      4.5
Education specific
to the care of
older adults
  Yes                            20     74.1       15     68.2
  No                              6     22.2        6     27.3
  Not sure                        1      3.7        1      4.5
Education specific to
care of patients
with delirium
  Yes                            12     44.4        1      4.5
  No                             14     51.9       18     81.8
  Not sure                        1      3.7        3     13.6
Do you feel you are able
to quickly and accurately
recognize delirium?
  Yes                            19     70.4       20     90.9
  No                              2      7.4        0      0.0
  Not sure                        6     22.2        2      9.1

Note. BSN = Bachelor of Science in Nursing; MSN = Master of Science
in Nursing.

TABLE 2. Preintervention and Postintervention
Questionnaire Results and Significance

              N       Mean        SD

Pretest      27       17.7       8.188
Posttest     22       20.7       4.864

           Minimum   Maximum   Unpaired
            Score     Score     t Test

Pretest       0        28      p = .1366
Posttest      0        28

TABLE 3. Chart Review

Delirium                       Fisher
Screening                      Exact
Conducted            %     n   Test, p

Preintervention      0     0
Postintervention    92    23   .000 ***

*** Statistically significant.

TABLE 4. Bedside Coaching Delirium
Screening Data
                        N      %

Patients assessed       71    --
Gender (female)         43   60.6
  Negative              62   87.3
  Positive               4    5.6
  Not able to assess     5    7.1
Coach-nurse agreement
  Yes                   67   94.4
  No                     3    4.2
  Missing data           1    1.4

Note. CAM = Confusion Assessment Method.
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Author:Gordon, Susan Jean; Melillo, Karen Devereaux; Nannini, Angela; Lakatos, Barbara E.
Publication:Journal of Neuroscience Nursing
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2013
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