Table 3

Representative quotations from study participants

The professional perspective on deliriumGrey areas in delirium management “I feel uncomfortable by the situation as I do not control it, I can't understand it, whereas I do understand things like the physiopathology of shock. Delirium is something that goes beyond our intellectual management (…) the other pathologies we control by managing the causes, but delirium is different…” (FG4I6, 47 years, female)
Need for constant attention“We have to wait for the medication to have an effect, but, in the meantime, it is really disheartening, sometimes the medication doesn't even work, and at other times you have to wait for the patient to be assessed by the doctor. You don't know what to do with them, which is stressful because you have to attend to other patients and meanwhile they remove their catheters…” (FG1E2, 38 years, female)
Underdiagnosis“In trauma ICUs, a patient with delirium is never diagnosed. It is a manifestation of the brain lesion and that's all.” (FG2E8, 27 years, female)
Stereotypes regarding patients with delirium “Typical scenario: an older patient, who is admitted, occupies all your attention because you expect them to give you a bad night, get distressed, remove catheters, etc. But, in the end, it is the adult, sedated, under analgesia, and with electrolytical alterations who gets agitated. You try to focus on age, when there are many other warning signs.”(FG7I3, 40 years, female)
Responsibility and nursing“… in the end, the patient with delirium is a responsibility for nurses, the doctor either doesn't like it or doesn't want to see the patient, and says that there is nothing they can give the person, so you can't leave the bedside, and you have no means to manage these patients…” (FG3E17, 37 years, male)
Different assessment criteria “When the intensive care doctors go in the morning to assess a disoriented patient who has been agitated all night, the assessment is almost always more positive, they see the patient more oriented than we do.” (FG1E4, 33 years, male)
Hypoactive delirium“Patients with hypoactive delirium are the most abandoned patients, they don't demand anything, they don't move and don't do anything, they are the ideal patient for intensive care…” (FG3E16, 39 years, female)
Implementing pharmacological and non-pharmacological delirium treatmentPharmacological treatment
There is no medication of choice“You don't have a specific drug for treating delirium, and the few that exist have many side effects, despite administrating the recommended dosage. I have had to intubate a patient due to the effects of the treatment.”(FG6I18, 31 years, female)
Discrepancies between the medical prescription and the dosage“I'm not sure of how to dose haloperidol, sometimes the patient is asleep all morning, but agitated all night, you don't know how to get it right.”(FG5I7, 54 years, male)
The drug choice is determined by the experience of use “You just don't trust it, and you use what you trust the most. You have to be able to quickly and effectively control the patient, you can't wait to see whether a new drug will work because the commercial delegate tells you so.”(FG5I10, 45 years, male)
Delirium is not a life-threatening emergency“You spend your whole shift calling the doctor, it's as if the patient were your sole responsibility and there is no way they will prescribe you anything…when they do, they prescribe a negligible dose in relation to the patient's weight…and if it is night time, sometimes you have to wait, they do not consider it to be an emergency.”(FG3E18, 29 years, male)
Different treatment in each shift“Sometimes, you have a very sleepy patient or you have people throwing themselves out of the bed. Also, you know that in each shift, what one person prescribes, another will remove. Therefore you have patients who, on the same day may have tried 3 or 4 different drugs for delirium.”(FG2E10, 39 years, female)
Nurses’ demands “In the end, the nurses request a solution you they don't have, you don't know what to do, sometimes I have had to sedate a patient. During some shifts, you avoid the nursing station because you don't know what to tell them, there are no fast solutions, sometimes you have to be patient and wait, stay by the patient's side.” (FG4I4, 43 years, male)
Non-pharmacological treatment
Verbal restraint: distrust“At first, you try to explain, but soon you are left without any arguments and with no patience (…) I don't know if any of you have had any success, I don't know what you tell the patient, in what sort of tone, and when is the best time for doing so, but never in the 14 years I have worked in the ICU have I been successful, and I don't believe it works.” (FG1E3, 39 years, female)
Verbal restraint: conflicts with its application “It seems like you are “the odd one out”, just because you spend some time trying to get to know what is wrong with the disoriented patient, or you lose time trying to orient them, knowing these are people who are bothering the other patients.” (FG2E8, 27 years, female)
Mechanical restraint: indiscriminant use and most used remedy“Everyone got restraints. Nobody even considered that medical prescriptions were necessary.” (FG4I3, 52 years, male)
“In the end, when you don't know what to say to the patient, you end up using restraints, it is the last fix before pharmacological treatment, sometimes you use them while awaiting medical orders.” (FG3E14, 41 years, male)
Mechanical restraint: medical orders“As a nurse, you can't use restraints unless they are prescribed, but the doctor doesn't write this down either. In the end, it's the nurse who decides.” (FG2E11, 28 years, male)
Sleep management“Sleeping seems to be an impossible feat, the patient wakes up due to the noise of the machinery, noises made by other patients, or the high tone of our conversations” (FG2E9, 34 years, female)
Healthy vs hostile environment“It is complicated trying to convince colleagues to keep their voices down during the night, sometimes the laughter is impossible to contain.”(FG2E12, 35 years, male)
“If you try and put yourself in the place of the patient, all you feel is fear, you are surrounded by people who are strangers and everything beeps, it is impossible to rest.”(FG7I5, 43 years, male)
Early mobilisation“It seems simple, but to lift an intubated patient, with all the pumps, the monitor, all the cables, drainages, catheters and so on is not easy, nobody likes to do it, sometimes it is more risky to mobilise the patient than to wait for delirium to appear and then manage it…”(FG3E15, 35 years, male)
Theme: work organisation in the ICUDelirium and care during the night shift“Is it really necessary to wake the patient in order to take his temperature at three in the morning, or wake him up to administer sleeping medication?” (FG2E9, 34 years, female)
“…at night time, you are bothering patients every hour, either to take their temperature, or due to the urine, or for the medication, or for a scale (…) the patient is easily woken, gets scared, and ends up getting disoriented. This way of working does not favor the patient's rest or wellbeing.”(FG7E5, 38 years, female)
Absence of protocol and conflicts among nurses“There is nothing established, there are no protocols on favoring sleep, at times you have to confront your colleagues, and in the end, the easiest thing is to agree on which care measures are going to be applied during that shift.” (FG3E15, 35 years, female)
“There are no protocols, you have to be there 24 hours a day, working at full capacity, we do nothing to modify our acts, perhaps we are actually part of the problem, we are lacking protocols in order for all of us to work along the same lines.” (FG6I16, 52 years, male)
Group pressure“You know that the patient doesn't need his vital signs taken every hour, once a night would be enough, but if you want to be left alone and not be criticized you keep on noting down their vital signs every hour, although you waken the patient and know that he should really sleep.”(FG7E3, 27 years, female)
  • FG, focus group; ICU, intensive care unit.