Assessing ICU Nurses' Knowledge of Delirium in Palestine: A Cross-Sectional Study

Abstract

Background Delirium in the intensive care unit (ICU) is a serious condition that significantly increases both mortality and morbidity. It is strongly associated with longer hospital and ICU stays, higher mortality rates, and more complications. The development of delirium in critically ill patients is one of the most important independent predictors of prolonged hospital stays and increased risk of mortality. The purpose of this study was to assess the current knowledge levels of ICU nurses in Palestine about ICU delirium.

Methods A cross-sectional study with nonprobability convenience sample method was used. The level of ICU delirium knowledge was evaluated using a questionnaire.

Results The results showed that the median knowledge score of ICU nurses regarding delirium was 6 out of 21, ranging between 3 and 13. This indicates a very low level of knowledge, as 96.4% of nurses scored between 0 and 11. Only 3.6% of nurses scored within the low knowledge range (12–14), and no nurses reached the moderate (15–17) or high (18–21) categories. All nurses had a positive perception of the importance of the ICU delirium assessment tool, as 71.9% of nurses think that the ICU delirium tool is very important. In comparison, the rest of the nurses (19.3%) reported it as an essential tool. Unfortunately, about 44% of ICU nurses were unaware of an assessment tool for ICU delirium. The most commonly heard tools for assessing ICU delirium were the Confusion Assessment Method for the ICU (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) tools (29.8 and 29.8%, respectively).

Conclusion In conclusion, the ICU nurses had limited awareness about ICU delirium, highlighting a significant knowledge gap. It is essential to address this gap through targeted education and training programs aimed at enhancing nurses' knowledge and skills. In conclusion, targeted training and education programs are crucial to equip ICU nurses with the necessary knowledge to recognize, prevent, and manage delirium effectively, ultimately leading to improved patient care outcomes.

Keywords

delirium - ICU - nursing knowledge - Palestine

Introduction

The intensive care unit (ICU) is a potentially pathogenic environment for critically ill patients, and thus critically ill patients are at risk of mental disturbances due to a variety of distressing factors, including medical illness on admission, pain, and anxiety resulting from surgery and other invasive procedures. Furthermore, mechanical ventilation (MV), hypotension, hypoxia, metabolic disturbances, restrictions, and environmental factors (such as light and noise) disrupt the patient's natural sleep cycle, which can lead to a lot of psychotic disorders such as delirium.[1] ICU delirium is a common and severe neurocognitive disorder affecting critically ill patients, significantly increasing morbidity and mortality .The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), defines delirium as an attention disturbance, a change in cognition that develops over a brief period of time, and a fluctuating course supported by the patient's medical history, physical examination, and laboratory results.[2] According to psychomotor behavior, delirium can be classified into three motoric subtypes: hyperactive delirium (characterized by agitation, aggression, hallucinations, and disorientation), hypoactive delirium (characterized by sedation, motor slowness, lethargy, and withdrawal from interactions), and mixed delirium (fluctuation between hypoactive and hyperactive subtypes).[3] [4] [5] Although the form of delirium that is most frequently identified outside the ICU is hyperactive delirium, the hypoactive and mixed types are more frequently seen there.[6] Many patients in the ICU experience hypoactive delirium, which is often subtle and can delay diagnosis, potentially leading to worse outcomes than hyperactive delirium. The rate of critically ill patients who experience delirium is 20 to 40%, and it can reach 60 to 80% among those on MV. ICU delirium with hyperactivity, which makes up about 23% of cases, is characterized by agitation, restlessness, emotional instability, and positive psychotic traits like hallucinations—illusions that frequently obstruct the provision of care. On the other hand, confusion, sedation, apathy, decreased responsiveness, slowed motor function, withdrawn attitude, lethargy, and sleepiness are typical symptoms of hypoactive delirium. The most typical type, which makes up about half of all cases, is mixed delirium, which exhibits a fluctuation of the two forms of hypoactive and hyperactive features.

There are two types of risk factors pertaining to delirium, nonmodifiable factors, and modifiable risk factors. The modifiable factors are ones that originate in the ICU, while nonmodifiable factors are those that are already present before the patient is admitted to the hospital. The entanglement of delirium lies in the fact that nonmodifiable and modifiable risk factors interact with one another in a multitudinous way to influence the effects and outcomes.[7] The most prevalent nonmodifiable factors are aging, dementia, functional disabilities, male gender, poor vision, and hearing and mild cognitive ailment. The most common precipitating factor for delirium is the aftereffect of medications, accounting for 39% of delirium cases, particularly psychoactive and cholinergic drugs. A 2022 study on risk factors for delirium in COVID-19 patients found that antipsychotics, cholinergic medications, acetaminophen, baricitinib, prednisolone, and sulfamethoxazole/trimethoprim were independent risk factors for delirium in this patient population.[8] Other studies conducted in 2023 maintained that medication exposures increase the risk of delirium.[9] [10]

Other precipitating factors are operations, anesthesia, untreated pain, infections, hypoxia, acute illnesses, and an acute aggravation of chronic illnesses.[7]

Delirium symptoms are difficult to distinguish and frequently mistaken with other conditions due to the delirium's fluctuating course and the complexity of ICU care. Thus, delirium is challenging to diagnose, so it may need the combined results of many tests.[6] The most commonly used delirium monitoring scales recommended by the CCM include the Confusion Assessment Method for the Intensive Care Unit (CAMICU)[7] and the Intensive Care Delirium Screening Checklist (ICDSC).[11] Only patients who respond to voice commands can be assessed for delirium; however, since most ICU patients are under sedation due to MV, it is necessary to use a scale to measure sedation or impaired consciousness. Sedation assessment precedes delirium assessment to ensure accurate results. Two such scales are the Richmond Agitation and Sedation Scale (RASS) and the Sedation and Agitation Scale (SAS).[12]

Delirium in the ICU represents a recurring problem that affects seriously ill patients, which can increase mortality rate, spread of the disease, and prolonged ICU stay, which will in turn delay some cases from receiving appropriate treatment and increase the financial cost. Therefore, it is very important for ICU nurses to be knowledgeable about delirium, enabling them to diagnose, evaluate, and treat delirium early by pharmacologically or nonpharmacologically.[2] Early identification is advantageous for therapy and can shorten the delirium's length and lessen its negative effects. Despite the fact that delirium screening is a common practice in many institutions, up to 72% of delirium episodes go unnoticed or receive an incorrect diagnosis.[13] [14]

In the absence of specific training programs in Palestine to improve nursing comprehension of delirium symptoms and assessment techniques, ICU nursing management usually assigns seasoned nurses without routinely evaluating their delirium expertise. Studies in other regions have shown that targeted training programs significantly improve nurses' ability to detect and manage delirium, leading to better patient outcomes.[2] The ICU has fewer nurses than patients, which limits the amount of time available for delivering high-quality care and adds to the workload of nurses in this demanding setting. In addition, the political climate puts a great deal of strain on the workforce. The particular health care environment in Palestine, which is characterized by scarce resources, unstable political conditions, and difficulties obtaining training, makes matters worse. Finding knowledge gaps and putting focused training in place are vital and this study attempts to evaluate the knowledge levels of ICU nurses in Palestine, which may affect their ability to identify and treat delirium.

Objectives

The purpose of this study was to assess the current knowledge levels of ICU nurses in Palestine about ICU delirium

Methods

Study Design

A cross-sectional design was used to determine the ICU nurses' level of knowledge about ICU delirium.

Sample and Sampling

A nonprobability convenience method was used to choose the participants, and the sample size was determined using G-power version 3.1.[15] Statistical test of paired sample t-test with an effect size of 0.5, alpha error probability of 0.05, and 1-beta probability of 0.80 was used to calculate the sample size, which came to be 120 ICU nurses. The sample was adjusted to be 150 after accounting for the 15% attrition rate. The study only included registered nurses who had spent more than a year providing care in the ICU (surgical or medical).

Site and Setting

The study took place at Palestine hospitals: Al-Watani Hospital (ICU and CCU), An-Najah National University Hospital (SICU, MICU, ICU, and CCU), Al-Arabi Specialized Hospital (ICU and CCU), Nablus Specialized Hospital (ICU), Rafidia Hospital (ICU), and Darwish Nazzal Hospitals (CCU).

Data Collection Procedure

Upon obtaining the required ethical approval, the researchers visited the above-mentioned sites and informed them about the study. Those ICU nurses who expressed interest in participation were approached by the researchers. The purpose of the study and its significance were explained. The study participants were reassured that there would be no direct or indirect harm. The questions asked during and after completion of the questionnaire were answered.

Instrument

The ICU nurses' knowledge about delirium in ICU was assessed using a questionnaire. The instrument consists of demographic data: gender, age, and educational level. This was followed by 21 multiple-choice questions about ICU delirium knowledge and four questions about delirium assessment using the CAM-ICU. Initially, a pilot study was conducted to test the reliability of the selected tool, as utilized in a recent study conducted in Saudi Arabia in 2023.[2] The participants got 1 point for each correct answer. A score of 18 to 21 indicates a high level of knowledge about delirium. A score of 15 to 17 indicates a moderate level of knowledge about delirium. A score of 12 to 14 indicates a low level of knowledge about delirium. A score of 0 to 11 indicates a very low level of knowledge about delirium.[2] The scoring categories (0–11 = very low, 12–14 = low, etc.) were defined based on the distribution of scores observed in the sample and aligned with similar scoring systems used in previous studies assessing knowledge levels among health care professionals. For instance, studies such as Aldawood et al[2] and Echeverría et al[15] have categorized knowledge levels into similar ranges to facilitate interpretation of results and highlight areas requiring intervention. Categorization provides a clear framework to differentiate between varying levels of knowledge, enabling targeted educational strategies.

The questionnaire was administered in the paper-based format during work hours in the ICU.

Inclusion Criteria

Only registered nurses with greater than 1 year of ICU experience at the Al-Watani Hospital (ICU and CCU), An-Najah National University Hospital (SICU, MICU, ICU, and CCU), Al-Arabi Specialized Hospital (ICU and CCU), Nablus Specialized Hospital (ICU), Rafidia Hospital (ICU), and Darwish Nazzal Hospitals (CCU) were included in the study.

Exclusion Criteria

• Non-ICU nurses.

• Registered nurses with less than 1 year of ICU experience.

• The ICU nurse who refused to participate.

Validity

The content validity of the questionnaire was assessed by seven experts, including four faculty doctors and three experienced ICU nurses. These experts evaluated each of the 21 items for relevance, clarity, and coverage of the topic. A standardized validation process was followed, where experts provided structured feedback on each item's content and format. Their suggestions were incorporated to refine the questionnaire, ensuring that it adequately measured the ICU nurses' knowledge about delirium. The use of multiple experts with diverse expertise provided a robust basis for establishing content validity.

Reliability

The reliability of the questionnaire was determined by assessing its internal consistency using Cronbach's alpha, which yielded a value of 0.80. This indicates good reliability, demonstrating that the items within the questionnaire are consistently measuring the same construct (knowledge about ICU delirium). Cronbach's alpha is a widely accepted statistical measure for reliability, and a value of 0.80 is considered acceptable in most social and health science research.

Statistical Analysis

Data were coded, entered, and analyzed by using SPSS version 25.

Ethical Consideration

The study was conducted in full adherence to the ethical guidelines established by the Declaration of Helsinki and the local Institutional Review Board (IRB) at An-Najah National University. Permission for the study was granted by the IRB (No: Nsg.Oct 2023/20). Confidentiality was maintained by collecting no participant names, assigning sequential numbers for data analysis, and ensuring the anonymity of the participants. Data were collected for research purposes only, and participation was completely voluntary. Participants were informed that they could withdraw from the study at any time without providing a reason, and they would be able to view the study's results once it was completed. The study adhered to all ethical standards specific to ICU settings, ensuring the protection of participants' rights throughout the research process.

Results

The study included 150 ICU nurses, with the majority being males (71.9%) and predominantly young, aged between 20 and 29 years (54.4%). Most participants held a bachelor's degree (73.7%), highlighting a relatively high educational level among the sample. A smaller proportion of nurses had a diploma (10.5%) or a master's degree (15.8%). These demographics suggest a workforce with foundational academic qualifications, but with potential gaps in specialized training related to ICU delirium (see [Table 1]).

Table 1 Demographic characteristics of participants

Demographics data		N	Percent
Age (y)	20–29	82	54.4
	30–39	55	36.8
	40–49	8	5.3
	50–59	5	3.5
Gender	Male	108	71.9
	Female	42	28.1
Education	Diploma	15	10.5
	Bachelor	111	73.7
	Master	24	15.8

The results showed that the median score for ICU nurses' level of knowledge about delirium was 6 out of 21, with a range between 3 and 13. This score falls within the 0 to 11 range, representing the “very low knowledge” category, which accounted for 96.4% of nurses. Such a low median score places the majority of nurses in the lowest percentile, highlighting a significant knowledge deficit. This reflects the urgent need for targeted educational programs to improve nurses' understanding and management of delirium in ICU settings, ensuring better patient outcomes (see [Table 2]).

Table 2 Intensive care unit (ICU) nurses' level of knowledge about ICU delirium

Level of knowledge	Median	Range
Total	6	3–13
	Level	Percent
Very low	0–11	96.4
Low	12–14	3.6
Moderate	15–17	0.0
High	18–21	0.0

According to [Table 3], there was no statistical significance between the level of ICU delirium knowledge and the nurses' demographic data (p > 0.05). However, while no statistically significant differences were found, the trend of lower knowledge scores among diploma holders compared to those with a bachelor's or a master's degree suggests the need for targeted educational strategies to address this gap. Specifically, those older than 50 years had the lowest median level of knowledge (3.5 out of 21), and despite no difference in gender, nurses with a master's degree had the highest median level of knowledge about ICU delirium. These trends emphasize the importance of focusing on educational interventions for nurses with lower qualifications to improve their knowledge and management of ICU delirium (see [Table 3]).

Table 3 Association between delirium knowledge score and ICU nurses' demographic characteristics

Demographics data		Median (range)	Sig.
Age (y)	20–29	7 (3–12)	KW = 0.162, p = 0.300
	30–39	6 (3–13)
	40–49	8 (5–8)
	50–59	3.5(3–4)
Gender	Male	6 (3–13)	MW = 0.720, p = 0.963
	Female	6 (5–12)
Education	Diploma	5 (3–11)	KW = 0.128, p = 0.164
	Bachelor	6 (3–12)
	Master	8 (3–13)

Abbreviations: ICU, intensive care unit; KW, Kruskal–Wallis test; MW, Mann–Whitney U test.

According to [Table 4], most ICU nurses recognize the importance of delirium assessment tools, with 71.9% of them considering the ICU delirium tool to be “very important” and 19.3% considering it “essential.” However, nearly half of the ICU nurses (44%) were unaware of the existence of any formal assessment tools for ICU delirium. Among those who were aware, the most commonly recognized tools were the CAM-ICU and ICDSC tools, each mentioned by 29.8% of nurses. Other tools, such as Delirium Detection Scale (DDS) and Nursing Delirium Screening Checklist (NuDESC), were less commonly known, with only 3.5% and 1.8% of nurses reporting familiarity with them, respectively. Despite the positive perception, the actual use of these tools was limited, as 35.1% of nurses reported never using a formal delirium assessment tool in the past month.

Table 4 Nurses' perception about the importance, type, and usage of delirium assessment

		N	Percent
Nurses perception about the importance of delirium assessment	Not important	0	0
	Important	13	8.8
	Very important	108	71.9
	Essential	29	19.3
Have you heard of any formal test of delirium applicable to the ICU	Yes	84	56.1
	No	66	43.9
Which test have you heard of?	CAM-ICU	45	29.8
	ICDSC	45	29.8
	DDS	6	3.5
	NuDESC	3	1.8
	Not heard of any test	53	35.1
Did you use a formal test of delirium when you made your assessment over the last month?	Always	16	10.6
	Often	39	19.3
	Sometime	40	26.3
	Rarely	13	8.8
	Never	53	35.1

Abbreviations: CAM-ICU, Confusion Assessment Method for the ICU; DDS, Delirium Detection Scale; ICDSC, Intensive Care Delirium Screening Checklist; NuDESC, Nursing Delirium Screening Checklist.

Discussion

The study aimed to assess the knowledge level of ICU nurses regarding ICU delirium. The results indicated a generally very low level of knowledge among the participants, as 96.4% of nurses' scores were in the very low category (0–11 out of 21) on the ICU delirium knowledge assessment. This finding is consistent with previous studies that have highlighted the knowledge gap among ICU nurses about delirium, particularly concerning its identification and management.[1] [16] According to a study by Lee et al[17] on the knowledge, barriers, and training needs of 71 ICU and ward nurses, ICU nurses reported a lower overall knowledge level compared to ward nurses regarding delirium care.

The low scores on questionnaire about the characteristics of delirium, risk factors, and the use of assessment tools suggest a critical need for improved education and training. Understanding the knowledge levels of ICU nurses regarding delirium is crucial for several reasons; delirium is a common and serious condition in critically ill patients that is associated with increased morbidity, mortality, and health care costs.[15] Therefore, early identification and management of delirium can significantly improve patient outcomes, including reducing the length of ICU stay and preventing long-term cognitive impairment.[2] Furthermore, the study's findings highlight a significant gap in the current knowledge base of ICU delirium knowledge assessment among ICU nurses, which, if addressed, could enhance patient care and outcomes in the ICU. Also, the results of this study provide new insights into the specific areas where ICU nurses lack knowledge on the ICU delirium assessment. Notably, a substantial number of nurses were unfamiliar with formal assessment tools like the CAM-ICU and ICDSC, which are essential for the early and timely diagnosis of delirium.[11] Furthermore, the confusion between terms like ICU psychosis and delirium and the lack of understanding of the risk factors and symptoms underscore the need for targeted educational interventions.

ICU psychosis is commonly defined as a cluster of psychiatric symptoms, which may also be referred to as delirium. It is characterized as an acute dysfunction of the brain presenting with psychiatric symptoms in patients who have no prior history of mental health disorders. Patients who experience ICU psychosis are typically in the hospital or ICU due to a significant illness, either from an acute onset of illness or from a chronic disease with an acute or chronic manifestation, such as the exacerbation of chronic obstructive pulmonary disease and in a lot of studies they considered ICU psychosis as a type of delirium.[18] [19]

These insights can inform the development of comprehensive training programs tailored to bridge these knowledge gaps. The results of this study are consistent with global trends, highlighting the significant knowledge gap among ICU nurses regarding delirium. However, there are unique factors in Palestine that contribute to this knowledge deficit. ICU nurses in Palestine face heavy workloads, especially due to the ongoing political situation and frequent conflicts. As a result, ICU departments are always busy, and nurses are responsible for caring for many critically ill patients at the same time, some of whom may experience delirium. Additionally, the relationship between ICU nurses and patients in Palestine is not governed by international standards, which may limit the quality of care provided.

The discussion of the study's findings is closely tied to the literature reviewed in the introduction. Previous research has consistently shown that delirium in the ICU is underdiagnosed and poorly managed due to inadequate knowledge and training among health care providers.[17] [20] A recent quantitative study conducted among 145 ICU nurses in Ireland in 2024 yielded similar results: many ICU nurses and clinicians are not well versed in the early signs and symptoms of delirium, leading to delayed diagnoses and improper interventions. This knowledge gap contributes to increased patient morbidity, prolonged ICU stays, and long-term cognitive impairments. Efforts to improve education on delirium management, such as specialized training and the use of formal assessment tools, are essential to bridge this gap and enhance patient outcomes[21]

In addition to the heavy workload, ICU nurses in Palestine do not receive formal educational programs related to delirium management. There is a lack of continuous training or specialized programs provided by hospitals or universities, which affects nurses' ability to recognize, assess, and manage delirium effectively. Due to limited financial support, there are no regular educational courses or workshops on delirium assessment tools, such as those used in this study. Also, time constraints make it difficult for nurses to properly assess and treat delirium. These local factors emphasize the urgent need for targeted, practical, and accessible educational interventions to bridge the knowledge gap and improve care in Palestinian ICU settings.

The current study reinforces these findings and extends them by providing specific data on the knowledge deficiencies among ICU nurses in Palestine. This aligns with global trends and suggests that similar challenges are present across different health care settings. The significant results, particularly the low knowledge scores, were somewhat expected given the literature. However, the extent of the knowledge deficit—96.4% scoring very low—was particularly striking. This result emphasizes the urgency of implementing educational interventions. The finding that nurses' knowledge did not significantly correlate with demographic factors such as age, gender, or education level suggests that the issue is pervasive and not limited to any specific subgroup of nurses. This indicates that broad-based educational initiatives are necessary rather than targeted interventions.

We recommend incorporating routine training on delirium assessment tools such as CAM-ICU and ICDSC into ICU orientation programs for new nurses to improve early delirium diagnosis and management. Additionally, regular training workshops should be organized for ICU nurses, focusing on the latest delirium diagnosis and management methods. These workshops should be accessible to all ICU nurses regardless of their educational background. Palestinian universities offering nursing programs should integrate delirium-related topics as part of their core curricula to equip graduates with the skills needed for ICU delirium care. Strengthening collaboration between hospitals and universities for continuing education on delirium management is crucial, with lectures and workshops to raise nurses' knowledge levels. Local health care institutions should also seek financial support from government bodies and international organizations to fund ongoing educational courses for ICU nurses. Moreover, future research should focus on developing standardized guidelines for delirium assessment in ICU settings, particularly in countries like Palestine, and assess the effectiveness of various assessment tools like CAM-ICU and ICDSC. Studies should investigate how familiarity with these tools impacts delirium recognition and patient outcomes, and examine barriers to their implementation due to ICU nurses' workload and lack of formal training. Furthermore, research should evaluate different educational programs, such as workshops, online courses, and simulation training, to enhance ICU nurses' knowledge and competency in delirium management.

Conclusion

ICU delirium is a common and undesirable condition in critically ill patients, leading to serious consequences such as an increased risk of death, prolonged ICU stays, higher medical costs, and reduced quality of life. This study, the first of its kind in Nablus, Palestine, supports existing knowledge about critical care nurses' understanding of ICU delirium, revealing that nurses lack adequate knowledge on this condition. In conclusion, the study highlights a critical knowledge gap among ICU nurses regarding ICU delirium, which has significant implications for patient care. It is essential to address this gap through targeted education and training to improve the detection and management of delirium in ICU settings. By enhancing nurses' knowledge and skills, health care institutions can ensure better patient outcomes and more efficient use of health care resources. Implementing training programs specifically focused on ICU delirium assessment can bridge the identified knowledge gap and enhance patient care. Future studies could evaluate the effectiveness of educational programs on ICU delirium knowledge retention and their impact on patient outcomes. This would provide valuable insights into the long-term effectiveness of these interventions.

Limitations and Future Research

This study had some limitations, including its cross-sectional design and reliance on self-reported data, which could introduce bias and limit the accuracy of the findings. Observational studies could address this limitation by providing a more accurate representation of nurses' actual knowledge, practices, and challenges in delirium management. Future research should also assess the impact of educational interventions on ICU nurses' knowledge about ICU delirium and patient outcomes. Furthermore, qualitative studies could provide deeper insights into the barriers nurses face in diagnosing and managing delirium, thereby informing more effective educational strategies.

Conflict of Interest

None declared.

Acknowledgments

The author(s) would like to thank An-Najah National University (www.najah.edu) for the technical support provided to publish the present manuscript. Special thanks also go to all the nurses.

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Publication History

Article published online:
25 April 2025