Management of IManagement of a Care FacilityCU Delirium

1. Introduction

In the critical care setting, haemodynamic failure is recognised by monitoring the patient’s blood pressure and pulse and treatment may involve fluid resuscitation or the use of inotropic agents (Webb & Singer, 2005). In respiratory failure, the patient’s respiration rate and oxygen saturations are closely monitored and ventilatory support is sought (Cutler, 2010). Just like the heart and lungs, the b


Managers are tasked to create their organisation’s vision in such a way that it will aide in assuring future stability. This academic paper will discuss how an organisation’s vision is created, communicated and implemented and how this vision will pave the way for conceptualizing its strategic direction in a chosen residential home.

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The residential home care that was discussed in this paper is a home care that provides older adult services to about 60-70 residents with various geriatric needs. The residential home care is divided into units depending on the needs assessments made on each resident during their admission. There are about four nearby residential home cares providing the same services. The home care is the newest of the four and is gradually gaining recognition within the serviceable area. In its everyday operations, bulk of the employees consists of nurses and health care aides. Major problems faced by the organisation are the shortage of nursing staff along with the need to expand the business due to increase influx of clients being admitted.

The vision and its stakeholders

An organisational vision is a statement of what the organisation wants to do and hopes to become in the future (Nagelkerk, 2005). In creating a vision, it must first be congruent with mission and philosophy of the organisation and anchored on shared values and beliefs (Polifko-Harris, 2005). At the same time, the vision must be dynamic and motivational to its stakeholders because the vision is said to be meaningful only to those who are involved in its creation (Roussel, 2011; Thamm, 2011; Allen, 2007)

A stakeholder is a person or a group that takes strong interest on organisation (Kelly and Tazbir, 2013). In health care industries such as the residential home care, the stakeholders include the patients or clients, nurses, medical practitioners, insurers, administrators, and accrediting bodies (Kelly and Tazbir, 2013). In vision planning, consideration of the stakeholders and fostering a good relationship with them are very crucial as their involvement and engagement in the organisation can bring the vision into reality (Kelly and Tazbir, 2013; Malloch and Porter-O’Grady, 2010). They must be adequately represented as they are expected to support management initiatives and perform certain roles for fulfilling organisational success (Gantz, 2010; Harris et al, 2010). As Sare and Ogilvie (2010) say, nursing is a people-centered profession and thrives in involvement. The more we get to involve people to share in the organisational vision, there is higher likelihood that the vision will be put to reality.

Oftentimes, it is heard that only those in the middle and upper management make decisions and policies for the organisation. However, it is not only them who must be involved in creating the vision. In the chosen health care setting, the stakeholders include the elderly residents and their families, the nursing personnel and other employees, unit managers and supervisors and the board of directors. Feedbacks and perceptions of service users are crucial in service improvements. Thus, satisfaction of the elderly residents and their families must be solicited from them. Moreover, the people working for the company especially the nursing staff who provide direct nursing care must be considered. Nurse leaders need to make the employees committed to the organisation and gain ownership of its goals and objectives so that the vision can be brought to reality (McIntyre and McDonald, 2013). Nurses who are motivated and satisfied in their work are more likely to perform better that contribute to better patient outcomes (Potter et al, 2014). As mentioned, the home care is now facing a shortage of nursing staff which can affect their level of dedication and work quality (McGilton et al, 2013; Peng et al, 2013). This should be one of the things that must be considered if the management would want to make the nursing staff form a sense of ownership of the vision.

Factors that may impact the organisational vision

Aside from the stakeholders, there are influential factors that must be paid attention to if the organisation is to create a feasible vision. Intrinsic and extrinsic factors can be assessed using SWOT analysis (Kelly and Tazbir, 2013). These factors that need consideration include the areas of operation, finances, competition, changing needs of clients, technological advances, changing political climate, market conditions, economy, competition, current trends and issues in healthcare (Nagelkerk, 2005).

Organisational vision and strategic decision

In consideration of the characteristics of the residential home care, its stakeholders and other environmental factors, the created vision is written below:

“Our vision is to be the foremost residential home care for older adults in the community that promotes independence and higher quality of life through excellent and safe nursing care.

The next step would be to create the strategic direction for the organisation. In the strategic management process, the strategic direction is the long term goals and objectives of the organisation that outlines the purposes of the organisation and its operational scope (Enz, 2009). It must be anchored on the organisation’s mission and vision statements (Enz, 2009). In consideration of the strategic direction, the organisational competencies will be assessed together with surrounding environmental factors (Wilson, 2005). In developing the strategic direction, answers to the following questions will be sought with the help of the management and key stakeholders: 1) What are the expertise of the home care?; 2) What kind of home care will it be in three or five years?; 3) What type of population will we be serving?; 4) What additional functions or services are we going to provide given the evolving market?; 5) What are the technology requirements given the evolving market?; and 6) What changes are taking place in the internal and external market that will affect the home care? (Paley, 1999).

Communicating the vision

One of the qualities of a highly effective leader is the ability to make the people involved in the organisation understand and remain committed to the vision (Gill, 2011). Continuous and sustainable communication of the vision enables members to be clearly informed of the current status of the organisation and its future directions (Gill, 2011). When properly communicated, shared vision prospers and stakeholders will most likely understand their roles and responsibilities in realising the vision inspite of uncertainties and problems along the way (Papp, 2001). The created vision will be communicated by: 1) finding key persons who will motivate others to listen and be engaged in the vision; 2) setting-up a formal communication team who will disseminate the new vision through advertisements and staff education; 3) including the vision in marketing ads of the home care; 4) place posters containing the vision in strategic locations within the organisation; 5) spark conversations among people around about the new vision; 6) create activities such as contests that are themed based on the vision; 7) get other’s feedback and perception of the new vision through personal interviews and group discussions; and 8) use social media and other information-dissemination technology that will keep others informed and reminded of the vision (Center for Creative Leadership, Cartwright and Baldwin, 2011).

Right leadership for vision sharing

For the organisation to see the fulfillment of its vision, everyone with vested interest in it must work collectively through appropriate leadership and management behaviours. Making everybody feel that they own and share a common vision is a major focus of transformational leadership. According to Bass and Riggio (2006), leaders must appeal to the followers’ sense of self-worth to ensure their commitment and involvement in the entire efforts and activities of the organisation. Transformational leaders motivate their followers to always put their best in what they do, empower them by making them involved in crucial organisational activities, and allow them to expand their potentials and abilities (Bass and Riggio, 2006). Followers are able also to develop a strong sense of identification with the organisation that moves them to working and thinking not just to suffice their self-interests (Hutchinson and Jackson, 2012).In nursing, transformational leadership has been seen as a model of leadership that is enabling, empowering and suitable for nurses to remain committed to excellent and safe care practises (Lievens and Vlerick, 2014; Ross et al, 2014; Schwartz et al, 2011).

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To embed the vision to the followers, the leaders must employ the four components of transformational leadership. These are idealised influence, inspirational motivation, intellectual stimulation and individual consideration (Doody and Doody, 2012; Schwartz et al, 2011). In idealised influence, the leader must be seen by the followers as a role model (Doody and Doody, 2012). The manager of the home care must set an example by ensuring that all personal actions are in accordance with the vision. They must be the frontline communicator of the vision to the staff and be the first person to act when everyone is having difficulty fulfilling the vision (Doody and Doody, 2012). Inspirational motivation must also be applied by encouraging followers to always work to achieve organisational goals and objectives while at the same time achieving their own goals (Bally, 2007). Allowing members to participate in decision and policy-making exemplifies intellectual stimulation (Schwartz et al, 2011). For example, the nursing staff can be involved in projects and programmes that will be launched to achieve the vision and strategic direction of the home care. Lastly, leaders in the home care must be open to the individual needs of the followers by supporting them in their actions, giving them recognition for their efforts and allowing them to achieve professional growth (Schwartz et al, 2011). Rewards and incentives can be given to those staff who exceptionally performed to achieve the goals set by the home care. They may also be given opportunities for further trainings and in-service education to make them more competent. In turn, these activities can bring about better services and improved patient outcomes.

Organisational objectives

Organisational objectives are the prescribed actions that will be used to achieve and evaluate organisational goals (Kelly, 2011). Based on the vision, the following are the organisational objectives:

Our residential home care aims to:

  • Deliver client-centered and holistic care to our residents
  • Create a therapeutic environment for our clients
  • Provide compassionate, ethical, safe, caring and dependable nursing services
  • Commit ourselves to quality improvement and safety standards
  • Increase the services we provide based on our clients’ changing needs
  • Put the organisation and clients’ needs first before our own interests
  • Respect, value and empower people within the organisation
  • Support individual growth and opportunities
  • Increase stakeholders’ satisfaction
  • Move for organisational stability and viability

Strategic planning process

Strategic planning is the process of setting the future direction of the organisation through alignment of its mission and vision with its actions to achieve the desired outcomes (Feldman and Alexander, 2012). The strategic planning process that will be done follows Odiorne’s recommendations (as cited in Swansburg, 1996):

  • Gap analysis. This involves identification of the problems of the organisation in order to determine what the organisation wants to do about it in the future.
  • Examining extrinsic factors. Assess outside influences that contribute to the problems identified.
  • Enumerate the critical issues. From a pool of problems identified, select the most pressing issues and those which more likely create a high-impact on the organisation.
  • Ranking the important. Plan according to the most important issues for the organisation.
  • Decide. Decide on the issues by involving all key stakeholders.
  • Time and resource planning. Construct a time frame as to when the objectives should be met. This will also include identifying who will be responsible and the resources that will be needed.

Summary and Conclusion

Managing an organisation is never an easy task. It gets more difficult as the organisation becomes more complex and the needs of stakeholders continue to rise. Nurse managers and leaders must be able to consider all factors inside and outside of the organisation and every individual who has an interest to it. Leaders and managers must craft a well-defined and shared vision to make everyone involved in the organisation to remain committed and motivated towards fulfilling it. Such work will entail the need to adopt transformational leadership through idealised influence, inspirational motivation, intellectual stimulation and individual consideration.

With the new vision, it is likewise necessary to craft the strategic direction and objectives of the organisation. In doing so, leader-managers must be able to align these to the vision, mission, philosophy, and values of the organisation. When all of these are in place, the organisation can now move to making a strategic plan for the entire organisation.


rain can acutely fail in critical illness. An acute disturbance in brain function is recognised as delirium (Page & Ely, 2011). Historically, delirium was accepted by the medical and nursing community as an inevitable consequence of the ICU experience (Shehabi et al., 2008). More recently, delirium is beginning to gain acceptance as a serious condition in the adult intensive care unit (ICU) and early identification and timely treatment is essential so as to reduce the detrimental effects on patient outcomes (Arend & Christensen, 2009 & Boot, 2011).

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Nurses are well-positioned to not only detect discrete fluctuations in levels of consciousness but to also minimise modifiable risk factors and to prompt doctors to review the critically unwell adult (Page & Ely, 2011). However, there is a growing recognition that delirium in the ICU is misunderstood and underreported by health professionals and hence continues to cause cognitive dysfunction in affected patients (Wells, 2010). This introduction discusses delirium in adult patients hospitalised in the ICU; specifically nurses’ knowledge, attitudes, beliefs and current practices regarding ICU delirium, and presents the literature review problem, question and the aim and objectives.

The literature has used numerous terms interchangeably to describe cognitive impairment in the ICU. There are references to ICU psychosis (Justice, 2000), ICU syndrome (Granberg-Axèll, 2001), acute confusional syndrome (Tess, 1991), and acute brain failure (Lipowski, 1980; cited in Page & Ely, 2011, p. 6). The multiplicity of terms in the literature may explain why the condition has not received the degree of prioritisation it deserves (McGuire et al., 2000). The above expressions are gradually being superseded by a more widely accepted expression termed ‘ICU delirium’ (Boot, 2011).

Criteria set by the ‘Diagnostic and Statistical Manual of Mental Disorders’ (DSM-IV; American Psychiatric Association, 2000) describes delirium as a disturbance of consciousness (i.e. limited awareness of surroundings) and cognitive fluctuations (e.g. a memory deficit); the onset is over a short period of time and the syndrome is a consequence of a physiological condition. There are three subtypes of delirium; namely: hypoactive, hyperactive and mixed delirium. Page & Ely (2011) provide data on the prevalence of delirium: One in five adult patients hospitalised in the ICU develop delirium. A higher incidence occurs in ventilated patients (four out of five patients).

A considerable body of research is dedicated to the investigation of the adverse effects of delirium on patient outcomes. A prospective cohort study by Girard (2010) concludes that the duration of delirium in ventilated patients in the ICU is an independent predictor of cognitive impairment up to 1 year following discharge. This conclusion has far-reaching implications for the growing population of patients who are concerned about the preservation of cognitive function following hospitalisation during a period of critical illness. Similarly, Ouimet et al., (2007) used a prospective study design to conclude that delirium increased the risk of mortality in a population of 820 patients admitted to the ICU for a period of more than 24 hours. In addition to this, delirium was associated with an extended period of hospitalisation. The implementation of preventative measures, early recognition tools and the timely delivery of treatment may prove useful in the preservation of cognitive function in affected patients (Boot, 2011).

Although there are several assessment tools available for ICU patients, the National Institute for Health and Clinical Excellence (NICE, 2010) recommends the use of the Confusion Assessment Method for the ICU (CAM-ICU; Ely et al., 2001). The tool has high validity for detecting the delirious non-intubated patient (Ely, et al., 2001); however the symptoms of hypoactive delirium such as lethargy and drowsiness are not always recognised by the CAM-ICU (McNicoll et al., 2005).

The topic of this review was selected based on observations made in clinical practice; for example, it was witnessed that very few delirium assessments were being performed in the ICU and subsequent conversations with critical care nurses reinforced the perception that approaches to delirium monitoring in the ICU are inconsistent. In an attempt to address this clinical problem, the topic of ICU delirium was selected as the main focus of inquiry for the present research. So as to construct a relevant and well framed review question it was necessary to explore the literature pertaining to this clinical problem.

In a telephone-based questionnaire study conducted in the Netherlands (Van Eijk et al., 2008) it was concluded that 7% of the ICUs surveyed in this nationwide study routinely practiced delirium monitoring using a validated tool such as the CAM-ICU; despite the presence of international guidelines that advocate delirium assessment practices. Ely et al., (2001) states that very few institutions routinely practice delirium monitoring despite well-documented adverse effects associated with the syndrome. The implications of this are that timely diagnosis and the implementation of management strategies are prevented (Ista et al., 2014).

Boot (2009) proposes that nurses in the ICU may not have the appropriate level of knowledge to guide nursing practice. On the contrary, Wells (2012) states that a lack of knowledge may not fully explain why nurses do not engage in delirium monitoring and that the reason lies with the barriers to delirium as identified by Devlin et al., (2008) such as difficulties in assessing intubated patients. An alternative explanation is that nursing practices are based on the deep-rooted belief that delirium is an expected consequence of critical illness (Boot 2009). Undoubtedly, a lack of scientific attention given to the topic of ICU delirium may have contributed to a lack of general awareness (Page and Ely, 2011). In recent years, there has been a growing recognition in the literature and clinical practice that a change in attitude is required, which may need to be supported by educational efforts. Prior to introducing a change in attitude; it is first necessary to understand why so many nurses are failing to incorporate screening into their routine practice (Wells, 2010).

In an attempt to gain an improved understanding of the perceived barriers, beliefs, current practices and knowledge levels of critical care nurses, Devlin et al., (2008) identified nurses’ responses regarding delirium monitoring in the ICU using a questionnaire design. One of the main findings from this study was that nurses who did not routinely practice delirium monitoring were unaware that the syndrome was underreported and that delirium is characterised by fluctuating symptoms such as levels of consciousness. The study’s findings bring to attention a severe deficit in nurses’ knowledge relating to questions about delirium in the ICU. Mention should be made here of an important limitation of the study, that is, the results are only representative of 331 nurses in the Massachusetts area of North America. By employing a systematic search strategy to identify similar research, a synopsis of the level of support required to alleviate the clinical problem will be created (Aveyard, 2010). There appears to be no published evidence of an attempt to produce a systematic review that has explored critical care nurses’ responses in relation to delirium and delirium monitoring in the ICU. In light of this, the present review will explore this gap in research evidence at the level of a literature review in which a selected body of literature will be critically appraised.

1.1 The Review Question

‘What knowledge, practices and attitudes do critical care nurses have about delirium and its assessment in the ICU?’

1.2 Aim and Objectives

The aim of this review is to critically appraise primary research studies to reveal the knowledge, practices and attitudes of critical care nurses regarding delirium in the ICU and its assessment, whilst identifying implications and recommendations for clinical practice.

The following objectives describe the individual steps that will be undertaken as part of this review:

  1. To employ a systematic search strategy to retrieve primary research articles that are relevant to the research question as specified above, through the use of inclusion and exclusion criteria.
  2. To use appropriate databases and hand searching techniques to identify additional articles that are relevant to the research question and that meet the inclusion and exclusion criteria.
  3. To critically appraise the selected research articles using a validated appraisal tool so as to establish their research quality and reliability.
  4. To extract the findings from the selected articles so as to effectively answer the research question.
  5. To draw conclusions from the findings whilst discussing the limitations of the review and implications and recommendations for clinical practice.

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American Psychiatric Association. (2000) Diagnostic and statistical manual mental disorders. 4th ed. Washington DC: Author.

Arend, E. & Christenson, M. (2009) Delirium in the intensive care unit: a review. Nursing in Critical Care, 14 (6): 145-154.

Aveyard, H. (2010) Doing a literature review in health and social care. A practical guide. 2nd ed. London: Open University Press.

Boot, R. (2012) Delirium: a review of the nurse’s role in the intensive care unit. Intensive and critical care nurses, 28 (3): 185-189.

Cutler, J. (2010) Critical care nursing made incredibly easy. London: Lippincott Williams & Wilkins.

Devlin, J. W., Fong, J.J. & Howard, E.P. et al. (2008) Assessment of delirium in the intensive care unit: nursing practices and perceptions. American Journal of Critical Care, 17 (6): 555-566.

Ely, E.W., Inouye, S.K. & Bernard, G.R. et al. (2001) Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The Journal of the American Medical Association, 286: 2703-2710.

Girard, T.D., Jackson, J.C. & Pandharipande, PP. et al. (2010) Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38 (7): 1513-1520.

Granberg-Axèll, A., Bergdom, I. & Lundberg, D. (2001) Clinical signs of ICU syndrome/delirium: an observational study. Intensive & Critical Care Nursing, 17 (2): 72-93.

Ista, E., Trogrlic, Z. & Bakker, J. (2014) Improvement of care for ICU patients with delirium by early screening and treatment: study protocol of iDECEPTIVE study. Implementation Science, 9: 143.

Justice, M. (2000) Does ICU psychosis really exist? Critical Care Nurse, 20: 28-39.

Lipowski, Z. J. (1980) Acute brain failure in man. Springfield , IL: Charles C Thomas.

McGuire, B., Basten, C. and Ryan, C. et al. (2000) Intensive care unit syndrome, a dangerous misnomer. Archives of Internal Medicine, 160 (7): 906-909.

McNicoll, L., Pisani, M. & Ely, E. (2005) Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. Journal of the American Geriatrics Society, 53: 495-500.

National Institute for Health and Care Excellence (NICE) (2010) Delirium: diagnosis, prevention and management [online]. Available from: [Accessed 13 January 2015].

Ouimet, S., Kavanagh, B.P. and Gotfried, S.B. et al. (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine, 33 (1): 66-73.

Page, V. & Ely, E. W. (2011) Delirium in critical care (core critical care). Cambridge, UK: Cambridge University Press.

Shehabi, Y., Botha, J. A. and Ernest, D. et al. (2008) Sedation and delirium in the intensive care unit: an Australian and New Zealand perspective. Anaesth Intensive Care, 36 (4): 570-578.

Tess, MM. (1991) Acute confusional state in critically ill patients: a review. Journal of Neuroscience Nursing, 23: 398-402.

Van Eijk, M.M., Kesecioglu, J. & Slooter, A. J. (2008). Intensive care delirium monitoring and standardised treatment: a complete survey of Dutch intensive care units. Intensive and Critical Care Nursing, 24 (4): 218-221.

Webb, A.R. & Singer, M. (2005) Oxford Handbook of Critical Care. 2nd ed. Oxford UK: Oxford University Press.

Wells, L. G. (2010) Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature. Australian Critical Care, 25 (3): 157-161.



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