Knowledge of Delirium among ICU Nurses in Saudi Arabia: A Cross-Sectional Assessment

1. INTRODUCTION

Delirium is an acute, fluctuating disturbance of consciousness, cognition, and attention, commonly observed among critically ill patients admitted to Intensive Care Units (ICUs). Globally, estimates indicate that it affects between 30% and 80% of ICU patients, particularly those who are mechanically ventilated or recovering from surgery, making its prevention and management a critical priority in ICU settings [1-3]. Beyond its high incidence, delirium is a strong predictor of poor clinical trajectories, including a threefold increase in mortality and long-term ICU-acquired cognitive impairment [4]. Despite its status as a quality-of-care indicator, recognition remains suboptimal. In particular, the hypoactive subtype, characterized by withdrawal and lethargy, is often missed, even though it comes with the highest risk of mortality due to its silent clinical presentation [3-5].

The etiology of delirium is multifactorial, involving predisposing factors such as chronic illness, cognitive impairment, and advanced age, together with precipitating triggers like infection, exposure to sedatives or other psychoactive drugs, electrolyte imbalance, and environmental stressors in the ICU [2, 4, 5]. This risk is further increased by limited family engagement, sensory deprivation, physical restraints, and sleep disruption [3, 5]. Diagnosing delirium is particularly challenging due to its fluctuating nature and overlap with other neurocognitive disorders, especially among mechanically ventilated ICU patients and those with hypoactive delirium. Historically, pharmacological interventions such as antipsychotics have been used for symptom control, but recent evidence suggests limited benefit and potential adverse effects, especially when used routinely [3, 4, 6]. Consequently, international guidelines increasingly emphasize non-pharmacological approaches as the foundation for delirium prevention and care [7, 8]. These include engaging family members in care, effective communication, minimizing sensory deprivation, cognitive stimulation, early mobilization, and optimizing sleep-wake cycles [1, 9-12].

To prevent complications, early detection of delirium is essential. Current ICU guidance emphasizes delirium as a core ICU outcome. It supports standardized monitoring with validated tools, alongside prevention/management strategies, thereby promoting its integration into routine ICU practice rather than treating assessment as optional [9]. Tools like the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are widely used to identify changes in consciousness or attention [3, 4, 6]. These tools rely on monitoring changes in mental status, attention, and consciousness, enabling healthcare providers to identify delirium early and initiate appropriate interventions. Nevertheless, their use remains inconsistent, with many ICU nurses reporting limited confidence in their effective application [11, 13-15].

ICU nurses play a central role in delirium care. Their continuous bedside presence enables early detection of cognitive changes and timely implementation of preventive measures [12, 16]. However, studies consistently show that ICU nurses have limited knowledge of delirium, particularly regarding the use of validated screening tools, recognition of hypoactive presentations, and identification of risk factors [17]. Similarly, Grover et al. [14] reported that most nurses had not received formal training in delirium and rarely prioritized its assessment. In Poland, Lange et al. [18] found that fewer than a fifth of ICU nurses routinely screened for delirium, citing a lack of institutional protocols and insufficient training as key barriers. A study in India concluded that although slightly more than three-fifths of nurses had average knowledge, few could demonstrate a robust understanding of non-pharmacological management [19]. These findings underscore the need for targeted education, as studies have shown that training can improve nurses’ ability to recognize and manage delirium, particularly hypoactive delirium, and to use standardized assessment tools effectively [20-23].

Previous Saudi research has assessed nurses’ knowledge of delirium across mixed acute-care settings [15]. However, evidence from Saudi Arabia remains limited regarding ICU-specific, domain-level assessments of the knowledge required for contemporary delirium care. Therefore, this study aimed to assess delirium knowledge among ICU nurses across five clinically relevant domains: general knowledge, clinical features, etiology and risk factors, management, and non-pharmacological interventions, central to early recognition and effective bedside prevention. By identifying specific domain-level gaps, this work identifies where education fails to translate into ICU expertise and provides a practical baseline for targeted, evidence-based ICU educational interventions in settings with a substantial burden of delirium.

2. MATERIALS AND METHODS

2.2. Setting and Samples

The study employed a total population sampling approach, targeting the full roster of ICU nurses (N = 143) working across the four adult intensive care units that represent all adult ICU services in Hail City, Saudi Arabia. This approach was selected because the eligible ICU nursing population was relatively small and accessible, allowing comprehensive assessment without selecting a subsample. Eligibility screening was conducted before recruitment. Based on predefined eligibility criteria, 20 nurses were excluded: those with less than 6 months of ICU clinical experience or those on extended leave during the data collection period. The six-month criterion was intended to include nurses who had completed their initial orientation period and gained sufficient exposure to routine ICU practice, while nurses on extended leave were excluded because they were not actively engaged in clinical care during the study period. Consequently, 123 nurses were eligible for inclusion, and all completed the questionnaire, resulting in 100% participation among the eligible population rather than the full roster of 143 nurses. A participant flow diagram illustrating eligibility screening, exclusions, recruitment, and inclusion in the final analysis is presented in Fig. (1). This near-census of the accessible workforce strengthens the sample's representativeness; however, the exclusion criteria may limit the applicability of the findings to newly appointed nurses and those temporarily absent from clinical practice.

3. RESULTS

4. DISCUSSION

This study aimed to evaluate nurses' overall knowledge of delirium and identify demographic and professional associations, using domain-level analysis to identify specific knowledge gaps. The findings suggest that nurses had relatively strong foundational knowledge, alongside lower scores in delirium management. Prior delirium training and ICU experience were significantly associated with total knowledge scores. In contrast, no significant associations were found between knowledge scores and demographic characteristics such as gender and age.

The present study identified a relatively high level of delirium knowledge among ICU nurses, evidenced by a mean total score of 25.4 ± 4.2 (72.6%). This level was higher than the average or intermediate levels reported in several previous studies. However, direct comparisons across studies should be interpreted with caution due to differences in measurement instruments, scoring systems, participant populations, and clinical settings. For instance, using the same Delirium Knowledge Questionnaire framework, Mathew et al. [19] observed that 61.6% of ICU nurses had only average knowledge, highlighting an urgent need for reinforced education on prevention and treatment. In the same vein, Xing et al. [28] found that more than half of their ICU cohort performed at an intermediate level, with “excellent” ratings remaining statistically rare. This knowledge deficiency extends beyond the ICU; Papaioannou et al. [29] reported a correct response rate of only 42.2% among general ward nurses regarding delirium definitions and identification methods. Within Saudi Arabia, Almoliky et al. [15] reported that only 7.3% of acute care nurses achieved a good level of knowledge, whereas 66.1% demonstrated poor overall knowledge. In addition, 78.2% had inadequate knowledge of delirium assessment, indicating a substantial gap in early recognition and systematic screening.

Although these local findings contrast with the present results, which indicated relatively high overall knowledge, domain-level analysis identified important areas of weakness. Most notably, the mean percentage score for Delirium Management (60.0%) was lower than the scores observed in the other knowledge domains. This finding may indicate that general understanding is stronger than knowledge of pharmacological and protocol-based management. The comparatively low management score is consistent with prior evidence of gaps in nurses’ knowledge of delirium prevention and management [10, 30], suggesting that although general concepts are grasped, the depth of clinical application remains insufficient for high-level critical care. Interestingly, this cohort demonstrated relatively strong knowledge of non-pharmacological management (75.6%), exceeding levels reported by Mathew et al. [19]. This finding also contrasts with that of Grover et al. [14], who reported that ICU nurses generally lacked awareness of non-pharmacological strategies. Given that only 26.8% of the current study sample had received previous delirium education, knowledge of interventions such as patient orientation and sensory stimulation may have been acquired through routine clinical exposure rather than structured education. However, this study did not assess actual bedside practice or the source of participants’ knowledge.

Previous delirium training was associated with higher total knowledge scores, with a large effect size (p < 0.001; Cohen’s d = 0.93). Despite the relatively high mean knowledge score of 73.2%, 73.2% of participants reported not having received formal delirium education, consistent with findings among Saudi acute-care nurses [15]. This pattern may suggest that informal clinical exposure could contribute to baseline knowledge; however, the study did not examine other potential sources of knowledge, such as self-directed learning, informal bedside teaching, or institutional protocols. Therefore, the coexistence of relatively high knowledge scores and limited reported formal training should be interpreted cautiously. Nevertheless, the higher scores among nurses who had received training support the value of structured delirium education [16, 18, 19, 28]. Previous studies have similarly indicated that education should extend beyond definitions to include bedside application, subtype recognition, assessment, and management planning [10, 30].

A notable finding was the non-linear association between professional experience and knowledge of delirium. Nurses with less than one year of ICU experience had a higher mean knowledge score than those with more than 15 years of experience. While the small size of the most senior subgroup (n = 4; 3.3%) precludes definitive statistical generalization, this trend suggests a potential 'recency effect.' It could indicate that recent graduates may be more attuned to current evidence-based guidelines integrated into modern nursing curricula. In contrast, senior staff may experience 'knowledge decay' in the absence of structured refreshers. Nonetheless, no definitive conclusions regarding a 'recency effect' or 'knowledge decay' can be drawn; the trend remains strictly exploratory. This finding contrasts with Christensen [17], who reported no significant association between experience and knowledge and highlighted a critical need to re-evaluate ongoing competency development for senior ICU staff to prevent knowledge decay.

Gender, age, education level, and job title were not significantly associated with total knowledge scores. Although Almoliky et al. [15] reported higher knowledge of assessment methods among female nurses, the present findings align with those of Grover et al. [14]. These results suggest that knowledge differences in this sample were not clearly explained by the measured demographic and professional characteristics. However, they should not be interpreted as evidence that such differences are absent in the broader ICU nursing population. Nevertheless, unit-wide education may help establish a consistent baseline of delirium knowledge among ICU nurses.

5. IMPLICATIONS

Based on the lower scores observed in delirium management and the association between prior training and higher knowledge, healthcare institutions may consider strengthening competency-based delirium education and reinforcing the use of validated delirium screening tools [13, 20-23]. Implementation could be coordinated by ICU nursing leadership in collaboration with nursing education and quality and patient safety teams. Delirium education could be incorporated into ICU orientation and reinforced through periodic education, audit and feedback, and clinical reminders, particularly when audits identify gaps in screening or management [31, 32].

Evidence from previous implementation studies suggests that multifaceted approaches, including education, reminders, local champions, and audit and feedback, can improve adherence to delirium-care practices [32, 33]. Simulation- and case-based learning may further support knowledge of delirium and assessment skills [34, 35]. In addition, structured approaches such as the ABCDE/ABCDEF bundle have been associated with improved delirium-related outcomes in critically ill adults by standardizing daily ICU routines, promoting lighter goal-directed sedation, and integrating non-pharmacological strategies such as early mobilization, sensory optimization, reorientation, and sleep regulation [36]. These recommendations should be interpreted as evidence-informed practice considerations, as the present study assessed knowledge only and did not evaluate clinical performance, implementation outcomes, or patient outcomes.

6. LIMITATIONS

This study has several limitations. It assessed self-reported theoretical knowledge rather than bedside performance or patient outcomes, and the cross-sectional design precludes causal inference. The use of a self-administered questionnaire may also have introduced response bias. Conducting the study in adult ICUs within a single Saudi city limits the generalizability of the findings, while excluding nurses with less than six months of ICU experience and those on extended leave may have introduced selection bias. Regrouping the Delirium Knowledge Questionnaire items and adding an “I don’t know” response option may limit comparability with studies using the original format. Finally, the small subgroup of nurses with more than 15 years of experience means that findings involving this group should be interpreted as exploratory.

CONCLUSION

ICU nurses demonstrated relatively high overall knowledge of delirium, although knowledge was lower in the delirium management domain. Previous delirium training and years of ICU experience were significantly associated with total knowledge scores. These findings highlight areas that may benefit from targeted continuing education and further evaluation of delirium assessment and management practices. Because of the cross-sectional design and the small sample sizes in some experience subgroups, the observed associations should be interpreted with caution.

REFERENCES