Cognitive Stimulation in an Intensive Care Unit: A Qualitative Evaluation of Barriers to and Facilitators of Implementation

Abstract

Background Delirium in the intensive care unit is associated with poor patient outcomes. Recent studies support nonpharmacological therapy, including cognitive stimulation, to address delirium. Understanding barriers to cognitive stimulation implemented by nurses during clinical care is essential to translating evidence into practice. Objective To use qualitative methods through a structured quality improvement project to understand nurses’ perceived barriers to implementing a cognitive stimulation intervention in a medical intensive care unit. Methods Data were collected through semistructured interviews with nurses in a medical intensive care unit. Data were categorized into themes by using thematic analysis and the Consolidated Framework for Implementation Research. During cognitive stimulation, nurses reviewed with patients a workbook of evidence-based tasks (focused on math, alertness, motor skills, visual perception, memory, problem-solving, and language). Results The 23 nurses identified 62 barriers to and 26 facilitators of cognitive stimulation. These data were summarized into 12 barrier and 9 facilitator themes corresponding to the following Consolidated Framework for Implementation Research domains: Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals. Nurses also identified several facilitators within the Process domain. Patient-specific variables, including sedation, were the most frequently reported barriers. Other barriers included cognitive stimulation not being prioritized, nursing staff–related issues, documentation burden, and a lack of understanding of, or appreciation for, the evidence supporting cognitive stimulation. Conclusions Implementation of cognitive stimulation requires a multidisciplinary approach to address perceived barriers arising from the organization, context, and individuals associated with the intervention, as well as the intervention itself.

ICU Delirium in Cardiac Patients

“…57 However, data on early cognitive exercise and interventions to prevent cognitive impairment in critically ill cardiac patients is limited. In one qualitative study, Parker et al 58 demonstrated many barriers to implementing early combined cognitive stimulation and goal-directed mobility performed by nurses in the medical ICU. In this study, nurses administered a workbook of evidence-based tasks to the patients at least once per shift, with tasks focused on math, alertness, problem-solving, and language.…”