Delirium in the Intensive Care Unit: influences on constructions past and present – a genealogical analysis

Background Delirium is an acute failure of normal brain functioning that, in the Intensive Care Unit (ICU), is recognised to be a serious and prevalent condition, being found to occur in 20-80% of ICU patients. ICU delirium has been shown to be a significant, independent predictor of a range of negative clinical outcomes including increases in: mortality, length of stay in ICU, length of stay in hospital, likelihood of discharge to a facility providing skilled care, and risk of long-term ‘dementia-like’ cognitive decline. Despite increasing evidence regarding the potential impact of delirium in the literature, and the availability of a validated assessment tool for use with intubated patients (CAM-ICU) since 2001, it is recognised that the implementation of routine testing in ICUs has been slow to develop. Furthermore, there is currently a significant paucity of literature that has examined how ICU staff in the UK think about delirium. There is a lack of any large-scale study that has included nurses’ knowledge and perceptions of ICU delirium in England. The research aimed to provide an insight into the factors that may influence how ICU staff think about delirium in their patients, taking into account the historical context as well as current perspectives. To address the research aim, five objectives were identified: 1. Critique the current literature on how ICU staff think about delirium, including their knowledge of delirium and their knowledge and attitudes toward delirium assessment. 2. Carry out a survey of ICU nurses and doctors in the UK, investigating their knowledge of and attitudes towards delirium and its assessment. 3. Carry out a Foucauldian genealogical analysis of the evolution of the definition of delirium in the Diagnostic and Statistical Manual (DSM) produced by the American Psychiatric Association (APA) from 1952-2013. 4. Synthesise the study findings with the Foucauldian genealogical lens, to provide a unique insight into potential influencing factors on ICU staff’s thinking about delirium. 5. Disseminate the insights that emerge and recommendations from these findings to the Critical Care practice community and Critical Care nursing course students and education policy makers ii Methods A survey design was implemented to address the second objective and was completed by 650 nurses and doctors working in UK ICUs. The third objective was addressed through a Foucauldian genealogical analysis of the evolution of the Diagnostic and Statistical Manual (DSM), published by the American Psychiatric Association (APA) and its definition of delirium from 1952 until the present time. A Foucauldian lens was then applied to the wider evaluation and discussion of findings from both strands of data, in order to afford a new perspective and unveil a unique insight into the topic area. Findings Findings demonstrated that there is still some evidence of the ‘disconnect’ shown in previous literature. Practioners’ recognition of the severity of delirium, and their wider knowledge of it and their assessment practice, is still limited. The genealogical analysis of the DSM revealed a classification manual whose evolution has a history of politically-driven development. It has been challenged and criticised for the lack of an objective underpinning rationale for its structure. Consideration of these data through a Foucauldian lens revealed potential power formations operating in both the current and historical context. A model is proposed setting these power formations within an over-arching context of an ‘Epistemic Dissonance of Mind-Body dualism’