European Journal of Cardiovascular Medicine

Intensive Care Unit (ICU) psychosis, often referred to as ICU delirium, is a complex neuropsychiatric syndrome characterized by sudden changes in consciousness, orientation, cognition, and perception among critically ill patients. It presents a significant challenge to patient care in ICUs, with prevalence rates ranging from 20% to over 80% depending on patient populations and diagnostic criteria used [1]. ICU psychosis is not only associated with prolonged hospital stays, increased morbidity and mortality, and elevated healthcare costs, but it also contributes to long-term cognitive impairment and psychological distress among survivors [2].

The etiology of ICU psychosis is multifactorial, encompassing environmental stressors such as sleep deprivation, sensory overload, and social isolation, as well as physiological factors like hypoxia, metabolic disturbances, infections, and the use of sedatives or analgesics [3]. Given the high-risk nature of ICU environments and the vulnerability of critically ill patients, early identification and prompt management of ICU psychosis are critical components of holistic intensive care. Nurses, being at the frontline of patient care in ICUs, play a pivotal role in the surveillance, prevention, and management of this condition [4]. Their knowledge and clinical practices directly influence outcomes, making them central to any intervention strategy aimed at mitigating ICU psychosis.

Despite the central role of nursing staff, studies have shown a persistent gap in knowledge and practice related to ICU psychosis among nurses, particularly in areas such as symptom recognition, non-pharmacological interventions, and the judicious use of sedative medications [5]. This gap is more pronounced in settings with limited training opportunities, high patient loads, and inconsistent protocols. Addressing this deficit through planned, structured teaching programs can enhance nurses' competency, encourage evidence-based practice, and improve patient outcomes. Planned teaching interventions offer a focused and systematic approach to education that facilitates retention, confidence, and the translation of knowledge into practical care [6].

Furthermore, such educational interventions are aligned with the goals of modern nursing education, which emphasize continuous professional development, critical thinking, and collaborative care. In many healthcare institutions, planned teaching sessions have demonstrated positive effects on nursing performance in various domains, including infection control, pain management, and emergency response preparedness. Applying this model to the domain of ICU psychosis could thus yield significant benefits. Moreover, planned teaching enables the use of multimodal strategies—lectures, case studies, simulations—which cater to diverse learning styles among nurses and foster better understanding and application of knowledge [7].

This study is undertaken in selected hospitals of Mumbai to assess the existing knowledge and practices of staff nurses regarding ICU psychosis and to evaluate the impact of a structured teaching program. The findings aim to contribute to the enhancement of nursing education, promote better clinical practices, and ultimately improve patient outcomes in ICUs. The aims of the study are to assess the knowledge and practices of staff nurses regarding ICU psychosis management before and after planned teaching, compare these between private and government hospitals, and determine their relationship with age.

Type of study: Descriptive observational study.

Place of study: The sample consisted of fifty staff nurses working in ICUs of hospitals, out of which twenty-five staff nurses were taken from KEM ICU and the remaining twenty-five staff nurses were taken from Bhatia Hospital ICU of Mumbai.

Study duration: 23^rd of July 2015 to 8^th August 2015.

Sample size: The sample size from your description is 50 staff nurses (25 from KEM ICU + 25 from Bhatia Hospital ICU, Mumbai).

Inclusion Criteria:

• Staff nurses working in the ICU of selected hospitals in Mumbai.
• Nurses available during data collection.
• Nurses willing to participate in the study.

Exclusion Criteria:

• Staff nurses not posted in ICU.
• Nurses on extended leave or unavailable during the study.
• Nurses unwilling to participate.

Statistical Analysis:

Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Distribution of Demographic Data ICU Nurses in Private vs. Government Hospital

Table 2: Distribution of ICU Staff Nurses With Regard To Their Knowledge of the Meaning of ICU Psychosis in Private vs. Government Hospital

Table 3: Distribution of ICU staff nurses with regard to knowledge regarding risk factors and causes of ICU psychosis in Private vs. Government Hospital

Table 4: Distribution of ICU staff nurses with regard to knowledge of the Diagnosis of ICU Psychosis in Private vs. Government Hospital

Table 5: Distribution of ICU staff nurses with regard to knowledge Manifestations of ICU Psychosis in Private vs. Government Hospital

Table: 6. Distribution of Practice Scores of Staff Nurses on Management of ICU Psychosis

Table: 7. Comparison of Pre- and Post-Teaching Scores on ICU Psychosis Management in Private and Government Hospitals

Table: 8. Correlation between knowledge and practice before and after planned teaching

Figure 1: Distribution of ICU staff nurses with regard to knowledge Manifestations of ICU Psychosis in Private vs. Government Hospital.

Figure: 2. Comparison of Government Pre-Test and Post-Test Observations across Nursing Activities

Figure: 3. Comparative Analysis of Nursing Activity Observations: Private vs. Government Institutions (Pre and Post Test)

The demographic comparison between private and government hospital nursing staff reveals notable differences. In private hospitals, all participants (100%) were within the 21–30 years age group, whereas the government hospitals showed a more diverse age distribution, with only 28% in the 21–30 group and the majority being older. ICU experience in private hospitals was mostly concentrated in the <1 year (40%) and 1–2 years (28%) brackets, whereas government hospital nurses had a wider distribution, including a higher proportion with ≥5 years of ICU experience (24%). Regarding experience outside the ICU in adult medical units, private hospital nurses were relatively less experienced, with 44% having <1 year, and none had ≥5 years; in contrast, government hospital staff had more balanced distribution across all experience levels. Similarly, in the surgical ICU category, all private hospital nurses had no prior experience, while government hospital nurses had varied experience, particularly 56% in the 1–2 years range. Educational qualifications also differed, with 76% of private hospital nurses holding diplomas, compared to 68% of government hospital nurses who held degrees. Lastly, prior knowledge of ICU psychosis was higher among private hospital nurses (68%) than their government counterparts (36%).

The comparison of pre-test and post-test responses regarding signs and symptoms of ICU psychosis among staff nurses in private and government hospitals shows significant improvement in knowledge after planned teaching in both settings. In private hospitals, awareness that ICU psychosis is characterized by “fluctuation in mental status, consciousness level manifested by hyperactivity” rose markedly from 68% pre-test to 88% post-test. Similarly, in government hospitals, this recognition improved from 48% to 96%. Recognition of “very lethargic and falling asleep” as a symptom also showed a substantial increase—from 28% to 84% in private hospitals, and from 40% to 84% in government hospitals.

Misconceptions declined after the intervention. For instance, the belief that “restless and agitated” or “restless and combative” were defining symptoms dropped from 32% to 8% and 20% to 4%, respectively, in private hospitals. A similar trend was observed in government hospitals, where such responses declined to 0% and 16%. Notably, responses associating ICU psychosis with incorrect signs like “alert and calm” or “fluctuation in emotion” also decreased across both groups. The comparison of pre- and post-test responses regarding the knowledge of predisposing, precipitating factors, and causes of ICU psychosis among staff nurses reveals a marked improvement after planned teaching, particularly in government hospitals. For predisposing factors, the correct response—“Intubation, CABG, 75 years male”—saw a significant increase in selection post-test, from 48% to 64% in private hospitals and from 40% to 96% in government hospitals. Meanwhile, incorrect options like “Hypertension, Hyperlipidemia, and chronic smoker” decreased substantially post-intervention, indicating improved understanding. Regarding precipitating factors, “Noisy environment” was correctly identified by 100% of private hospital nurses in the post-test, up from 40% pre-test. Similarly, in government hospitals, correct identification rose from 36% to 88%. Incorrect beliefs such as “Hormonal imbalance” and “High cholesterol level” dropped dramatically in both groups, reflecting enhanced clarity after teaching. When evaluating the causes of ICU psychosis, “Hepatic encephalopathy” emerged as the most correctly identified cause post-test, increasing from 24% to 52% in private hospitals and from 48% to 76% in government hospitals. Selections of “Chronic alcohol” and the combined “Both a and c” option declined post-test, particularly in government hospitals, indicating reduced confusion about multifactorial causes.

The pre- and post-test comparison highlights a clear improvement in the knowledge of ICU psychosis manifestations and related cognitive abnormalities among staff nurses in both private and government hospitals after planned teaching. For manifestations of ICU psychosis, “restlessness” was most correctly identified, increasing from 72% to 100% in private hospitals and from 64% to 92% in government hospitals post-test. Misidentification of symptoms such as “palpitation” and “diarrhoea” declined notably, with “palpitation” dropping to 0% in private hospitals and to 8% in government hospitals. When identifying the abnormality associated with fluctuating between stupor and hypervigilance, understanding was somewhat mixed. In private hospitals, the correct multifactorial option “both disturbance in thought process and perception” (option d) dropped from 48% to 24%, suggesting some post-test confusion. In contrast, government hospital nurses showed a modest improvement in recognizing “disturbance in alertness” (from 4% to 28%) but had varied responses, indicating only partial conceptual clarity.

In the case of incoherent speech and disorganized thinking, the correct response “disturbance in thought process” improved in both groups—from 36% to 40% in private hospitals and from 16% to 60% in government hospitals. This reflects better understanding of cognitive dysfunction post-intervention. Meanwhile, the previously more selected incorrect answer “disturbance in attention and memory” (option d) declined substantially in both settings. The comparison of pre- and post-test scores across various nursing domains in private and government hospital groups reveals a marked improvement in knowledge and skills following planned teaching interventions. In both groups, “Orientation and effective communication” showed substantial improvement. The private hospital group improved from 29 (19%) to 118 (61%), while the government hospital group rose from 13 (9%) to the same post-test score of 118 (61%), indicating strong gains in communication strategies. “Nursing procedures” also demonstrated significant improvement. The private group advanced from 94 (63%) to 136 (91%), and the government group from 63 (41%) to 136 (91%), reflecting enhanced understanding and execution of clinical protocols. For “Avoidance of external stimuli,” private hospital nurses improved from 112 (75%) to 136 (91%), and government hospital nurses from 75 (50%) to 132 (88%), suggesting better environmental control awareness post-intervention.

In “Ensuring comfort,” the private group showed notable gains from a low baseline of 39 (16%) to 132 (66%), whereas the government group, though improving from 15 (8%) to 88 (44%), lagged behind, indicating a need for further focus in this area. Regarding “Enhancing mobility,” the private group improved impressively from 24 (48%) to 49 (98%), while the government group rose from 10 (20%) to 39 (78%), showing increased attention to mobilization practices in ICU care. “Maintaining records” saw nearly equal improvement in both groups, with the private group moving from 89 (59%) to 135 (90%) and the government group from 82 (55%) to 135 (90%), reflecting enhanced documentation practices. Lastly, “Other activities” such as psychosocial support and patient engagement also improved, with the private group rising from 105 (53%) to 161 (80%), and the government group from 53 (26%) to 161 (78%).

The analysis of pre- and post-teaching knowledge and observation scores on ICU psychosis management revealed statistically significant improvements in both private and government hospital groups. In the private hospital group, the mean knowledge score increased from 11 to 18 (t = 11, p < 0.05), and the observation score improved from 21 to 34 (t = 8, p < 0.05), indicating a significant effect of the teaching intervention. Similarly, in the government hospital group, the mean knowledge score rose from 9 to 19 (t = 10, p < 0.05), and the observation score increased from 16 to 27 (t = 12, p < 0.05), also demonstrating statistical significance. When comparing between the two hospital setups, the post-test knowledge score difference was greater in the government group (mean difference = 10, t = 3), which was statistically significant, whereas the private group showed a non-significant difference (t = 1.3). Observation scores showed significant improvement in both groups post-intervention (t = 3 in private, t = 4 in government).

Pre-test (r = 0.0156): This shows a very weak positive correlation between knowledge and practice before the planned teaching. It is nearly zero, indicating almost no relationship between the two variables initially.

Post-test (r = 0.1894): After the planned teaching, the correlation increased slightly to a weak positive correlation, suggesting that the intervention may have led to a modest improvement in the alignment between knowledge and practice.

The findings of the present study clearly demonstrate that planned teaching interventions significantly enhanced the knowledge and observational competencies of staff nurses regarding ICU psychosis management in both private and government hospital settings. This aligns with the outcomes reported by Babu et al. [8], who observed significant improvement in nursing knowledge following structured teaching programs. The greater post-test knowledge score gain in the government hospital group (mean difference = 10) compared to the private group (mean difference = 7) is comparable to findings by Sharma et al. [9], who also noted higher receptiveness among government hospital nurses, possibly due to limited prior exposure. Furthermore, the increase in correct identification of signs and symptoms such as fluctuating mental status and lethargy reflects a pattern noted by Joshi and colleagues [10], where cognitive symptoms were underrecognized prior to educational intervention.

Similar improvements in recognition of predisposing and precipitating factors—such as intubation and noisy environments—were reported by Thomas et al. [11], confirming the effectiveness of targeted teaching strategies. The decreased reliance on incorrect options post-intervention aligns with observations by Kapoor et al. [12], highlighting the importance of debunking misconceptions in nursing practice. In terms of management practices, our findings of enhanced scores in domains like orientation, mobility, and avoidance of external stimuli mirror those by Fernandes et al. [13], who documented improved care quality following nurse education programs.

Moreover, the significant gains in "Ensuring comfort" and "Other activities" domains are similar to findings by Patel and Varma [14], who emphasized the role of comfort measures in mitigating ICU psychosis. Notably, the marked improvements in documentation and communication practices resonate with studies by Ramesh et al. [15], underlining the role of systematic training in improving ICU nursing outcomes. The increase in observational scores post-intervention (private: t = 3; government: t = 4) supports earlier evidence from Narayanan and George [16], who demonstrated statistically significant changes in nursing behavior post-education.

Additionally, when considering cognitive symptom identification, the rise in correct responses regarding disturbances in thought processes and perception matches the observations of Pillai and Krishnan [17], who noted conceptual confusion pre-intervention and clarity thereafter. The slight post-test decline in selecting the correct multifactorial symptom explanation in the private group may indicate the need for more in-depth or repeated teaching sessions, as previously emphasized by Khan et al. [18].

The statistical significance of the knowledge and observation score improvements in both groups echoes the findings of Mehta et al. [19], affirming that structured educational programs substantially enhance ICU nursing performance. Lastly, as Gupta and Roy [20] concluded, consistent and repeated educational efforts are essential for long-term retention and translation of knowledge into practice, suggesting that similar strategies could further consolidate these findings.

We conclude that, the study clearly demonstrate that planned teaching interventions significantly improved both knowledge and practice related to the management of ICU psychosis among staff nurses in both private and government hospital settings. Across all domains—ranging from symptom identification to understanding of predisposing and precipitating factors, and implementation of appropriate nursing interventions—there was a marked enhancement in post-test performance. Nurses from both groups exhibited better conceptual clarity, reduced misconceptions, and improved confidence in managing ICU psychosis. While private hospital nurses started with relatively higher baseline knowledge, the government hospital nurses showed greater gains post-intervention, particularly in recognizing cognitive manifestations and applying clinical protocols. Improvements were also evident in nursing practices such as communication, mobility support, environmental control, and record-keeping. Overall, the study highlights the effectiveness of structured educational programs in enhancing the competency of nursing staff in critical care environments, leading to better patient outcomes and quality of care.

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