Factors influencing delirium nursing competency among nurses in integrated nursing care wards in South Korea: a cross-sectional study

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J Korean Biol Nurs Sci. 2025;27(2):256-265

Publication date (electronic) : 2025 May 27

doi : https://doi.org/10.7586/jkbns.25.022

Jeeyoung Yeon, Gisoo Shin

College of Nursing, Chung-Ang University, Seoul, Korea

Corresponding author: Gisoo Shin. College of Nursing, Chung-Ang University, Heukseok-ro 84, Dongak-gu, Seoul 06974, Korea Tel: +82-2820-5975 Fax: +82-2-8247951 E-mail: gisoo@cau.ac.kr

Received 2025 April 11; Revised 2025 May 5; Accepted 2025 May 6.

Abstract

INTRODUCTION

Delirium, derived from the Latin term deliria, meaning “to go off the furrow,” refers to an acute and fluctuating disturbance in consciousness, orientation, memory, cognition, perception, and behavior [1]. This condition is frequently observed among patients in neurological intensive care units and occurs more frequently in older adults, post-surgical patients, and those with comorbid brain or chronic systemic conditions [2]. Early detection and timely management of delirium are crucial, as it is often reversible with appropriate intervention [1,2].

Older adults are particularly vulnerable to delirium due to diminished homeostatic regulation, sensory impairments, high prevalence of chronic illnesses, reduced resilience to acute stressors, sleep deprivation, and psychosocial stressors such as bereavement or social isolation [3]. Delirium in the elderly is often misdiagnosed as dementia or depression, leading to delayed treatment, which may result in stupor, coma, or even death in severe cases [4]. The pathophysiology of delirium involves disruptions in cerebral metabolism, decreased synthesis of acetylcholine, neurotransmitter imbalances, stress-related changes in brain metabolism, and right hemisphere dysfunction [1,2]. Neurotransmitter imbalances, particularly involving acetylcholine, dopamine, serotonin, gamma-amnionobutyric acid, glutamate, norepinephrine, opioids, somatostatin, beta-endorphin, and cortisol identified as key contributors to the development of delirium [5]. Delirium symptoms categorized into cognitive disturbances, psychiatric manifestations, sleep-wake cycle disruptions, and neurological abnormalities. These symptoms often intensify in the evening and tend to fluctuate significantly throughout the day [1,2,5].

In elderly patients, delirium may manifest through disorientation and wandering behaviors, such as pulling out intravenous lines or attempting to leave the hospital room, which can lead to falls [3]. Moreover, delirium in older adults recognized as an independent risk factor for increased mortality [4]. South Korea has projected to become a super-aged society by 2025, with individuals aged 65 and older comprising over 20% of the population, and this figure is expected to exceed 40% by 2050 [6]. In response, the government has implemented an integrated nursing care (INC) model to alleviate caregiver burden and improve patient safety amid rising chronic disease prevalence and increased family satisfaction. This model allows professional nurses and nursing assistants to deliver comprehensive care in place of informal caregivers, thereby enhancing direct nursing time, improving patient satisfaction, and yielding better health outcomes [7]. With the progression toward an aging society, the hospitalization rate of elderly patients who are at elevated risk for delirium is steadily increasing [4,6]. INC wards, which allow patients to receive nursing services without a caregiver present, see a higher admission rate among older adults, as families seek to alleviate the burden of caregiving [6,7]. As such, this ward presents a high-risk environment for the development of delirium [4]. For nurses working in such settings, possessing sufficient knowledge about delirium is essential for the early recognition of symptoms and the provision of timely and appropriate interventions. This is particularly important because delirium is an acute mental status change that can deteriorate rapidly, requiring nurses to make accurate judgments and respond effectively based on a solid understanding of the condition [2]. Furthermore, nursing with delirium patients can be highly stressful for nurses due to unpredictable behaviors, aggression, and fluctuating levels of consciousness [8]. In addition, nurses in INC wards often face higher patient-to-nurse ratios and the absence of family caregivers, which results in greater occupational stress compared to their counterparts in general wards or intensive care units [9]. Most critically, the lack of epidemiological data on the incidence of delirium in INC wards and the absence of standardized criteria for classifying its severity mean that patients with delirium are admitted to these wards without specific restrictions, thereby increasing the demand for nursing care in this context [10]. To address this issue, the 2024 revision of the service guidelines introduced resolute units for critically ill patients with delirium [11].

However, INC wards nurses found to lack both the skills to apply clinical guidelines, and the techniques required for proper delirium assessment [9,10]. Prior research has established a strong association between nurses’ knowledge of delirium and their competency in providing effective nursing care, with those possessing higher knowledge demonstrating greater proficiency [12]. Furthermore, delirium nursing care is not a mandatory component of nursing education in INC wards. Many nurses report not having received formal education on the subject, and delirium knowledge levels remain comparable to those reported a decade ago. This delirium knowledge deficit contributes significantly to nurses' stress when caring for delirious patients [9].

Emotional intelligence plays a crucial role in alleviating the stress experienced by nurses, particularly in high-demand clinical environments. It was defined as the ability to perceive, understand, regulate, and effectively utilize emotions [13]. Nurses with high emotional intelligence are better equipped to comprehend the confusion experienced by delirious patients, remain composed in the face of aggressive behaviors, and foster a stable and therapeutic care environment. This competency not only facilitates positive interactions with patients but also enhances communication and rapport with family members. Emotional intelligence contributes directly to patient safety and treatment outcomes in INC wards [14].

Delirium nursing competency is of particular importance for nurses in INC wards settings due to both the nature of these wards and the characteristics of patients with delirium. INC wards operate under a model in which nurses provide comprehensive care and daily living support without the presence of family caregivers. Given that delirium is strongly associated with cognitive decline, increased risk of injury, prolonged hospitalization, and higher mortality, a nurse’s ability to detect and manage delirium early can significantly influence patient outcomes [6,7]. Previous study has shown that nurses who receive delirium-specific education are more capable of recognizing symptoms promptly and responding effectively, which in turn improves recovery rates and overall quality of life for patients [15]. Moreover, because delirium is often dismissed as a temporary state of confusion, it requires a prominent level of clinical sensitivity to subtle changes in patient condition. Thus, delirium nursing competency encompasses more than theoretical knowledge; it involves a practice-oriented, integrative skill set that enables nurses to respond swiftly and appropriately in complex clinical scenarios [16].

Therefore, knowledge of delirium, the ability to manage related stress, emotional intelligence, and practical delirium nursing competency are interrelated core elements in the delivery of high-quality, patient-centered care in INC wards. This study aims to investigate the levels of delirium knowledge, delirium nursing-related stress, emotional intelligence, and delirium nursing competency among nurses in INC wards, and to identify factors influencing their competency. The findings are expected to provide foundational data for the development of targeted interventions aimed at enhancing delirium nursing competency in these settings.

METHODS

RESULTS

1. Characteristics of participants

Among the participants, 91 nurses (49.5%) were in their 20s, 61 (33.2%) in their 30s, and 32 (17.3%) were aged 40 or older. In terms of educational level, 157 (85.3%) held a bachelor's degree, 20 (10.9%) held an associate degree, and 7 (3.8%) held a master’s degree. The average total clinical career was 6.30 ± 5.88 years, and the average duration of career in the current department was 2.70 ± 2.22 years. Regarding the availability of manual for delirium nursing care in the ward, 99 participants (53.8%) responded affirmatively, while 85 (46.2%) reported the absence of such manual for delirium nursing care. A total of 111 participants (60.3%) had experience of education for delirium, with 70.3% citing "clinical experience" and 29.7% citing "continuing education" as the primary modes of instruction. All participants (97.8%) expressed a need for delirium education, and 74.5% reported experiencing conflict with caregivers of patients with delirium (Table 1).

Table 1.

General Characteristics of Participants (N = 184)

2. Levels of delirium knowledge, delirium nursing-related stress, emotional intelligence, and delirium nursing competency

The mean score for delirium knowledge was 32.10 ± 4.80 out of 45, with the highest correct response rate in the subdomain of etiology and the lowest in the domain of nursing management. The average score for delirium nursing-related stress was 57.83 ± 18.15 out of 100, while the mean emotional intelligence score was 80.03 ± 12.50 out of 112. The mean score for delirium nursing competency was 68.87 ± 8.04 out of 96 (Table 2).

Table 2.

Levels of Delirium Knowledge, Delirium Nursing-related Stress, Emotional Intelligence, and Delirium Nursing Competency (N = 184)

3. Differences in the levels of delirium knowledge, delirium nursing-related stress, emotional intelligence, and delirium nursing competency according to participants` characteristics

Delirium knowledge showed statistically significant differences based on age (F = 4.68, p = .010), position (t = −2.25, p = .026), total clinical career (F = 3.46, p = .033), experience with delirium education (t = 3.26, p = .001). Delirium nursing-related stress, however, did not significantly differ by age (F = 0.58, p = .561), educational level (F = 0.84, p = .434), position (t = −1.32, p = .095), total clinical carrier (F = 0.20, p = .820), career in the current department (F = 0.86, p = .426), third-shift work (t = −0.20, p = .840), presence manual for delirium nursing care (t = −1.22, p = .226), experience of education for delirium (t = −1.17, p = .242), perceived need for delirium education (t = 0.87, p = .384), or conflict with the caregiver of patients with delirium (t = 0.47, p = .638). Emotional intelligence varied significantly with age (F = 4.10, p = .018) and experience of education for delirium (t = −3.16, p = .002). Delirium nursing competency significantly differed only by experience of education for delirium (t = 2.09, p = .038) (Table 3).

Table 3.

Differences in the Levels of Delirium Knowledge, Delirium Nursing-related Stress, Emotional Intelligence, and Delirium Nursing Competency According to Participant’s Characteristics (N = 184)

4. Correlation among delirium knowledge, delirium nursing-related stress, emotional intelligence, and delirium nursing competency

There were significant positive correlations between delirium nursing competency and delirium knowledge (r = .24, p = .001), as well as between delirium nursing competency and emotional intelligence (r = .23, p = .001) (Table 4).

Table 4.

Correlations among Delirium Knowledge, Delirium Nursing-related Stress, Emotional Intelligence, and Delirium Nursing Competency

5. Factors influencing delirium nursing competency

To identify factors influencing delirium nursing competency, multiple regression analysis was conducted using variables that showed significant differences, specifically experience of education for delirium, need for delirium education, delirium knowledge, delirium nursing-related stress, and emotional intelligence as independent variables. The experience of education for delirium was treated as a dummy variable.

The regression model was statistically significant (F = 7.18, p < .001). The Durbin-Watson statistic was 1.94, indicating no violation of independence assumptions, and variance inflation factors were all below 10, suggesting no multi-collinearity concerns.

Significant predictors of delirium nursing competency included experience of education for delirium (β = 0.16, p = .031), delirium knowledge (β = 0.20, p = .006), and emotional intelligence (β = 0.27, p < .001). Among these, emotional intelligence had the strongest influence, followed by delirium knowledge and experience of education for delirium. The explanatory power of the model was 12% (adjusted R² = 12%) (Table 5).

Table 5.

Factors influencing Delirium Nursing Competency

DISCUSSION

This study investigated levels of delirium knowledge, delirium nursing-related stress, emotional intelligence, and delirium nursing competency among nurses working in INC wards across four general hospitals and examined the factors influencing their delirium nursing competency.

The mean score for delirium knowledge (32.10 out of 45) was consistent with previous studies conducted in tertiary hospitals using the same instrument [10], yet lower than scores reported in cancer specialty hospitals where nurses are more frequently exposed to delirium [23]. These discrepancies likely reflect institutional differences in delirium prevalence. The expansion of INC wards following the coronavirus disease 2019 pandemic has increased exposure to delirium education and manual [24]. However, delirium remains an underemphasized topic in required educational programs within these units. Compared to international study, the delirium knowledge level remains low, underscoring the need for tailored, mandatory education programs that align with the ward’s unique characteristics [15]. Among delirium knowledge subdomains, the highest scores were in delirium etiology, while the lowest were in nursing management findings consistent with prior research [19]. This suggests a gap between symptom recognition and appropriate intervention, highlighting the importance of strengthening training focused on nursing management of delirium.

The average delirium nursing-related stress score was 57.83 out of 100, comparable to or slightly lower than scores reported in tertiary hospitals [25]. Given the lower severity of cases in general hospitals, this outcome seems plausible. Nonetheless, unresolved stress related to delirium nursing care may lead to burnout and job dissatisfaction, emphasizing the need for psychological support and institutional interventions.

The average emotional intelligence score was 80.03 out of 112. Participants demonstrated stronger self-awareness but lower scores in emotional utilization and regulation, mirroring previous findings [26]. Given the close, continuous interaction with patients in this ward, the development of emotional intelligence particularly in regulation and application, is essential for effective therapeutic relationships [14]. Thus, educational programs focusing on emotional intelligence should be developed and aligned with institutional needs.

The mean delirium nursing competency score was 68.87 out of 96, slightly lower than that reported among intensive care unit (ICU) nurses [22], due to the higher incidence and risk of delirium in ICU. Notably, low subdomain scores in collaboration, communication, and evaluation suggest a connection with knowledge deficiencies and lack of confidence [15,26]. To enhance collaboration and communication among nurses in INC wards, educational programs must address both knowledge and emotional competencies [27]. This study also confirmed that nurses who had experience of education for delirium scored higher in nursing competency, consistent with prior research [22]. Education for delirium has been shown to reduce complications by improving nursing performance [16], and competency can be enhanced through repeated instruction. Hence, sustainable, and diverse educational strategies are needed.

Significant positive correlations were found among delirium knowledge, emotional intelligence, and delirium nursing competency, confirming that both delirium knowledge and emotional intelligence are key predictors. Experience of education for delirium also played a crucial role. Also, the findings of this study indicate that delirium knowledge and emotional intelligence are key factors influencing nurses’ competency in delirium nursing care in INC wards. Given that delirium is an acute cognitive disorder with rapid onset and fluctuating symptoms, early recognition and timely intervention are critical both of which are largely dependent on the nurse’s level of knowledge regarding delirium [9,19]. When nurses possess sufficient understanding of their causes, symptoms, and appropriate interventions, they are better equipped to deliver effective care, making delirium knowledge a core component of delirium nursing competency [10]. Furthermore, nurses with high emotional intelligence are more attuned to the nonverbal cues of patients with delirium, can respond with empathy, and play a significant role in building trust not only with patients but also with their families [7,12,14]. This highlights emotional intelligence as an essential attribute for nurses in integrated care settings [28]. Considering the unique environment of INC wards, where family members or caregivers are often not present, the role of the nurse as a primary support figure becomes even more crucial, especially in managing the confusion and anxiety experienced by patients with delirium [13,27]. Therefore, an integrated educational program that enhances both delirium knowledge and emotional intelligence is essential to improve nurses’ competency in delirium nursing care.

Notably, stress related to delirium did not have a significant impact on delirium nursing competency. This may be attributed to the fact that the participants were employed at general hospitals, where the severity of patient conditions and the proportion of patients with delirium may be relatively lower compared to those in tertiary care settings [29].

This study has limitations in generalizability due to the use of convenience sampling from general hospitals in specific regions. Nevertheless, it offers valuable insights by identifying predictors of delirium nursing competency and comparing them with prior findings, thereby reinforcing the importance of delirium nursing care within integrated nursing care.

CONCLUSION

This descriptive study analyzed data from 184 nurses working in INC wards at four general hospitals located in Seoul and Daejeon, South Korea. It aimed to assess their levels of delirium knowledge, delirium nursing–related stress, emotional intelligence, and delirium nursing competency, and to identify factors influencing delirium nursing competency. The findings revealed that delirium knowledge, emotional intelligence, and experience of education for delirium were significant influencing factors, explaining 12% of the variance in delirium nursing competency. Based on these findings, it is recommended that future research within the field of nursing should continue to explore a broader range of variables that may influence delirium nursing competency, particularly among nurses working in integrated care settings. In addition, the delirium nursing competency of nurses working in INC wards is expected to have significant academic and clinical implications for the Korean biological nursing science. In particular, nurses' delirium experiences and case-based insights can inform the development of educational curricula and policy recommendations promoted by society, contributing to the integration of academic theory with clinical practice for delirium patients. These practical competencies are anticipated to serve as a catalyst in shifting the society’s research agenda toward a more clinical orientation, playing a key role in bridging the gap between academic advancement and practical application.

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