ICU护士应用最佳证据开展谵妄评估的实践现状及影响因素研究——基于理论域框架的质性分析

Study on the Current Practice and Influencing Factors of ICU Nurses Using Best Evidence for Delirium Assessment—A Qualitative Analysis Based on the Theoretical Domains Framework

摘要: 目的：基于理论域框架(TDF)探析ICU成人患者谵妄评估中护士应用循证最佳证据的促进因素与实施障碍，为临床推进谵妄规范化循证评估提供实践依据。方法：以理论域框架为理论支撑编制半结构化访谈提纲，采用目的抽样选取湖北省某三甲医院24名ICU在岗护士开展一对一访谈；运用主题分析法对访谈录音转录文本进行编码、提炼核心主题。结果：当前ICU护士谵妄评估多依靠个人临床经验与直观症状观察，标准化循证评估落实不足，临床实践与指南推荐存在明显落差。实施障碍主要包含三方面：科室环境资源配置不足、护士循证评估知识技能欠缺、危重患者护患沟通配合困难；促进因素为护士认可循证护理价值、明晰规范化谵妄评估对医患双方的获益、具备改善患者预后的职业使命感。临床管理层面需完善谵妄评估管理制度、补充护理人力、简化评估工具、推进护理信息化建设；同时常态化开展谵妄指南与量表实操培训，全面提升护士循证评估能力。结论：落实基于最佳证据的ICU谵妄评估能够提升筛查精准度、优化危重患者照护结局。临床推行循证谵妄评估同时存在多重阻力与内在驱动因素，管理者可针对性制定综合优化策略，推动ICU谵妄评估标准化、同质化开展。

Abstract: Objective: To explore the facilitators and barriers of ICU nurses implementing evidence-based delirium assessment for ICU adult patients under the guidance of Theoretical Domains Framework (TDF), so as to provide practical references for standardized evidence-based delirium assessment in clinical practice. Methods: A semi-structured interview outline was developed based on TDF. Purposive sampling was adopted to recruit 24 ICU nurses from a tertiary hospital in Hubei Province for face-to-face interviews. Thematic analysis was used to code transcribed interview texts and extract core themes. Results: At present, ICU nurses mainly rely on personal clinical experience and intuitive symptom observation for delirium assessment, while standardized evidence-based assessment is poorly implemented, leading to an obvious gap between clinical practice and guideline recommendations. Barriers fell into three categories: insufficient environmental and resource support, inadequate nurses’ knowledge and skills in evidence-based assessment, and poor communication and cooperation with critically ill patients. Facilitators included nurses’ recognition of the value of evidence-based nursing, full awareness of the benefits of standardized delirium assessment for patients and medical staff, and strong professional responsibility to improve patients’ prognosis. Hospital management should formulate standardized delirium assessment regulations, supplement nursing manpower, simplify assessment tools and accelerate nursing information construction. Regular training on delirium guidelines and scale operation is also essential to improve nurses’ evidence-based assessment competency. Conclusion: Evidence-based delirium assessment can improve screening accuracy and optimize care outcomes of critically ill ICU patients. Multiple barriers and internal driving factors coexist in the implementation process. Targeted comprehensive intervention strategies should be formulated to promote standardized and consistent delirium assessment in ICU.