Delirium is a disturbance of consciousness characterized by impaired attention, often precipitated by acute changes in physical condition. Its incidence is estimated to be approximately 10% - 30% in general wards and 70% - 80% in intensive care units [1][2]. Given that delirium is associated with prolonged hospitalization and increased mortality [3], preventing its onset and enhancing the quality of care following its onset are critical clinical priorities.

Delirium results from a complex interplay between environmental and patient-specific factors. Primary management strategies involve addressing the underlying etiologies and managing symptoms using psychotropic medications such as antipsychotics. Since delirium care is most effective when delivered via a multidisciplinary approach, clinical guidelines strongly emphasize the necessity of interprofessional collaboration [4][5].

Nursing records serve as pivotal tools for facilitating communication among healthcare providers [6], making them indispensable for multidisciplinary delirium care. While the delivery of high-quality care is essential, accurate and comprehensive records of these practices are vital. Strengthening the synergy between clinical practice and records is expected to foster inter-professional collaboration, ultimately contributing to improved quality of care. However, standardized guidelines for nursing records specific to delirium care are currently lacking in Japan and internationally. Although existing general nursing record guidelines provide broad principles, they offer insufficient guidance on how to specifically record the unique characteristics of delirium care, such as the “diurnal fluctuation of symptoms” and “diverse non-pharmacological interventions (e.g., environmental modification and reorientation)”. Nurses may find it challenging to determine the appropriate level of detail for their records. Consequently, there is a risk that delirium care interventions, even when implemented effectively, remain undocumented and are thus rendered invisible. Admittedly, the quality of records, characterized by accuracy and conciseness, is crucial, and a higher frequency of recording does not necessarily equate to better practice. However, if healthcare professionals recognize the necessity of multidisciplinary collaboration in delirium care, it is reasonable to infer that they will more frequently record essential details, such as patient reactions, care content, and clinical judgments. In this context, the quantity of records is not entirely independent of their quality; rather, the frequency of recording can be considered one of the valid proxies for the active information sharing that facilitates the actual implementation of multidisciplinary collaboration. To date, however, no studies have been found internationally that focus on the relationship between nursing records in delirium care and the actual practice of multidisciplinary collaboration. Therefore, as a foundational study, the authors developed the NRDC-Acute to measure the frequency of nursing records for delirium care among nurses in acute care hospitals, based on the context of the Japanese healthcare system [7]. The NRDC-Acute comprises 13 items across four factors and has demonstrated reliability and validity. These four factors are: “Record of PRN Pharmacological Delirium Care,” “Record of Non-Pharmacological Delirium Care,” “Record of Regular Pharmacological Delirium Care,” and “Record of Collaboration for Delirium Care.”

To establish the ideal form of nursing records that contribute to effective multidisciplinary collaboration in delirium care, it is essential to first understand the factors influencing current recording practices. Therefore, as a foundational first step toward this goal, this study aimed to exploratorily examine the individual nurse and organizational characteristics associated with the total NRDC-Acute score in Japan.

A total of 232 questionnaires (44.6%) were returned, of which 218 (41.9%) were used for analysis.

The number of valid responses in this study was 218, which exceeded the required sample size of 157. Therefore, we were able to perform data analysis using the necessary sample size for the statistical analysis. Looking at the individual characteristics of the participants, all the nurses had a wide range of experience, from minimal to extensive experience.

The results of the multiple regression analysis showed that the frequency of nursing records related to delirium care was associated with “total years of experience as a shift leader nurse in their wards” and “experience attending training related to nursing records.”

As previously stated, shift leader nurses are responsible for coordinating the nursing process in the ward during a shift. The quality of a shift leader nurse’s behavior significantly affects the quality of nursing in the ward [11][12]. This association can be explained from two perspectives. First, given their responsibility to oversee nursing care across the entire ward, shift leader nurses are presumed to be well-versed in their organization’s specific nursing record rules. Without a thorough understanding of these rules, they would be unable to fulfill their core duties of ensuring a safe therapeutic environment and educating shift member nurses [11][16][17]. It is likely that this mastery enables them to understand precisely what aspects of delirium care require documentation, leading them to record with clear intent and autonomy based on a recognition of its necessity. Second, during their shifts, shift leader nurses act as a central hub for multidisciplinary collaboration [11][17][18]. Through their experience in coordinating with various professionals, they have likely identified effective recording practices that are practically useful for delirium care, which may contribute to the higher frequency of their records.

We believe that participation in training on nursing records provides an opportunity to reconfirm the need for nursing records while considering recent medical and nursing trends. Therefore, participation in nursing record training may be associated with the frequency of actual nursing records in this study. Nursing records are also positioned as legal evidence, and their content must be accurate [19][20]. In delirium care, there are many opportunities to provide assistance when ensuring patient safety if symptoms of delirium occur. If we consider the frequency of nursing records in delirium care, it is possible that participation in training and increased awareness of the need for records, especially those related to medical safety, may be related to the frequency of nursing records. In contrast, Okaisu et al. [21] stated that nursing record training alone does not lead to changes in nursing record practices in the long term and that there is a need to improve nursing record systems. In connection with this, our study examined 21 candidate factors associated with the frequency of nursing records. Multiple regression analysis resulted in an adjusted R² of 0.057. This result implies that unmeasured organizational and environmental factors might have a stronger impact on record frequency than individual nurse characteristics. First, system-related factors, such as the interface design of Electronic Health Records and the physical burden of typing, may have played a role. Even if nurses intend to record delirium care, usability issues or time constraints can act as barriers to actual recording behavior. Second, we speculate that the organizational culture and social norms within the ward may influence practice as much as or potentially more than formal training. Record practices may be shaped by unwritten rules or group conformity rather than just official manuals. If the ward atmosphere prioritizes operational efficiency over detailed recording, nurses may unconsciously align with this norm, potentially leading to the omission of records for invisible delirium care in the documentation. Furthermore, reliance on verbal communication and tacit knowledge in clinical settings could present a paradox regarding records. In teams where information is smoothly shared via conversation or implicit understanding, nurses may perceive written records as redundant or less urgent. While such high-context communication facilitates daily operations, it may unintentionally obscure the necessity of records as legal evidence and accountability. These perspectives suggest the need for future research to investigate the influence of ward climate and communication styles on recording behavior.

The findings suggest two key directions for clinical practice. First, priority should be given to enhancing the delirium care competency of shift leader nurses. This would enable skilled leaders to mentor staff on effective documentation, thereby contributing to the quality improvement of both nursing records and delirium care across the ward. Second, it may be necessary to integrate specific training on documentation into delirium care education, a topic that has not traditionally been central. Promoting these strategies could not only increase record frequency but also facilitate the active information sharing essential for multidisciplinary collaboration in delirium care.

This study has several limitations. This study was based on a survey conducted among nurses in Japan. Therefore, the results are based on the discretion and role of nurses in Japan, and caution is necessary when generalizing the implications of the results to other situations and countries. To the best of our knowledge, this study is the first to examine the factors pertaining to the frequency of nursing records of delirium care among nurses in acute care hospitals. Thus, we believe that this study provides meaningful insights. In this study, since hospital participation was limited to 41 facilities, it is necessary to consider the possibility of selection bias. Nursing record frequency was quantitatively measured using a self-assessment method, which may have led to social desirability bias.

Furthermore, this study used a cross-sectional design. Consequently, causal relationships cannot be inferred; only correlations were identified.

We conducted an exploratory study on the factors associated with the frequency of nursing records for delirium care among nurses in acute care hospitals in Japan. The frequency of nursing record entries for delirium care was assessed using the NRDC-Acute. A total of 21 variables related to individual nurses and organizational characteristics were considered potential factors. Multivariate analysis revealed two factors, “total years of experience as a shift leader nurse in their wards” and “experience attending training related to nursing records,” as being associated.

The authors are grateful to all the participants in this study. We would like to thank Editage (https://www.editage.com/) for English language editing.