The Single Question in Delirium (SQiD) is a widely used delirium detection tool utilising discussion between clinicians and informants. This study aims to understand how the SQiD works in clinical settings.
Using qualitative methodology, with a grounded theory framework, informant interviews were analysed to understand better how the SQiD works in clinical contexts. Participants were the adult relatives, carers, or friends (informants) of inpatients in an oncology ward at an acute hospital in Sydney, Australia. The informant was an available person whom staff would ordinarily approach for collateral information. The SQiD was administered and recorded by nursing staff. The recording was transcribed verbatim, checked, and then thematically analysed independently by two researchers. Themes/subthemes were determined and discussed until consensus was reached, then reviewed with a third researcher. Patient demographics, including documented diagnosis of delirium, were extracted from their Electronic Medical Record.
Of 29 interviews, 15 patients screened positive for delirium, six of whom had a documented diagnosis of delirium. Emergent themes included
This study indicates that the SQiD’s usefulness might be enhanced by providing clinicians with specific education about delirium, and differentiation between delirium and other neurocognitive disorders. Moreover, education could be accompanied by measures to encourage clinicians to extend SQiD discussions, act on SQiD findings, and embed the SQiD in clinical practice through implementation strategies. Clinician investment was inconsistent and warrants further investigation.
Delirium is a syndrome, characterised by a disturbance in attention and awareness that develops over a short period and fluctuates over time,
We hypothesise that the popularity of the SQiD may relate to its simplicity and face validity. The SQiD comprises a single question
Although validated and used clinically,
The study setting was the haematology/oncology ward at a large university-affiliated acute hospital in Sydney, Australia. A nursing in-service on delirium and screening tools, including the SQiD, was conducted on the ward. A brief outline of the SQiD talks study was provided, including the aim and consent processes. Nurses were provided with verbal and written instructions about obtaining assent from both the patient and informant to participate in the interview in the context of limited initial disclosure, followed by full consent (see below). Nurses were given a printed prompt for their use of the SQiD question
Patients and their nominated informant were recruited to the study if they were adults able to communicate in English and provide informed consent. Patients and their informant were approached by nursing staff opportunistically when an informant was present at the bedside. As per the instructions provided to nursing staff, potential participants were invited to participate in a clinical communication study with nurses and advised about what this entailed (recording the conversation and accessing electronic medical records [EMR] for clinical details). Full details about the study were delayed until after the recording took place. Assent (agreement) to participate in the recording was essential. If assent to record was given, the nurse then audio-recorded the SQiD and subsequent conversation, in the patient’s presence.
After the recording was made, the study purpose and rationale were explained to the patient and informant by a research team member, to enable them to provide informed consent to participate. If the patient assented to participate but was unable to provide informed consent, their ‘person responsible’ was approached to consent on their behalf. Limited delayed full disclosure of the nature of the study was necessary to mitigate bias in the patient and informant response, caused by education regarding delirium that would occur during full informed consent.
Basic demographic data (age, sex), and documentation of delirium and/or dementia diagnoses in the patient’s EMR were recorded.
For consenting participants, audio files were transcribed verbatim, checked, and de-identified. A record was made of whether the SQiD interview was positive or negative for delirium, and the SQiD outcome was compared to contemporaneous clinician documentation of delirium on the patient’s EMR. No research standard was applied to determine true positives or negatives for delirium as this was not a validation study. Participants were planned to be recruited until data saturation (i.e., when no new themes emerged with analysis of further transcripts).
Interview transcripts were analysed using thematic analysis (Braun and Clarke (2006), within a grounded theory framework (Glaser & Strauss, 1967) (
Data analysis
Grounded theory methodology was chosen to underpin the analysis for this study,
The interview transcripts were thematically analysed independently by two researchers (NH, AW), using the method of Braun and Clarke (2006). The interview transcripts were read twice, then analysed line-by-line and organised (coded) into themes and subthemes. As subsequent transcripts were analysed, an iterative process was used to re-examine data in light of evolving themes. Data were then mapped and organised into themes as analysis continued at a micro (each transcript) and macro (the whole dataset) level to ensure that they continued to represent the data accurately.
Methodological rigor
Attree and Milton’s quality appraisal checklist was used to guide the study methodology
Recruitment was from November 2022 to April 2023. Twenty-nine patients and their informants were recruited, the range in interview duration was 7-211 seconds (mean 66.1 seconds) (
| SQiD Positive (n=15) | SQiD Negative (n=14) | |
|---|---|---|
| Mean age (range) | 75.9 (65-92) | 68.2 (50-86) |
| Patient sex (Female, n,%) | 8, 53% | 5, 36% |
| Pre-existing diagnosis of cognitive impairment in EMR (n, %) | 1, 7% | 0, 0% |
| Informant cohabitating with patient (n, %) | 10, 67% | 11, 79% |
| Average interview length (seconds) (range) | 111.4 (63-211) | 21.7 (7-65) |
| Delirium documented in Health Record (n, %) | 5, 33% | 1, 7% |
Three themes emerged in the thematic analysis:
| Theme | Sub-theme | Quote (I=informant, N=nurse, P=patient) |
|---|---|---|
| Recognition of “confusion” |
Orientation | N: “And like place, and time and…knows where she is?” (interview 8) |
| Fluctuation | N: “Does it have any improvements at all? Or it’s just a steady decline, or…? Does she have bouts of, where she comes back to being…” (interview 22) |
|
| Duration/ onset | N: “Mmm. And do you think like that she is more like orientated and not confused when she’s in hospital, or is she the same as she is here at home as well?” (interview 22) |
|
| Underlying cause | N: “Six months? Was there anything that kind of, you think, maybe like triggered it, or it just kind of happened one day, woke up and that just how she was, or…?” (interview 22) |
|
| Equating confusion as normal old age change | I: “Uhh, not really, no. It’s, uhh, like most people as they age, their memory isn’t like it used to be” |
|
| Recognition of “confusion” |
Memory impairment | I: “She’s had that confusion, like she was sitting down there having breakfast, and not long after she’s ‘ah, wonder when I can have breakfast’, you know? So, she is getting confused.” (husband, interview 24) |
| Change in cognition | I: “I was just noticing that she took a lot longer to answer, and just not totally understanding the question” (niece, interview 3) |
|
| Functional change | I: “One time there, I was trying to get her into the shower, and she just couldn’t understand to put her step forward, to get into the shower… yet, two days later, she was able to get into the shower, and wash herself” (husband, interview 24) | |
| Perceptual disturbance | I: “Umm, just like seeing stuff, uhh seeing uhh random stuff, talking to himself a lot, umm, we never saw like those, those things…before” (grandson, interview 29) |
|
| Fluctuation | I: “If I based it on, umm, some calls that my dad has felt he needed to make to me, or which nurses have made to me when he’s been disoriented, then that’s seemed to be more in the… late afternoon” (daughter, interview 16) | |
| Underlying cause | I: “So we not sure whether it’s actually the fall or the drug, because it started on the same day” (grandson, interview 29) |
|
| Recognition of ‘normalcy’ | I:“No, I don’t think he’s been more confused lately…he’s just the same as he normally is” (friend, interview 10) |
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| Operational factors |
I: “Oh is that it?! Oh I was expecting 20 questions!!” (friend, interview 10) | |
| Operational factors |
Inaccessible conversations in native language (separate conversations between informant and patient) | N: “Okay. So, do you feel that your mum has been more confused lately?” |
| Joining the SQiD discussion | I: “Ohh, umm. When I rang in last night he…” |
|
| Inhibiting information gathering | P: “Don’t answer that one!” |
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| Informant discomfort: normalising and minimising the patient’s symptoms | I: “Very…a little bit grumpy, because he was going through a lot of pain and a lot of discomfort…so I would try not to talk too much [too]…which is a bit hard for me” (de facto partner, interview 27) |
|
| Corroboration/ endorsement | I: “Well, this morning my partner was telling me what he was dreaming, he had a bit of ummm, I don’t know, what do you call it, hallucinations?” |
|
| Operational factors |
I: “I can’t answer that because I’m from the Gold Coast…Dad would probably be able to answer that” (son, interview 22) | |
| Interpreting the SQiD outcome |
No becomes a yes | N: “So does (the patient) seem to be more confused lately?” |
| Unclear SQiD outcome | I: “we…it’s hard to tell…see, she’s been to hospital so many times, and she’s had so many tests, and so much medication and…I do find that there might be some…forgetfulness” |
|
| The SQiD outcome |
Team’s dismissal of informant information | N: “Is it something that you’re really concerned, or…” |
| Team takes informant information seriously | I: “But then, it happened again last week, and I rang up and spoke to [doctor’s name], his assistant, and they said ‘I’ll talk to him’, and then they said to bring her in.” (husband, interview 24) |
This theme reflected both nursing staff and informant concepts of
This theme reflected practical aspects of administering the SQiD. Patients and informants commented on the ease and brevity of the tool (
The patient’s presence during the SQiD conversation had various impacts. Sometimes the patient provided useful information, but on other occasions appeared to inhibit information gathering. Some informants appeared to be uncomfortable disclosing information in front of the patient, leading to normalising or minimising potential symptoms of delirium.
The interpretation of the SQiD outcome was not straightforward. There were occasions where an initial negative response to the SQiD became a positive result through further discussion with an inquisitive nurse. On other occasions, the SQiD result was unclear despite discussion (
The outcome of informants raising concerns about possible delirium with treating teams was infrequently discussed. However, there was a range of responses from dismissal to action (
Three overarching themes emerged:
Illustrative quotes are presented in
| Overarching theme | Subtheme | Quotes (I=informant, N =nurse, P=patient) |
|---|---|---|
| Clinician investment/ confidence | Lack of investment | N: “Hello. Do you think (the patient) has been more confused lately?” |
| Communication techniques | Active listening | I: “Confused. Umm. No, not until she got to hospital” |
| Checking | N: “So when she was initially confused, like, what was the behaviours that were happening? Or like, what were you noticing?” |
|
| Combining open and closed questioning | N:” And how so, like what have you noticed?” |
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| Empathy and validation | N: “It’s not helpful for you, if you’re feeling forgetful as well” (interview 25) |
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| Paraphrasing the SQiD | N: “No? And he hasn’t had any, like, bouts of confusion that you’ve noticed or…since coming into hospital, or since he’s been here?” (interview 23) |
|
| Use of humour | N: “And what date it is as well?” |
|
| Collusion with informant/patient | I: “I don’t know whether that’s confusion? Right, coz it’s hard to say. There’s forgetfulness, which, to me, is different from confusion” |
|
| Knowledge of delirium and other cognitive disorders | Focus on orientation rather than full spectrum of delirium symptoms | N: "So, say like, short term memory, kind of little things, you know, maybe more forgetful but…he knows where he is and stuff like that?" (interview 25) |
| Delirium not differentiated from other cognitive impairment | P: “Yeah, I’ve always had a little problem with short term memory” |
Immersion in the SQiD transcripts revealed that some nurses were more engaged or confident in following on from the SQiD prompt compared with others. Following an initial negative response to the SQiD, nurses varied from immediately ending the discussion to asking follow-up questions. In some cases a negative response was revised to a positive result via an iterative discussion between informant and nurse.
A variety of communication techniques were used by nurses, influencing the richness of information gathered and outcome. These techniques included active listening, checking and encouragement to enhance engagement. This intersected with the nurse’s curiosity and persistence that characterised some interviews, resulting in clarifying and sometimes even completely revising responses.
A nuanced interviewer tended to demonstrate a combination of open and closed questions, conveyed empathy and validation during the conversation, or used humour to defuse tension.
Some nurses followed up on the initial SQiD by paraphrasing it or exploring specific features of delirium, which elicited different or more detailed responses from the informant.
Nurse:
Informant:
Nurse:
Informant:
Nurse:
SQiD conversations where the patient actively contributed to discussions were more challenging to interpret (see
The nurse’s knowledge of delirium was evident in follow-up questions asked. Often, probing questions centred on orientation, rather than the full range of symptoms comprising syndromic delirium (e.g. inattention, fluctuation).
Nurse:
Although the SQiD conversation was focused on identifying recent changes in cognition, there were occasions where this may have been conflated with an underlying longer-term cognitive disorder, like dementia, which was not distinguished from syndromic delirium by the nurse.
Few publications utilise qualitative methods to better understand the functionality of delirium screening tools.
New insights were derived about what nurses and patients understand by the term
The premise of the SQiD is that clinicians could lead the informant from a colloquial understanding of confusion, via nuanced questioning, towards an indication of delirium presence or absence.
It also emerged that judging the SQiD outcome can be difficult. While some nurses accepted a negative response to the SQiD at face value, others were more curious and went on to explore symptoms of delirium, sometimes eliciting a different, potentially more accurate result. The SQiD may engage curiosity and interest in detecting delirium in some clinicians, while others apply it with less engagement.
The overarching themes derived illustrate the challenges of embedding delirium screening in clinical practice, and opportunities for enhancing the efficacy of the SQiD by optimising the information gathered from informants. Clinician knowledge about delirium appears to be an important factor in achieving a useful SQiD. This study shows that clinician understanding of delirium cannot be assumed. Nurses with a more thorough understanding of the nature of delirium and its differentiation from other cognitive disorders, may be able to probe for delirium symptoms in a more targeted manner and identify longer-term cognitive impairment which may predispose to delirium.
Delirium management is an important consequence of detection.
Communication techniques emerged as important in helping or hindering the SQiD conversation. The use of validation, encouragement, paraphrasing, and humour, facilitated data gathering from informants, echoing the observations of others.
This overarching theme of communication was closely linked with investment in the SQiD tool. Curiosity and/or investment in engaging in discussion moved the interaction beyond the single question to activate effective delirium screening. This is in contrast with tools like the 4AT, which although giving the clinician less flexibility in administration, provide measurable observations and cognitive tests with patients themselves.
Although no new themes emerged in the final interview, we may not have reached data saturation. As a pragmatic time-limited clinical study with minimal funding, we relied on staff who were undertaking the study additional to their regular clinical duties during a period of COVID-related staff shortages, leading to challenges in participant recruitment. Additionally, as analysis was based on transcripts only, important concurrent nonverbal communication may have been missed. Nursing staff administering the tool were not blinded to the study aims. This, along with recording the informant interview, may have affected participation and discussion in various ways, e.g., by encouraging an enhanced clinical interaction that was not reflective of usual practice.
This is the first qualitative study examining how the SQiD works in delirium screening. We gained insights into how nurses and informants conceptualise confusion, operational aspects of the tool, and the nuances of interpreting the screening result. Overarching themes situated the tool within real-world clinical contexts, observing challenges of clinician investment and engagement in delirium screening, variable knowledge bases and communication skills. The findings suggest a need for further qualitative analysis of the SQiD in clinical settings, particularly how effectiveness may be improved by harnessing the function of the SQiD in leveraging communication between clinicians and families/carers to encourage clinician curiosity and interest in delirium detection.
The views canvassed in the following article reflect the beliefs of the three authors and not the institutions they represent.
The authors confirm contribution to the paper as follows:
Conceptualisation: MS, AW; data curation: NH; formal analysis: NH, AW; funding acquisition: NH, AW; investigation: NH; methodology: NH, AW, MS; project administration: NH, AW; supervision: MS, AW; writing– original draft: NH, AW; writing – review and editing: NH, MS, AW.
Approval for this research was gained from the Concord Hospital Human Research Ethics Committee (protocol no. 2022/ETH01450).
MS was the original developer of the SQiD tool.
The authors thank Dr Alexandra Thoms and Ms Yu Ting Chan, along with the nursing staff of the study ward, for their assistance in data collection.