An educational improvement study on improving delirium learning through a novel delirium infographic in a public hospital setting

Introduction

Delirium, a serious medical condition, is often under-recognised and sub-optimally managed by hospital staff.^1,2 It accelerates cognitive decline and is associated with increased mortality and institutionalisation.^2–5 Educational interventions improve delirium recognition, underscoring their pivotal role in enhancing care standards.^6,7 The International delirium curriculum prioritises delirium in medical education and recommends integrating the curriculum requirements in medical degree programmes.⁶

The medical education landscape is evolving with a paradigm shift towards harnessing novel educational strategies. A scoping review on microlearning, the acquisition of knowledge or skills in small units, has shown a positive effect on knowledge and confidence among health professional students.⁸ The review has implications for educational researchers, faculty, and academic administrators to apply microlearning in practice to advance course content in didactic and clinical settings.⁸

Microlearning applications include infographics, podcasts, videos, and electronic learning modules, which can leverage digital technology for an engaging learning experience.^9,10 Infographics are visual representations of information that help communicate complex concepts and information efficiently and effectively.¹¹ As an emerging pedagogy in medical education, infographics enable students and clinicians to engage in “just-in-time” learning.¹⁰ We hypothesised that implementing a delirium infographic with microlearning as a pedagogy would improve delirium learning among medical students within a Geriatric Psychiatry Liaison Service.

Our study evaluates an educational intervention using a novel infographic to improve delirium learning among medical students within the Geriatric Psychiatry Liaison Service at Changi General Hospital, a public hospital in Singapore.

Methods

Study setting, design and participants

Duke-NUS Medical School is a postgraduate program in Singapore and one of three medical schools in Singapore with on-site placements in psychiatry for Year 2 clerkships across four public hospitals: Changi General Hospital, Singapore General Hospital, Sengkang General Hospital and the Institute of Mental Health, a tertiary Psychiatry Hospital in Singapore.

The Geriatric Psychiatry Liaison Service is a service provision for geriatric wards in Changi General Hospital, and the liaison team composition comprises a Consultant Old Age Psychiatrist, trainees in psychiatry, and psychologists.¹² Before August 2022, the study site had no prior placements for Duke-NUS year 2 medical students within the Geriatric Psychiatry Liaison Service team. In August 2022, Duke-NUS year 2 medical students had a clinical attachment with the liaison team during their two-week placement with the Department of Psychological Medicine at the study site in Changi General Hospital, a public hospital with over 1000 beds.¹²

The interdisciplinary study team comprised a study lead Old Age Psychiatrist, one pharmacist, an advanced practice nurse, an analyst, one General Adult Psychiatrist, two Duke-NUS medical students posted in August 2022 in the Department of Psychological Medicine in Changi General Hospital, an academic expert in medical education from the Department of Gastroenterology in another public hospital, an International Academic Geriatrician and all Duke-NUS Psychiatry faculty who were General Adult Psychiatrists across three other public hospitals.

In this educational improvement study, we employed the Plan Do Study Act (PDSA) methodology with PDSA cycles to design, develop, implement, and assess the infographic’s effectiveness in delirium education.¹³ We employed the Model For Improvement with a time frame of 18 months from August 2022.¹⁴

All medical students posted to the Geriatric Psychiatry Liaison Service during the study period from September 2022 to November 2023 were eligible participants in the current study. The study’s Old Age Psychiatrist implemented the infographic as an educational intervention and conducted bedside teaching to medical students on delirium assessment, diagnosis, and detection using 4AT.^15–17

In the first PDSA cycle, we designed a needs assessment questionnaire to facilitate a student-centric approach to the infographic’s design. In subsequent PDSA cycles (cycles 2 to 6), we implemented and evaluated the usefulness of the infographic to augment delirium learning.

We used an anonymous survey as a measurement tool with a qualitative learner-reflective approach to evaluate delirium learning in all PDSA cycles.

“Tell us about your reflections on delirium learning in the Geriatric Psychiatry Liaison Service” was the open-ended question in free text format in the anonymous survey questionnaire.

PDSA methodology and interventions are discussed in detail below.

Figure 1 on PDSA cycles.

Figure 1.PDSA Cycles

1^st PDSA cycle

We aimed to design the first version of the delirium infographic.

P (Plan): In September 2022, the interdisciplinary study team was convened to brainstorm ideas about improving delirium learning in the Geriatric Psychiatry Liaison Service. The meeting resulted in the co-production of a needs assessment survey questionnaire.

Supplementary Table 1: The study team’s suggestions on designing the needs assessment survey and qualitative evaluation of learner reflections

D (Do): The needs assessment survey was administered to all Duke-NUS year 2 medical students posted to the Geriatric Psychiatry Liaison team between October 2022 and November 2022. Following the pre-learning survey, the Old Age Psychiatrist delivered a 15-minute induction huddle about the service, with a bedside demonstration of 4AT, a delirium detection tool,^15–17 and discussed a clinical diagnosis of delirium using the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5) diagnostic criteria.¹⁸ After the completion of psychiatry assessments by the Geriatric Psychiatry Liaison team, the Old Age Psychiatrist conducted the second 15-minute learning huddle with the medical students to discuss feedback and learning reflections.^19,20 The learners subsequently participated in the second anonymous survey, which evaluated qualitative feedback on delirium learning. Participant consent was voluntary and implied if the medical students had completed the anonymous survey.

S (Study): We analysed the needs assessment survey data and studied the results.

A (Act): We reflected on the needs assessment survey results, and the Old Age Psychiatrist sketched the first version of the infographic’s layout and content involving the 2 Duke-NUS students in the study team. The content included various learning headings on a summary of what delirium is,^{2–5,15,18,21} diagnosis using DSM diagnostic criteria,¹⁸ subtypes^{4,15,18,22,23} validated detection tools,^{3,5,15,16,24,25} triggers and precipitants,³ physical examinations,^15,21 investigations,^15,21 multicomponent interventions in delirium prevention,⁵ medication review,^5,15,26–30 pharmacological and non-pharmacological risk reduction and management,^15,21 complications and outcomes in delirium.^2–5,15,21

2^nd PDSA cycle

The Old Age Psychiatrist implemented the first version of the delirium infographic as an educational intervention during the initial learning huddle with the medical students in the geriatric ward. The infographic was shared with the medical students as a preface to subsequent clinical assessments. After the learning huddle, the medical students participated in the bedside clinical assessments with the Geriatric Psychiatry Liaison team. After completing clinical assessments in the geriatric ward, the Old Age Psychiatrist delivered the second learning huddle. The students were then invited to reflect on delirium learning using an anonymous survey.

The study period for the second cycle was between December 2022 and June 2023.

Following discussions and feedback from the study interdisciplinary team, we added delirium distress and refined the medication review component of the infographic by including over-the-counter drugs.

3^rd and 4^th PDSA cycles

In PDSA cycles 3 and 4, we implemented the second version of the infographic between June 2023 and August 2023 and evaluated medical student reflections on delirium learning similar to cycle 2.

Following discussions and feedback from the study interdisciplinary team, championing delirium was added to the infographic content in cycle 3 and refined in cycle 4.

5^th and 6^th PDSA cycles

We tested the third version of the infographic on medical students posted in September 2023 for cycle 5 and November 2023 for cycle 6 and evaluated learner reflections similar to cycles 3 and 4.

The infographic design and aesthetics were further improved in cycle 5 and at the end of cycle 6.

International Delirium guidelines,^15,21 scientific evidence on delirium care,^{1–7,21–39} interprofessional education,⁴⁰ international delirium curriculum and Singapore’s Ministry of Health Outcomes and Standards for undergraduate medical education recommendations⁴¹ and the PDSA cycles guided the creation and refinements for a learner-centred delirium infographic.

The study’s educational interventions and ideas for achieving the aim were discussed with the study team and the International Academic Geriatricians through multimodal communication, emails, virtual platforms (including Zoom), and in-person meetings.

Data collection and analysis

A government web-based survey tool was used to design the study’s anonymous questionnaire.⁴² The Old Age Psychiatrist collected the study data prospectively from learners using anonymous online survey questionnaires.

The quantitative data from the needs assessment questionnaire in the first PDSA cycle was analysed using descriptive statistics.

In all PDSA cycles, qualitative methodology was employed, and we evaluated the medical students’ written reflections on delirium learning. The qualitative data was analysed thematically, coding reflections into specific themes and sub-themes to enhance the depth of qualitative analysis.

Results

A total of 28 medical student learners participated in 6 PDSA cycles with a 100% response rate to the anonymised survey.

The needs assessment survey results in the first PDSA cycle, analysed using descriptive statistics, are presented in the supplementary material. The data is presented in absolute counts due to the small number of study participants.

Refer to Supplementary material on needs assessment survey results (Supplementary Figure 1-3).

The results of thematic analysis for all PDSA cycles (Table 1-3).

The study analyst was a single coder who conducted the coding process, systematically identifying and categorising key themes and sub-themes within the reflections provided by participants. The analysis read through the responses multiple times to immerse in the data and generated initial codes by highlighting significant phrases and ideas in the responses.⁴³ Codes were grouped into broader themes that reflected shared patterns across participant responses. The thematic structure was refined iteratively to ensure coherence and clarity. The analyst reviewed themes to confirm that they accurately represented the data and provided meaningful insights into participants’ reflections on delirium learning. The themes, with some exemplary quotes, are listed below.

In the PDSA 1^st cycle, all 7 participants provided learner reflections. The data analysis identified 4 themes:

Team approach, knowledge enhancement, learning opportunities and recognition of delirium.

“A great learning opportunity to have a first-hand experience and to partake in different parts of a comprehensive geriatric psychiatry assessment.”

In the PDSA 2^nd cycle, the qualitative data of all 9 participants were extracted, generating 3 themes: visual appeal, infographic comprehensiveness and conciseness, which highlighted the infographic’s usefulness in delirium learning. The medical students expressed the infographic as useful and visually appealing.

“It’s good to have a graphical review, not cluttered.”

“A good overview for delirium: its diagnostic criteria, clinical features, management, and what we can do in other settings outside of psychiatry.”

“Useful one-page summary and overview of the important aspects of delirium knowledge.”

In the PDSA 3rd cycle, extracting all 4 participants’ qualitative data generated four themes: understanding diagnostic criteria, pre- and post-approach, the importance of education, and case-based learning. All 4 themes expressed the usefulness of the infographic in knowledge enhancement and understanding delirium and recommended that the infographic be disseminated to all healthcare professionals.

“Delirium is commonly seen in hospital settings. Hence, I find it particularly useful and strongly suggest this to be promoted to all healthcare professionals.”

PDSA 4^th cycle had 2 participants, and data extraction generated three themes: visual presentation, diagnostic criteria, and case-based discussion.

“Clearly shows the criteria, causes, and management for delirium.”

PDSA 5^th cycle had 3 participants, and analysis of learner reflections generated three themes: efficacy of screening tools, preparation for clinical practice and holistic approach.

"Succinctly presented, which allows easy memory retrieval."

PDSA 6^th cycle had 3 participants, with 5 themes generated from analysis of learner reflections: the screening tool’s effectiveness, theoretical foundation, bedside teaching, challenges in practice, and sequential learning journey.

“Helpful in terms of the 4AT screening tool.”

The final version of the delirium infographic ( Figure 2 ).

Figure 2.Final Infographic

Discussion

This educational improvement study on 28 medical students supports the implementation of an infographic as an educational intervention to improve delirium learning in a Geriatric Psychiatry Liaison Service. The learner reflections in this study demonstrate the usefulness of qualitative methodology in quality improvement studies.⁴⁴

The thematic analysis results indicated knowledge enhancement in all 6 PDSA cycles; the other recurring themes were the infographic’s comprehensiveness and visually appealing aesthetics. A mixed methods systematic review on digital education in delirium for healthcare professional students has demonstrated that digital programmes should be visually attractive, with opportunities for clinical practice and timely and appropriate feedback.⁴⁵ Consistent with the systematic review’s key findings and practice implications, we designed a visually appealing infographic in our study.⁴⁵

Microlearning was the pedagogy employed in our study, designed for learners to use the information in the infographic in “just-in-time” learning.^10,46 Evidence indicates that microlearning reduces cognitive overload by breaking down complex information into micro units.¹⁰ Furthermore, research in medical education has demonstrated that people learn better with cues and when words and pictures are presented simultaneously.⁴⁷ While there is emerging research data on podcasts and other technology-enhanced education in delirium,⁴⁵ robust data on microlearning in delirium education is lacking. We, therefore, propose the need for research advances on microlearning applications in delirium education with robust qualitative and quantitative study designs.

The study’s strengths include using a novel microlearning pedagogy and a comprehensive delirium infographic and the involvement of medical learners in study design, infographic content, and aesthetics, emphasising a learner-centred approach. The study’s qualitative approach captured the rich data on medical student reflections on delirium learning, which quantitative data alone may fail to capture.

We acknowledge the study’s limitation, reporting findings from a one-off educational intervention in a convenience sample of medical students. The study has selection bias, a potential limitation we recognise. The study is a quality improvement initiative, and having a large sample and collecting comprehensive demographic data with a control group of learners was not feasible, which we acknowledge as study limitations. The thematic analysis was undertaken by a single coder (study analyst), and we addressed this limitation using a systematic approach to thematic analysis. We did not capture patient-related outcomes such as length of stay, mortality and institutionalisation, which are essential but out of the study’s scope as an educational Quality Improvement study. Notwithstanding the limitations, we believe the results are meaningful, and the qualitative data captured real-time learner feedback.

We have now integrated the infographic into the Duke-NUS medical school electronic learning portal for psychiatry clerkship, which all medical students can access, embedding digital education in delirium. Plans are underway to disseminate the infographic to all residents and junior doctors in training at the study site as part of hospital orientation.

Through this publication, we aspire to promote the infographic as a digital intervention that students and clinicians can access at any time for “just-in-time” learning.

Conclusions

Our single-site educational improvement study, conducted in a real-world clinical setting, supports implementing a delirium infographic as an educational intervention, with microlearning as the pedagogy to augment delirium learning in a Geriatric Psychiatry Liaison Service in a public hospital in Singapore. We propose future research directions on microlearning as a pedagogy in delirium education to augment learner acquisition of knowledge and translation into improved patient care.

Acknowledgements

The authors thank Professor Robert Stewart, South London and Maudsley NHS Foundation Trust, Kings College London, Professor Jugdeep Dhesi, Professor of Geriatric Medicine, Guy’s and St Thomas’ NHS, Kings College London, and the clinical team, with whom the first author undertook an observer placement in 2019. The placement inspired the first author to undertake the study.

The authors thank Professor Terry Quinn, Professor of Geriatric Medicine at the University of Glasgow, for the comments on delirium detection using 4AT, delirium prevention and outcomes in the infographic content.

The authors thank Professor Alasdair MacLullich, Professor of Geriatric Medicine at the University of Edinburgh, for the comments on delirium distress and patient and caregiver education in the infographic content.

The authors thank all Duke-NUS learners participating in the Geriatric Psychiatry Liaison Service provision and this educational improvement study.

We thank Alvin Chew Zhen Jie, Office of Improvement Science, Changi General Hospital.

The authors thank Esha Tirukonda, a school student, Joan Shim Yoke Yen, Senior Associate Executive, Psychological Medicine, Changi General Hospital and Nurazila Binti Zakaria, Manager of Clinical Services – Medical Affairs, Changi General Hospital, for their inputs on aesthetics in the infographic.

Author contributions

BB conceptualised the infographic’s study design, creation, aesthetics and production.

BB wrote the article’s first draft, which was revised by MW.

All authors were involved in the study design, planning, interpretation of data and critical revisions.

MHT was the analyst.

All authors have consented to the publication in Delirium or Delirium Communications.

Ethics statement

Ethics Committee: SingHealth Centralised Institutional Review Board Exemption applies to healthcare, quality and service improvement studies. SingHealth Centralised Institutional Review Board, Singapore, advised exemption from a formal application for ethical approval as this study is deemed a quality improvement study.

Sources of study funding

None.

Declaration of conflict of interests

None.

Participant consent

Voluntary consent was required to participate in the educational improvement study, and consent was implied if the medical students completed the anonymous survey.

Author’s note

DRIVER Diagram⁴⁸ was accessed from the Institute for Healthcare Improvement as a visual representation of the contributors to achieve the study aims.

SQUIRE-EDU Guidelines⁴⁹ have been used to craft the manuscript writing.