Non-pharmacological psychiatric nursing interventions for auditory hallucinations in patients undergoing mechanical ventilation

Abstract

BACKGROUND

Auditory hallucinations are common among patients undergoing mechanical ventilation, are often linked to sedation and stress, and may prolong recovery. As such, effective nonpharmacological nursing strategies are required.

AIM

To explore and evaluate the clinical effectiveness of non-pharmacological psychiatric nursing interventions for auditory hallucinations in patients undergoing mechanical ventilation.

METHODS

Retrospective clinical data from 110 patients with auditory hallucinations while undergoing mechanical ventilation were divided into 2 groups (n = 55 each): study (bundled rehabilitation nursing), and control (routine care). The Auditory Hallucination Rating Scale and Hamilton Anxiety and Depression Scales (HAM-A and HAM-D, respectively) were used to assess changes in hallucinations and psychological status. Duration of mechanical ventilation, single auditory hallucinations, and hospital stay were compared. Sedation levels were assessed using the Richmond Agitation-Sedation Scale.

RESULTS

The study group exhibited significantly shorter mean duration of mechanical ventilation (6.56 ± 1.13 days), single hallucinations (3.34 ± 1.08 minutes), and hospital stay (12.22 ± 1.07 days) compared with the control group (8.03 ± 1.04 days, 5.13 ± 1.22 min, and 14.18 ± 1.27 days, respectively) (P < 0.05). After nursing intervention(s), both groups exhibited reduced Auditory Hallucination Rating Scale, HAM-A, and HAM-D scores; however, the reductions were more pronounced in the intervention group (P < 0.05), with no significant baseline differences (P > 0.05). The study group exhibited lower Richmond Agitation-Sedation Scale scores both at and after extubation (P < 0.05). Satisfaction with nursing care was higher in the intervention group (92.72%) than in the control group (76.36%) (P < 0.05).

CONCLUSION

Bundled rehabilitation nursing interventions for auditory hallucinations in patients undergoing mechanical ventilation effectively improve hallucination symptoms and psychological status, shorten mechanical ventilation and hospitalization, promote recovery, and enhance patient satisfaction.

Key Words: Mechanical ventilation; Auditory hallucinations; Psychiatry; Bundled rehabilitation care; Sedation

Core Tip: Results of this study demonstrated that bundled rehabilitation nursing interventions significantly improved outcomes of mechanically ventilated patients experiencing auditory hallucinations. These non-pharmacological strategies reduced the duration of hallucinations, anxiety, and depression scores. Moreover, they shortened mechanical ventilation and hospitalization, and enhanced patient satisfaction with nursing care. These findings provide evidence supporting the integration of structured psychiatric nursing care into critical care protocols to address psychological distress in patients undergoing mechanical ventilation, promote faster recovery, and reduce reliance on pharmacological interventions.

INTRODUCTION

Mechanical ventilation is a clinically important therapeutic modality. In clinical practice, some patients may develop psychotic symptoms, such as auditory hallucinations, due to factors such as isolation in the intensive care unit (ICU) environment and drug-induced metabolic disturbances, with an incidence rate of 27%[1,2]. However, such symptoms are frequently misinterpreted as delirium or drug side effects and, consequently, are overlooked. Auditory hallucinations not only exacerbate negative emotions and compromise treatment efficacy, but also prolong the duration of mechanical ventilation and ICU stay while increasing the risk for stress-related disorders[3,4]. Current clinical practice relies primarily on sedative medications for symptom control; however, this approach carries the risk for excessive sedation, circulatory suppression, and worsened delirium. As such, exploring non-pharmacological strategies centered on psychiatric rehabilitation nursing is important. Non-pharmacological nursing interventions include cognitive interventions, psychological support, family involvement, and multidisciplinary follow-up. These approaches can directly alleviate auditory hallucinations without increasing medication burden, enhance patients’ psychological security and ventilation synchrony, shorten the duration of mechanical ventilation, reduce reintubation rates, and establish cognitive and emotional foundations for post-ICU rehabilitation[5]. Bundled rehabilitation nursing adopts a patient-centered approach that integrates evidence-based nursing with rehabilitation medicine. It involves a systematic and standardized combination of multiple proven rehabilitation nursing measures implemented concurrently within a defined timeframe to maximize patient recovery and minimise complications[6]. Accordingly, this retrospective study analyzed the efficacy of bundled rehabilitation care in patients experiencing auditory hallucinations.

MATERIALS AND METHODS

General data

This retrospective study collected clinical data from 110 patients hospitalized at the authors’ institution between January 2022 and December 2024, who experienced auditory hallucinations during mechanical ventilation. This study complied with the requirements of the Declaration of Helsinki. The inclusion criteria were as follows: Age ≥ 18 years; duration of mechanical ventilation ≥ 24 hours; absence of indications for deep sedation[6]; underwent endotracheal intubation ventilation; exhibited/experienced auditory hallucinations; and patients and their families provided informed consent. The exclusion criteria were as follows: Coma with concomitant cranial trauma or stroke; cognitive impairment; abnormal hepatic or renal function; emergency state requiring deep sedation, and analgesic or sedative treatment. Patients were divided into 2 groups (n = 55 each) according to the nursing intervention implemented. The control group comprised 55 patients (29 male, 26 female; mean age, 52.33 ± 5.16 years (range: 38-71 years); mean body mass index 21.74 ± 1.05 kg/m² (range: 19.7-23.6 kg/m²). Causes of admission included the following: Postoperative pneumonia (n = 14), severe pneumonia (n = 26), and respiratory failure (n = 15). The study group also comprised 55 patients [28 male, 27 female; mean age, 53.07 ± 5.24 years (range: 35-76 years); mean body mass index, 21.08 ± 1.13 kg/m² (range: 20.2-23.3 kg/m²)]. Causes of admission included the following: Postoperative cases (n = 12); severe pneumonia (n = 29), and respiratory failure (n = 14). Clinical characteristics between the groups were comparable (P > 0.05).

Protocol

Control group: The control group received conventional nursing interventions, with clinical monitoring, vital signs, including temperature, heart rate, respiratory rate, and blood pressure. Fluid intake and output were recorded over a 24-hour period, with particular attention devoted to blood gas levels. Medications were administered as prescribed.

Position management: Patient positioning was adjusted every 2 hours to ensure that the head of the bed remained elevated ≥ 30° to maintain functional limb positioning.

Ventilator management: Strict adherence to standard protocols for ventilator operation. Initially, the pressure-assisted controlled ventilation mode was used with a respiratory rate of 10-20 breaths/minute, pressure control at 10-22 cmH₂O, positive end-expiratory pressure 5-10 cmH₂O, and oxygen concentration maintained between 35% and 70%. Before extubation, the transition to pressure support ventilation mode with pressure support was set at 10-15 cmH₂O, positive end-expiratory pressure at 5-8 cmH₂O, and oxygen concentration adjusted to 30%-35%. All parameters were individually titrated according to patient clinical responses. A spontaneous breathing trial was performed before extubation, with a successful trial permitting extubation.

Airway management: The endotracheal tube was securely fixed and appropriately positioned. Each nursing shift measured and documented the scale’s distance from the tube to the incisors.

Monitoring of airway patency: To ensure safety, nursing assistance was required during turning or repositioning.

Nutritional support: Patient nutritional tolerance was closely monitored, and dietary management was implemented.

Health education: The necessity of mechanical ventilation was explained to each patient, and potential complications were described. Particular emphasis was placed on the causes and management of auditory hallucinations to enhance patient understanding.

Research group: This group received cluster-based rehabilitation nursing implemented by department nurses.

Cognitive intervention: Nurses proactively obtained medical history information provided by patients and their families, assessed whether patients had cognitive impairments, and designed personalized cognitive intervention plans based on the assessment results. Through orientation training, patients’ abilities to recognize the time, location, and people were enhanced, helping them to better perceive the surrounding environment. During the handover process, nurses explained the current environment to patients, proactively inquired about them, and devoted attention to their subjective feelings to alleviate their anxiety and tension. Before performing various medical and nursing operations, nurses explained the process and purpose of the operations to patients in detail, popularized knowledge related to the patients’ disease(s), and helped improve their memory and comprehension abilities. Audio-visual stimulation was provided according to patient preferences, such as playing soft and pleasant light music or the patients' favorite songs. During family visits, nurses guided family members to participate in the patients’ cognitive function training. Emphasis was placed on daily communication with patients, and active efforts were made to build a trusting relationship, laying a foundation for the implementation of precise psychological support.

Sleep support: Curtains were kept open during the day to ensure sufficient indoor light, reducing noise and light interference in the afternoon and night. The alarm volume of monitors at night was lowered, and indoor lights were dimmed to ensure that environmental sound was < 45 decibels and illuminance did not exceed 40 Lux. Nursing and treatment work were arranged in a centralized manner as much as possible, and earplugs or eye masks were provided to patients according to their actual needs. Patients were helped to maintain a natural sleep-wake cycle and to perform scientific pain and sedation management. If patients experienced difficulty falling asleep or restlessness, the cause was first evaluated, and arbitrary additional medication was to be avoided. The ward temperature was adjusted to 24-26 °C, and humidity was maintained at 50%-60% to create a comfortable resting environment.

Early mobilization: If a patient had been on mechanical ventilation for > 24 hours, early mobilization was considered. Doctors and nurses worked together to comprehensively consider patients’ respiratory function indicators, ventilation parameters, and muscle strength scores to determine whether the patient was suitable for early mobilization and to help confirm the intensity level of mobilization. Physicians were mainly responsible for evaluating the overall condition of patients, whereas nurses determined the specific level of early mobilization through muscle strength assessment and [Richmond Agitation-Sedation Scale (RASS)] score. If the patient exhibited signs of intolerance during mobilization, such as a mean arterial pressure < 65 mmHg or > 110 mmHg, heart rate < 40 beats/minute or > 130 beats/minute, or expressed discomfort and requested to stop through gestures, expressions, or body movements, corresponding measures were implemented immediately. Throughout the early mobilization process, medical staff closely monitored changes in patient condition and ensured safe fixation of various pipelines. To prevent reflux and aspiration, enteral nutrition was temporarily discontinued during mobilization to prevent reflux and aspiration. Simultaneously, the highest level of early mobilization that the patient could tolerate was accurately recorded.

Humanist care: Nurses proactively communicated in depth with the patient’s family members to fully understand the patient’s daily habits and personal preferences to formulate and implement personalized nursing measures. On the one hand, importance was attached to nonverbal communication methods. Nurses faced patients with a smile and conveyed encouragement through actions such as giving “thumbs up” and shaking hands. A flexible visiting schedule was implemented for family members; the frequency and duration of visits were appropriately increased in accordance with the actual wishes of patients and their families to enhance emotional support and improve patient cooperation with treatment. However, effective communication with patients must be maintained for a timely understanding of their psychological states and specific needs. Simultaneously, necessary psychological counseling and emotional support were provided to family members who were guided to encourage patients from multiple psychological and emotional aspects to enhance their confidence in overcoming the disease.

Observation indicators

Treatment outcomes: Mechanical ventilation duration, single auditory hallucination duration, and hospitalization length were observed and recorded for both patient groups.

Auditory hallucination(s): Auditory hallucination symptoms were assessed using the Auditory Hallucination Rating Scale (AHRS) before and 4 weeks post-intervention. Higher scores indicate more severe symptoms[7].

Psychological status: Assess the patient’s psychological state using the Hamilton Anxiety and Depression Scales (HAM-A and HAM-D, respectively) before and 4 weeks post-intervention. The HAM-A comprises 14 items scored 0-4 each, with 7 as the cut-off point; higher scores indicate greater anxiety severity. The HAM-D comprises 17 items, with items 4-6, 12-14, and 16 scoring 0-2 points, and the others scoring 0-4 points. A score of 7 was the cut-off point, with higher scores indicating more severe depression[8].

Sedation status: The RASS was administered during and after extubation to evaluate patient sedation levels. Scores of -5 to -3 indicated sedation, -2 to 0 denoted ideal sedation, and 1 to 4 signified agitation[9].

Satisfaction with nursing care: On discharge, a satisfaction survey was administered to assess patient satisfaction with nursing care, covering aspects including diagnostic and treatment environment, health education, nursing skills, and service attitudes. The maximum total score was 100 points. Scores ranged as follows: 0-60 points, dissatisfied; 61-79, fair; 80-89, satisfied; and ≥ 90, very satisfied[10]. Overall satisfaction = satisfied + very satisfied.

Statistical analysis

Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY, United States). Count data are presented as numbers and percentages. Intergroup comparisons were performed using the χ² test. Normally distributed continuous data are expressed as mean ± SD, with intergroup comparisons performed using t-tests. Differences with P < 0.05 were considered to be statistically significant.

RESULTS

Comparison of clinical outcomes

The study group exhibited a significantly shorter duration of mechanical ventilation and hospital stay than those for the control group (P < 0.05) (Table 1).

Table 1 Comparison of clinical treatment outcomes, mean ± SD.

Group	n	Mechanical ventilation, days	Single auditory hallucination, minutes	Postoperative hospital stay, days
Research	55	6.56 ± 1.13	3.34 ± 1.08	12.22 ± 1.07
Control	55	8.03 ± 1.04	5.13 ± 1.22	14.18 ± 1.27
t		7.099	6.273	8.753
P value		0.000	0.001	0.001

Comparison of auditory hallucinations before and after nursing intervention

Post-intervention assessments revealed reduced AHRS scores in both groups, with the study group exhibiting lower scores than those in the control group (P < 0.05). No significant preintervention differences were found between the groups (P > 0.05) (Table 2).

Table 2 Comparison of Auditory Hallucination Rating Scale scores before and after nursing intervention, mean ± SD.

Group	n	Pre-intervention	Post-intervention
Research	55	8.71 ± 2.06	4.24 ± 1.03a
Control	55	8.63 ± 2.11	5.65 ± 1.22a
t		0.201	6.549
P value		0.841	0.001

^aP < 0.05 vs pretreatment values within the same group.

Comparison of psychological status before and after nursing intervention

Following assessment, both groups exhibited reduced HAM-A and HAM-D scores post-intervention, with the study group scoring lower than the control group (P < 0.05). No significant differences were observed between the pre-intervention groups (P > 0.05) (Table 3).

Table 3 Comparison of Emotional State Scores before and after nursing care, mean ± SD.

Group	n	HAM-D		HAM-A
		Pre-nursing	Post-nursing	Pre-nursing	Post-nursing
Research	55	13.09 ± 1.15	7.56 ± 1.25a	14.49 ± 1.37	8.42 ± 1.12a
Control	55	13.11 ± 1.23	6.48 ± 1.13a	14.55 ± 1.40	7.05 ± 1.211
t		0.088	4.752	0.227	6.162
P value		0.930	0.000	0.821	0.000

^aP < 0.05 vs pretreatment values within the same group.

HAM-A: Hamilton Anxiety Scale-Anxiety; HAM-D: Hamilton Anxiety Scale-Depression.

Intergroup comparison of sedation status during and after extubation

Measurements revealed that the RASS scores during and after extubation were lower in the intervention group than in the control group (P < 0.05) (Table 4).

Table 4 Comparison of Richmond Agitation-Sedation Scale scores at the time of extubation and post-extubation, mean ± SD.

Group	n	During extubation	After extubation
Research	55	7.15 ± 1.26	4.24 ± 1.03a
Control	55	8.63 ± 2.11	5.65 ± 1.22a
t		4.466	6.549
P value		0.001	0.001

^aP < 0.05 vs pretreatment values within the same group.

Comparison of patient satisfaction with nursing care

Questionnaire surveys indicated that patient satisfaction with nursing care in the study group was 92.72%, which was higher than that in the control group (76.36%) (P < 0.05) (Table 5).

Table 5 Comparison of satisfaction with nursing, n (%).

Group	n	Very satisfied	Satisfied	Neutral	Dissatisfied	Overall satisfaction
Research	55	36 (65.45)	15 (27.27)	4 (7.28)	0 (0)	51 (92.72)
Control	55	25 (45.45)	17 (30.91)	9 (16.36)	4 (7.28)	42 (76.36)
χ2						9.273
P value						0.001

DISCUSSION

With changing environmental factors, the prevalence of severe respiratory diseases continues to increase, adversely affecting patients’ respiratory function and overall health, necessitating respiratory support. Mechanical ventilation is widely used clinically to sustain respiratory function, safeguard patient lives, and enhance resuscitation success rates[11]. However, most patients undergoing mechanical ventilation experience stressful reactions. Due to tracheal intubation procedures, administration of sedative and analgesic medications, and the confined ICU environment, these patients frequently exhibit psychiatric symptoms, such as anxiety and auditory hallucinations[12]. As covert and distressing symptom manifestations, auditory hallucinations can negatively affect treatment outcomes and prognosis. Consequently, there is an urgent need to explore targeted nursing strategies.

This retrospective study evaluated the feasibility and efficacy of bundled rehabilitation care in patients who experienced auditory hallucinations during mechanical ventilation. The results demonstrated that the intervention group, after receiving bundled non-pharmacological psychiatric rehabilitation care, had a significantly shorter duration of mechanical ventilation and hospital stay than the control group. Additionally, the duration of individual hallucinations was markedly reduced, and the differences were statistically significant. These findings suggest that this care model effectively ameliorated auditory hallucinations in patients undergoing mechanical ventilation, while accelerating overall recovery.

The AHRS scores further corroborated these findings. The post-intervention scores decreased in both groups; however, the reduction was markedly greater in the study group. This indicates that non-pharmacological interventions demonstrate superior efficacy compared with conventional care in controlling auditory hallucination intensity and frequency[13-15]. Mechanistically, the bundled rehabilitation nursing model likely exerted its effects through multiple synergistic pathways. First, structured sleep support interventions, including maintaining a natural light-dark cycle, minimizing nocturnal noise and light, and optimizing the ward environment, directly promoted sleep-wake rhythm normalization. Improved sleep architecture reduces sensory misperception and hallucinatory susceptibility by stabilizing neurophysiological function. Second, cognitive interventions, such as reality orientation training, personalized communication, and family involvement, enhance patients’ reality testing and environmental awareness. Strengthened reality orientation may counteract the disorienting effects of the ICU environment, thereby reducing the frequency and duration of hallucinatory episodes. Furthermore, early mobilization and humanistic care contribute to psychological stabilization and emotional support, which in turn mitigate anxiety and depressive symptoms, both of which are recognized contributors to hallucination severity.

These findings align with those of previous research investigating perceptual abnormalities in patients in the ICU, demonstrating that interventions incorporating environmental adaptation, cognitive-behavioral techniques, music therapy, and family involvement can reduce sensory deprivation and anxiety, thereby lowering the incidence and severity of hallucinations. Notably, the study group exhibited significantly lower HAM-A and HAM-D scores than the control group, indicating the efficacy of this nursing model in alleviating anxiety and depressive symptoms. Such emotional improvements may serve as crucial mediating mechanisms to reduce auditory hallucinations. Reduced anxiety levels decrease sympathetic nervous system hyperarousal and improve sleep architecture, thereby undermining the physiological basis of hallucinations. Alleviating depressive symptoms assists patients in rebuilding their reality-testing abilities, diminishing subjective distress and behavioral responses associated with auditory hallucinations. Nonpharmacological psychiatric rehabilitation nursing generates synergistic effects through multisensory stimulation, cognitive restructuring, and social support[16,17]. Shortening the duration of mechanical ventilation not only reduces the risk for ventilator-associated complications but also decreases sedative usage and associated side effects such as delirium and circulatory suppression. A shorter hospital stay directly lowers medical costs and alleviates the pressure on bed turnover[18,19]. Furthermore, the duration of single auditory hallucinations in the study group decreased, from > 5 minutes to approximately 3 minutes, indicating significantly reduced distress. This facilitated improved treatment compliance and early engagement in activities, thereby fostering a virtuous cycle.

It is important to note that, although this study emphasized non-pharmacological strategies, all patients, including those in the study group, received standardized sedation management as per the institutional protocol. Sedative medications were not entirely avoided; however, the study group demonstrated reduced sedative requirements, as reflected by lower RASS scores during and after extubation. These findings suggest that bundled interventions may attenuate the need for pharmacological sedation by addressing the underlying psychological and environmental triggers of agitation and hallucinations. Future prospective studies should incorporate stricter medication use protocols, such as standardized sedation titration schedules and documentation of all psychoactive medications, to better control for this potential confounding factor and further validate the independent effects of non-pharmacological care.

Concurrently, this research revealed that non-pharmacological psychiatric bundled rehabilitation nursing not only alleviates auditory hallucinations in patients undergoing mechanical ventilation, but also optimizes sedation management and nursing experience. The study group exhibited significantly lower RASS scores both during and after extubation than the control group, which is consistent with relevant reports in the literature[20,21]. This indicates that maintaining patients within the target range for light sedation is more feasible, thereby avoiding the respiratory depression, delayed extubation, and delirium associated with excessive sedation. This outcome correlates with concurrent improvements in auditory hallucinations and anxiety symptoms; emotional stability reduces the reliance on sedatives, whereas shallow sedation preserves cognitive and communicative abilities. This facilitates the acceptance of interventions, such as environmental orientation and music therapy, thereby alleviating symptoms[22]. Notably, the study group exhibited significantly higher satisfaction with nursing (92.72%) than the control group, indicating reduced suffering, enhanced dignity, and strengthened information support. This further validates the humanistic values of the nursing model[23,24].

Although this retrospective study met sample size thresholds, it remained vulnerable to selection bias and context-specific practice patterns, thus constraining external validity. As such, confirmation in multicenter, randomized trials is imperative. Moreover, follow-up ceased at discharge, precluding quantification of post-ICU auditory-hallucination recurrence, residual anxiety or depression trajectories (HAM-A/HAM-D), and quality-of-life recovery (Short-Form-36) at 1-3 months, thereby limiting inferences regarding intervention sustainability. Adequately powered, prospective, multisite studies with extended longitudinal endpoints are required to address these gaps.

CONCLUSION

In summary, implementing bundled rehabilitation nursing for auditory hallucinations in patients undergoing mechanical ventilation experiencing auditory hallucinations helps alleviate hallucinatory symptoms, improve psychological well-being, shortens the duration of mechanical ventilation and hospital stay, advances the rehabilitation process, and achieves high patient satisfaction with care.