Nurses' Attitudes and Practices Related to Sedation: A National Survey

Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study

BACKGROUND

Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce.

AIM

To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making.

DESIGN

Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis.

SETTING AND PARTICIPANTS

This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate.

FINDINGS

Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation.

CONCLUSION

Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns.

IMPLICATIONS FOR CLINICAL PRACTICE

Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.

Perspectives on Sedation Among Interdisciplinary Team Members in ICU: A Survey Study

OBJECTIVE

To explore the interdisciplinary team members' beliefs and attitudes about sedation when caring for mechanically ventilated patients in the ICU.

DESIGN

Cross-sectional survey.

SETTING

A 17-bed cardiothoracic ICU at a tertiary care academic hospital in Colorado.

SUBJECTS

All nurses, physicians, advanced practice providers (APPs), respiratory therapists, physical therapists (PTs), and occupational therapists (OTs) who work in the cardiothoracic ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We modified a validated survey instrument to evaluate perspectives on sedation across members of the interdisciplinary ICU team. Survey responses were collected anonymously from 111 members (81% response rate). Respondents were predominantly female (70 [63%]). Most respondents across disciplines (94%) believed that their sedation practice made a difference in patients' outcomes. More nurses (48%), APPs (62%), and respiratory therapists (50%) believed that sedation could help alleviate the psychologic stress that patients experience on the ventilator than physicians (19%) and PTs/OTs (0%) (p = 0.008). The proportion of respondents who preferred to be sedated if they were mechanically ventilated themselves varied widely by discipline: respiratory therapists (88%), nurses (83%), APPs (54%), PTs/OTs (38%), and physicians (19%) (p < 0.001). In our exploratory analysis, listeners of an educational podcast had beliefs and attitudes more aligned with best evidence-based practices than nonlisteners.

CONCLUSIONS

We discovered significant interdisciplinary differences in the beliefs and attitudes regarding sedation use in the ICU. Since all ICU team members are involved in managing mechanically ventilated patients in the ICU, aligning the mental models of sedation may be essential to enhance interprofessional collaboration and promote sedation best practices.

Postoperative recovery among head and neck cancer patients receiving microvascular free flap surgery with implementing nurse-protocolized targeted sedation: relationship of use of sedatives and mechanical ventilation to length of ICU stay

PURPOSE

Patients receiving microvascular free flap surgery are usually admitted to a high-dependency adult intensive care unit (ICU). Research is limited to investigate postoperative recovery among head and neck cancer patients in the ICU. This study aimed to evaluate a nursing-protocolized targeted sedation on postoperative recovery and to examine the relationship of demographic characteristics, use of sedation, mechanical ventilator to length of ICU stay in patients receiving microvascular free flap surgery for head and neck reconstruction.

METHODS

This retrospective study involves 125 ICU patients at a medical centre in Taiwan. Medical records were reviewed between 1 January 2015 and 31 December 2018 including surgery-related data, medications and sedations used, and ICU-related outcomes.

RESULTS

The mean length of ICU stay was 6.2 days (SD = 2.6), and the mean duration of mechanical ventilation was 4.7 days (SD = 2.3). The daily dosage of sedation used in patients who received microvascular free flap surgery was dramatically reduced since the postoperative day (POD) 7. Over 50% of patients switched to PS + SIMV ventilator mode on POD 4. Duration of sedation used (r = 0.331, p < 0.001), total dosage of sedation (r = 0.901, p < 0.001), clear consciousness (r =  - 0.517, p < 0.001), and duration on mechanical ventilator (r = 0.378, p < 0.001) are correlated with the length of ICU stay.

CONCLUSION

This study provides an understanding of the use of sedation, mechanical ventilator, and length of ICU stay to inform the continued education for clinicians.

Patients' experiences and perceptions of dignity in end-of-life care in emergency departments: A qualitative study

AIMS

To explore and understand the experiences of patients with advanced illness in relation to dignity during end-of-life care in emergency departments.

DESIGN

Qualitative study based on Gadamer's hermeneutics.

METHODS

Between September 2019 and February 2020, 16 in-depth interviews were carried out with advanced illness patients who attended emergency departments. The participants were informed priorly and signed informed consent. The data were analysed using an inductive strategy for finding emerging themes. The Consolidated Criteria for Reporting Qualitative Research was used for writing the study's report.

RESULTS

In the data analysis process, two main themes emerged that glean the experiences of patients in relation to dignity during end-of-life care in emergency departments. 'Dignity as an individual's attribute' and 'Acting with dignity: Dignity as a behavioural attribute'.

CONCLUSION

Patient dignity in end-of-life care is centred around the principle of control (of oneself, one's death and one's emotions). The strategies required for patients to preserve their dignity can be somewhat incompatible with the dynamics and objectives of healthcare professionals who work in emergency departments.

IMPACT STATEMENT

The dignity of patients with advanced illness who attend emergency departments is a relevant issue that merits being addressed from the patients' perspective. Participants have identified that dignity is a way of being and behaving in the face of illness. Emergency departments need to respect end-of-life patients' desires by supporting and accompanying them, avoiding therapeutic obstinacy. We recommend care to be centred on patients' well-being, to respect their autonomy and decision-making processes, and to allow prompt referrals to palliative care services.

PATIENT OR PUBLIC CONTRIBUTION

Managers from the Emergency Departments participated in the study design and patients' recruitment. Patients' relatives were informed about the study's aim, and they contributed to the development of the interview protocol.

Clinical Nurse Specialist Practice: Impact on Improving Sedation Practice in Critical Care

PURPOSE/OBJECTIVES

Prolonged mechanical ventilation results from deeper levels of sedation. This may lead to impaired respiratory muscle functioning that develops into pneumonia, increases antibiotic use, increases delirium risk, and increases length of hospitalization. A trauma and surgical intensive care unit interdisciplinary team conducted a quality improvement project to lighten sedation levels and shorten mechanical ventilation time.

DESCRIPTION OF THE PROJECT

The project included multimodal elements to improve sedation practice. Standardizing the spontaneous awakening trial algorithm, creation of electronic health record tools, integration of sedation practices into daily rounds, and focused education for nursing were implemented in April 2021 through October 2021.

OUTCOME

A reduction of median hours spent on mechanical ventilation was achieved. Mechanical ventilation hours decreased from 77 to 70. Richmond Agitation Sedation Scale levels improved from a median of -2 to -1, and daily spontaneous awakening trials increased from 10% to 27% completed.

CONCLUSION

The quality improvement project demonstrated that, with increased daily spontaneous awakening trials and lighter sedation levels, the time patients spent on mechanical ventilation was shortened. There was no increase to self-extubation with lighter sedations levels. Shorter time on mechanical ventilation can reduce patient harm risks.

Prospective Validation of Sedation Scale Scores That Identify Light Sedation: A Pilot Study

BACKGROUND

Intensive care unit (ICU) sedation guidelines recommend targeting a light sedation level, but light sedation has no accepted definition, and inconsistent levels have been proposed.

OBJECTIVE

To determine Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores that best describe patients' ability to follow voice commands.

METHODS

This prospective, observational pilot study enrolled a convenience sample of ICU patients receiving mechanical ventilation. Pairs of trained investigators evaluated scores on the Sedation-Agitation Scale and Richmond Agitation-Sedation Scale and ability to follow commands before and up to 2 hours after sedation lightening in a blind, independent, simultaneous fashion. Positive predictive values (PPVs) and likelihood ratios (LRs) of Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores associated with light sedation (ability to follow at least 3 commands) were calculated.

RESULTS

Ninety-six assessments (50 before and 46 after lightening of sedation) were performed in medical ICU patients. Scores best associated with ability to follow at least 3 commands were Sedation-Agitation Scale score of 4 (PPV, 0.88; 95% CI, 0.70-0.98; LR, 14.0) and Richmond Agitation-Sedation Scale score of -1 (PPV, 0.81; 95% CI, 0.61-0.93; LR, 10.7), superior to previously recommended thresholds of Sedation-Agitation Scale score of 3 (PPV, 0.62; 95% CI, 0.48-0.75; LR, 3.1) and Richmond Agitation-Sedation Scale score of -3 (PPV, 0.52; 95% CI, 0.39-0.64; LR, 2.0).

CONCLUSIONS

The level of sedation most associated with the ability to follow commands appears higher than previously recommended. Further study is needed regarding the effects of sedation level on ICU patients' ability to follow commands and assessment of delirium, pain, and patient preferences.

Intensive care nurses' experiences using volatile anaesthetics in the intensive care unit: An exploratory study

OBJECTIVE

To explore the experiences intensive care nurses have with volatile anaesthetics in the intensive care unit.

RESEARCH METHODOLOGY AND DESIGN

A qualitative exploratory and descriptive design was used. Data were collected in 2019 from individual interviews with nine intensive care nurses, who were recruited using purposive sampling. Data were analysed using systematic text condensation.

SETTING

The study was undertaken in two general intensive care units from different university hospitals in Norway where volatile anaesthetics were utilised.

FINDINGS

Three categories emerged from the data analysis: experiencing the benefits of volatile anaesthetics; coping with unfamiliarity in handling volatile anaesthetics; and meeting challenges related to volatile anaesthetics in practice.

CONCLUSION

The intensive care nurses had positive experiences related to administering volatile anaesthetics in the intensive care unit and responded positively to the prospect of using it more often. Because volatile anaesthetics were rarely used in their units, the participants felt uncertain regarding its use due to unfamiliarity. Collegial support and guidelines were perceived as pivotal in helping them cope with this uncertainty. The participants also experienced several challenges in using volatile anaesthetics in the intensive care unit, with ambient pollution being regarded as the main challenge.

Critical Care Nurse Burnout, Moral Distress, and Mental Health During the COVID-19 Pandemic: A United States Survey

BACKGROUND

The COVID-19 pandemic has and will continue to have a tremendous influence on intensive care unit (ICU) nurses' mental health.

OBJECTIVES

The purpose of this study was to describe the impact of COVID-19 on nurse moral distress, burnout, and mental health.

METHODS

Between October 2020 and January 2021 this descriptive study recruited a national sample of nurses who worked in the ICU during the COVID-19 pandemic through American Association of Critical Care Nurses newsletters and social media.

RESULTS

A total of 488 survey responses were received from critical care nurses working in the U.S. during the COVID pandemic. Over two thirds of respondents experienced a shortage of personal protective equipment (PPE). Nurse respondents reported moderate/high levels of moral distress and burnout. Symptoms of moderate to severe depression and anxiety were reported by 44.6% and 31.1% of respondents, respectively. Forty-seven percent of respondents were at risk for having posttraumatic stress disorder (PTSD). Lack of perceived support from administration and shortage of PPE were associated with higher levels of burnout, moral distress, and PTSD symptoms.

CONCLUSIONS

Respondents had higher anxiety and depression than the general population and higher risk for having PTSD than recent veterans or patients after traumatic injury. High levels of reported burnout and moral distress increase the risk of nurses leaving ICU practice or the profession. This study offers important insights about the mental health of nurses during a global pandemic that can guide the development of customized interventions for ICU nurses related to this health care crisis.

Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in an intensive care unit: an experience of a Canadian community hospital in conducting a quality improvement project

BACKGROUND

Clinical guidelines suggest that routine assessment, treatment, and prevention of pain, agitation, and delirium (PAD) is essential to improving patient outcomes as delirium is associated with increased mortality and morbidity. Despite the well-established improvements on patient outcomes, adherence to PAD guidelines is poor in community intensive care units (ICU). This quality improvement (QI) project aims to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU and to describe the experience of a Canadian community hospital in conducting a QI project.

METHODS

A ten-member PAD advisory committee was formed to develop and implement the intervention. The intervention consisted of a multidisciplinary rounds script, poster, interviews, visual reminders, educational modules, pamphlet and video. The 4-week intervention targeted nurses, family members, physicians, and the multidisciplinary team. An uncontrolled, before-and-after study methodology was used. Adherence to PAD assessment guidelines by nurses was measured over a 6-week pre-intervention and over a 6-week post-intervention periods.

RESULTS

Data on 430 and 406 patient-days (PD) were available for analysis during the pre- and post- intervention periods, respectively. The intervention did not improve the proportion of PD with guideline compliance to the assessment of pain (23.4% vs. 22.4%, p=0.80), agitation (42.9% vs. 38.9%, p=0.28), nor delirium (35.2% vs. 29.6%, p=0.10) by nurses.

DISCUSSION

The implementation of a multifaceted and multidisciplinary intervention on PAD assessment did not result in significant improvements in guideline adherence in a community ICU. Barriers to knowledge translation are apparent at multiple levels including the personal level (low completion rates on educational modules), interventional level (under-collection of data), and organisational level (coinciding with hospital accreditation education). Our next steps include reintroduction of education modules using organisation approved platforms, updating existing ICU policy, updating admission order sets, and conducting audit and feedback.

Risk factors and outcomes among delirium subtypes in adult ICUs: A systematic review

PURPOSE

Use systematic review methodology to summarize risk factors and outcomes for each delirium subtype (hypoactive, hyperactive and mixed) in an adult ICU population.

MATERIALS AND METHODS

We searched the MEDLINE, Embase, CINAHL, SCOPUS, Web of Science and PsycINFO databases from database inception until August 13, 2018, with no restrictions.

RESULTS

Of 9635 abstracts, 20 studies were included. Older age was not associated with any delirium subtype in 4/7 (57%) studies. Sex was not associated with any delirium subtype in 4/4 (100%) studies. Mortality was consistently associated with hypoactive delirium in 4/7 (57%) studies. The evidence supporting the association of APACHE-II score, mechanical ventilation, length of stay, duration of delirium and removal of tubes were inconsistent across studies.

CONCLUSIONS

Although included studies reported on many subtype-specific risk factors and outcomes, heterogeneity in reporting and methodological quality limited the generalizability of the results and the evidence for many subtype-specific risk factors or outcomes is inconsistent across studies. Standardized methodology and the creation of a universal template for collecting data in ICU delirium studies are essential moving forward; helping to identify subtype-specific risk factors or outcomes and strengthen the association of potential risk factors or outcomes.