Original article
Factors influencing nurse sedation practices with mechanically ventilated patients: A U.S. national survey

https://doi.org/10.1016/j.iccn.2009.10.004Get rights and content

Summary

Objectives

Mechanically ventilated patients commonly receive sedative medications. There is increasing evidence that sedative medications impact on patient outcomes. Nursing behaviour is a key determinant of sedation administration. The purpose of this study was to determine factors that influence nurse sedation administration to mechanically ventilated patients.

Methods

The Nurse Sedation Practices Scale was mailed to a random sample of 1250 members of the American Association of Critical Care Nurses.

Results

A response rate of 39% was obtained. Respondents were primarily staff nurses (73%) with a bachelor's degree in nursing (59%) from various intensive care unit (ICU) settings. We limited the analysis to adult ICU practitioners (n = 423). The majority of nurses (81%) agreed that sedation is necessary for patient comfort. Nurse attitudes towards the efficacy of sedation for mechanically ventilated patients was positively correlated with nurses’ report of their sedation practice (rs = .28, p < .001) and their intent to administer sedation (rs = .58, p < .001). Attitudes did not vary with respect to individual or practice setting characteristics.

Conclusion

Nurses’ attitudes impact sedation administration practices. Modifying nurses’ attitudes on sedation and the experience of mechanical ventilation may be necessary to change sedation practices with mechanically ventilated patients.

Introduction

Mechanically ventilated patients are commonly sedated to ensure patient safety, to induce patient amnesia, to decrease anxiety and agitation and to prevent ventilator dysynchrony (Jacobi et al., 2002, Rhoney and Murry, 2003, Sun and Weissman, 1994, Weinert et al., 2001). However, there is increasing evidence that sedative medications impact on patients’ physical and psychological outcomes. Amount or duration of sedation is associated with an increased time of mechanical ventilation, longer ICU stays and more reintubations (Kollef et al., 1998, Kress et al., 2000). Increased duration of mechanical ventilation increases the incidence of pneumonia, airway damage, decreases mobility, decreases self-care ability, and increases health care costs (De Jonghe et al., 2002, Douglas et al., 2002, Kollef et al., 1998, Ostermann et al., 2000). Sedation increases the risk of developing depressive symptoms, delirium and delusional memories of ICU (Ely et al., 2004, Nelson et al., 2000, Samuelson et al., 2006). Patients with delusional memories have an increased risk of anxiety and post-traumatic stress disorder (Jones et al., 2001).

Guidelines from the Society of Critical Care Medicine (SCCM) identify an easily arousable and calm patient as the desired level of sedation for mechanically ventilated patients (Jacobi et al., 2002). However, only 20–30% of ICUs in the United States and 29% of Canadian critical care physicians report using sedation protocols that would help achieve these aims (Mehta et al., 2006, Rhoney and Murry, 2003). Even when sedation endpoints are specified, the actual depth of sedation is often greater than desired (Martin et al., 2006).

Nursing judgment and behaviour is a key determinant of patients’ sedative exposure and level of sedation. Experienced nurses look for other causes of agitation prior to administering sedative medications, while inexperienced nurses use sedative medications more readily (Egerod, 2002). Nurses consider common physical and interpersonal events such as the presence of endotracheal tubes, use of restraints and loss of control as more stressful than patients’ evaluations (Cochran and Ganong, 1989). Agreement between nurses on appropriate sedation (defined by amount and type of patient movement) is inconsistent (Egerod, 2002, Weinert et al., 2001). In addition to nursing experience and assessment, other factors have been identified by nurse focus groups that influence sedation administration including quality of communication between physicians and nurses, nurses’ beliefs regarding mechanical ventilation, patients’ families, nurse workload, and patient acuity (Weinert et al., 2001). These factors have not been validated in a quantitative study. Understanding the complexities of sedation administration is necessary to improve the management of patients’ symptoms: balancing patient comfort and minimising complications. Thus the specific aims of this study were:

  • 1.

    To describe nurses’ self-reported sedation administration practices and the factors that may influence those practices.

  • 2.

    To identify individual or workplace characteristics that impact sedation administration practices.

Section snippets

Design

For this descriptive, associational study, packets including the Nurse Sedation Practices Scale, an explanatory cover letter, an incentive (laboratory value pocket guide), and a return envelope were mailed to a randomly generated list of 1250 national members of the American Association of Critical Care Nurses. A follow up letter was mailed to non-respondents within two weeks of the initial mailing. Subjects were tracked utilising a letter and number code to which only the principal

Survey respondent characteristics

Table 1 summarises characteristics of respondents. Respondents were predominantly staff nurses (73.3%) with a bachelor's degree in nursing (58.9%). Years of ICU experience ranged from less than one year to greater than 20 years. Half of respondents (49.5%) were certified in critical care nursing. Approximately half (52.2%) of respondents worked in a combined medical-surgical unit. Sedation assessment scales were utilised in 70.4% of the respondent's units and sedation protocols in 60.5%. The

Discussion

The aims of this study were to describe factors that influence nurse sedation administration to mechanically ventilated patients and to identify individual or workplace characteristics that impact sedation practices. As predicted by the Theory of Planned Behavior, a third of the variance in intention to sedate mechanically ventilated patients was accounted for by nurses’ attitudes. However, other theory constructs did not have a significant association with sedation administration. Reasons for

Conclusion

The majority of nurse respondents felt that sedation was necessary for patient comfort and characterised mechanical ventilation as uncomfortable and stressful. These attitudes influenced nurses’ self-reported sedation administration practices. Furthermore, these attitudes did not vary significantly in relation to any individual or practice setting characteristic measured. Although nurses’ knowledge was not evaluated in this study, there are indications of knowledge gaps such as a belief that

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Acknowledgements

The authors acknowledge the assistance of Dr. Carol O’Boyle, RN, PhD for her assistance in utilising the Theory of Planned Behavior in scale development. This project was supported by a grant made available by the Greater Twin Cities Area Chapter of the American Association of Critical Care Nurses and Medtronic. The views expressed herein are those of the authors and no official endorsement by the Greater Twin Cities Area Chapter of the American Association of Critical Care Nurses or Medtronic

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