Barriers to Changing Sedation Practice for Patients Undergoing Mechanical Ventilation on the Intensive Care Unit: A Qualitative Interview Study of Clinical Staff

TL;DR

This study explores why ICU staff struggle to improve sedation practices for ventilated patients, finding that cultural norms, lack of training, and workload issues are major barriers.

Contribution

The paper identifies under-prioritization of sedation in ICU practice and training, cultural barriers, and the need for multidisciplinary interventions to improve patient outcomes.

Findings

Sedation is under-prioritized in ICU practice and education, limiting individualized care and innovation.

Cultural norms and staff perceptions act as both barriers and safety mechanisms in sedation practices.

Improving sedation requires addressing cultural barriers, enhancing education, and considering staff retention and workload.

Abstract

Medical sedation is a requirement for mechanical ventilation for most patients admitted to the intensive care unit (ICU). Sedation can help minimise patient discomfort, pain and distress, but can lead to hypotension, bradycardia, prolonged ventilation and delirium. Improving sedation practice is key to improving sedation‐related patient outcomes.

This study aims to explore ICU staff experience with sedation practices and identify potential areas for improvement and innovation.

Semi‐structured interview study exploring views, experiences and clinical decision‐making of ICU medical and nursing staff from two NHS adult ICUs in Yorkshire, England. Interviews were recorded to enable anonymous transcript production. Transcripts were coded using reflexive thematic analysis guided by Braun and Clarke's six‐stage method.

We interviewed 18 members of ICU medical and nursing staff and using thematic analysis four interrelated themes were identified. First, staff perception of sedation, including understanding and reasoning around sedation goals. Second, the impact that ICU culture has on sedation practices. Third, sedation education and training for clinical staff. Finally, motivation to change, aspects impacting the delivery of sedation practices on ICU and key considerations for innovating change.

Sedation practices in ICU are shaped by complex interactions between clinical framing, cultural norms, education and training and organisational pressures. Optimising sedation and implementing innovation require prioritisation of sedation as an active, goal‐directed treatment, supported by structured education and leadership engagement.

This analysis offers novel insights into barriers and facilitators to innovating sedation practices for mechanically ventilated patients, highlighting under‐prioritisation in clinical practice and training, cultural barriers and external influencers like staff retention and workload.

What is known about the topic
○Current international guidance suggests employing a multimodal, multidisciplinary approach to tailor analgesia and sedation to individual patient needs.○The adverse effects associated with sedation can significantly impact both patients and the NHS.○There is a lack of work investigating barriers to implementing sedation interventions, the majority of which have not considered the multidisciplinary approach to sedation, have not investigated barriers to new sedative agents and were conducted outside of the UK context.
What this paper adds
○This analysis illustrates how sedation is under‐prioritised in daily practice as well as in education and training. Staff perception, combined with ICU culture, not only limits individualisation of care and impedes innovation but also functions as a safety mechanism.○Improving sedation practice requires a complex intervention that addresses cultural barriers and the under‐prioritisation of sedation in current practice, while increasing sedation education and training and considering external influencers like staff retention and workload.

What is known about the topic
○Current international guidance suggests employing a multimodal, multidisciplinary approach to tailor analgesia and sedation to individual patient needs.○The adverse effects associated with sedation can significantly impact both patients and the NHS.○There is a lack of work investigating barriers to implementing sedation interventions, the majority of which have not considered the multidisciplinary approach to sedation, have not investigated barriers to new sedative agents and were conducted outside of the UK context.

Current international guidance suggests employing a multimodal, multidisciplinary approach to tailor analgesia and sedation to individual patient needs.

The adverse effects associated with sedation can significantly impact both patients and the NHS.

There is a lack of work investigating barriers to implementing sedation interventions, the majority of which have not considered the multidisciplinary approach to sedation, have not investigated barriers to new sedative agents and were conducted outside of the UK context.

What this paper adds
○This analysis illustrates how sedation is under‐prioritised in daily practice as well as in education and training. Staff perception, combined with ICU culture, not only limits individualisation of care and impedes innovation but also functions as a safety mechanism.○Improving sedation practice requires a complex intervention that addresses cultural barriers and the under‐prioritisation of sedation in current practice, while increasing sedation education and training and considering external influencers like staff retention and workload.

This analysis illustrates how sedation is under‐prioritised in daily practice as well as in education and training. Staff perception, combined with ICU culture, not only limits individualisation of care and impedes innovation but also functions as a safety mechanism.

Improving sedation practice requires a complex intervention that addresses cultural barriers and the under‐prioritisation of sedation in current practice, while increasing sedation education and training and considering external influencers like staff retention and workload.