Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units
ObjectivesVarious strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a clu...
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| description | ObjectivesVarious strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.DesignA qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period. Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.ResultsThree themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.ConclusionsThe current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality.DESIST registration number NCT01634451 |
| doi_str_mv | 10.1136/bmjopen-2018-024549 |
| format | Article |
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Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.DesignA qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period. Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.ResultsThree themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.ConclusionsThe current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality.DESIST registration number NCT01634451</description><identifier>ISSN: 2044-6055</identifier><identifier>EISSN: 2044-6055</identifier><identifier>DOI: 10.1136/bmjopen-2018-024549</identifier><identifier>PMID: 31129576</identifier><language>eng</language><publisher>England: BMJ Publishing Group LTD</publisher><subject>Anesthesia ; Clinical medicine ; Codes ; Conscious Sedation - methods ; Critical care ; Critical Care - methods ; Critical Care Nursing ; Delirium ; Focus Groups ; Humans ; Intensive Care ; Intensive Care Units ; Medical research ; Nurses ; Pain ; Patients ; Physical Therapists ; Physicians ; Qualitative research ; Quality ; Quality Improvement ; Researchers ; Scotland ; Sleep ; Surgery ; Ventilators</subject><ispartof>BMJ open, 2019-05, Vol.9 (5), p.e024549-e024549</ispartof><rights>Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.</rights><rights>2019 Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. 2019</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-b472t-dac6a53e06b4bf86ab30617e0e093922f46a290478aa633b30c033360796429a3</citedby><cites>FETCH-LOGICAL-b472t-dac6a53e06b4bf86ab30617e0e093922f46a290478aa633b30c033360796429a3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://bmjopen.bmj.com/content/9/5/e024549.full.pdf$$EPDF$$P50$$Gbmj$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://bmjopen.bmj.com/content/9/5/e024549.full$$EHTML$$P50$$Gbmj$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,27526,27527,27901,27902,53766,53768,77570,77601</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31129576$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Kydonaki, Kalliopi</creatorcontrib><creatorcontrib>Hanley, Janet</creatorcontrib><creatorcontrib>Huby, Guro</creatorcontrib><creatorcontrib>Antonelli, Jean</creatorcontrib><creatorcontrib>Walsh, Timothy Simon</creatorcontrib><creatorcontrib>Development and Evaluation of Strategies to Improve Sedation practice in inTensive care (DESIST) study investigators</creatorcontrib><title>Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units</title><title>BMJ open</title><addtitle>BMJ Open</addtitle><description>ObjectivesVarious strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.DesignA qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period. Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.ResultsThree themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.ConclusionsThe current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality.DESIST registration number NCT01634451</description><subject>Anesthesia</subject><subject>Clinical medicine</subject><subject>Codes</subject><subject>Conscious Sedation - methods</subject><subject>Critical care</subject><subject>Critical Care - methods</subject><subject>Critical Care Nursing</subject><subject>Delirium</subject><subject>Focus Groups</subject><subject>Humans</subject><subject>Intensive Care</subject><subject>Intensive Care Units</subject><subject>Medical research</subject><subject>Nurses</subject><subject>Pain</subject><subject>Patients</subject><subject>Physical Therapists</subject><subject>Physicians</subject><subject>Qualitative research</subject><subject>Quality</subject><subject>Quality Improvement</subject><subject>Researchers</subject><subject>Scotland</subject><subject>Sleep</subject><subject>Surgery</subject><subject>Ventilators</subject><issn>2044-6055</issn><issn>2044-6055</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>9YT</sourceid><sourceid>ACMMV</sourceid><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><recordid>eNqNkUtrGzEUhUVpaUKSX1Aogm66mVTvGXVRKKYvCGTRZC3uzFzbMmPJkTSBQH58ZeyGNKsKgS663zno6hDyjrNLzqX51G83cYehEYx3DRNKK_uKnAqmVGOY1q-f1SfkIucNq0tpq7V4S04k58Lq1pySx8UapgnDCjOFMNIeUvKYMi2Rxl3xW599WNGMIxQfA_X7XTBkf490gISfKdC7GSZfKlDvcpnHhz2GfrUu9PcQS_F5_UJF5-BLPidvljBlvDieZ-T2-7ebxc_m6vrHr8XXq6ZXrSjNCIMBLZGZXvXLzkAvmeEtMmRWWiGWyoCwTLUdgJGydgcmpTSstUYJC_KMfDn47uZ-i-OAoSSY3C75LaQHF8G7fzvBr90q3jujZVd9q8HHo0GKdzPm4uq_DDhNEDDO2QkhBefadryiH16gmzinUMerlLBdWxMQlZIHakgx54TLp8dw5vYBu2PAbh-wOwRcVe-fz_Gk-RtnBS4PQFX_l-MfaHazfg</recordid><startdate>20190501</startdate><enddate>20190501</enddate><creator>Kydonaki, Kalliopi</creator><creator>Hanley, Janet</creator><creator>Huby, Guro</creator><creator>Antonelli, Jean</creator><creator>Walsh, Timothy Simon</creator><general>BMJ Publishing Group LTD</general><general>BMJ Publishing Group</general><scope>9YT</scope><scope>ACMMV</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>88G</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>BTHHO</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>K9-</scope><scope>K9.</scope><scope>KB0</scope><scope>M0R</scope><scope>M0S</scope><scope>M1P</scope><scope>M2M</scope><scope>NAPCQ</scope><scope>PHGZM</scope><scope>PHGZT</scope><scope>PIMPY</scope><scope>PJZUB</scope><scope>PKEHL</scope><scope>PPXIY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>PSYQQ</scope><scope>Q9U</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20190501</creationdate><title>Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units</title><author>Kydonaki, Kalliopi ; Hanley, Janet ; Huby, Guro ; Antonelli, Jean ; Walsh, Timothy Simon</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-b472t-dac6a53e06b4bf86ab30617e0e093922f46a290478aa633b30c033360796429a3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Anesthesia</topic><topic>Clinical medicine</topic><topic>Codes</topic><topic>Conscious Sedation - methods</topic><topic>Critical care</topic><topic>Critical Care - methods</topic><topic>Critical Care Nursing</topic><topic>Delirium</topic><topic>Focus Groups</topic><topic>Humans</topic><topic>Intensive Care</topic><topic>Intensive Care Units</topic><topic>Medical research</topic><topic>Nurses</topic><topic>Pain</topic><topic>Patients</topic><topic>Physical Therapists</topic><topic>Physicians</topic><topic>Qualitative research</topic><topic>Quality</topic><topic>Quality Improvement</topic><topic>Researchers</topic><topic>Scotland</topic><topic>Sleep</topic><topic>Surgery</topic><topic>Ventilators</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Kydonaki, Kalliopi</creatorcontrib><creatorcontrib>Hanley, Janet</creatorcontrib><creatorcontrib>Huby, Guro</creatorcontrib><creatorcontrib>Antonelli, Jean</creatorcontrib><creatorcontrib>Walsh, Timothy Simon</creatorcontrib><creatorcontrib>Development and Evaluation of Strategies to Improve Sedation practice in inTensive care (DESIST) study investigators</creatorcontrib><collection>BMJ Open Access Journals</collection><collection>BMJ Journals:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Psychology Database (Alumni)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>BMJ Journals</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Consumer Health Database (Alumni Edition)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Consumer Health Database</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>ProQuest Psychology</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest Central (New)</collection><collection>ProQuest One Academic (New)</collection><collection>Publicly Available Content Database</collection><collection>ProQuest Health & Medical Research Collection</collection><collection>ProQuest One Academic Middle East (New)</collection><collection>ProQuest One Health & Nursing</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>ProQuest One Psychology</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>BMJ open</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Kydonaki, Kalliopi</au><au>Hanley, Janet</au><au>Huby, Guro</au><au>Antonelli, Jean</au><au>Walsh, Timothy Simon</au><aucorp>Development and Evaluation of Strategies to Improve Sedation practice in inTensive care (DESIST) study investigators</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units</atitle><jtitle>BMJ open</jtitle><addtitle>BMJ Open</addtitle><date>2019-05-01</date><risdate>2019</risdate><volume>9</volume><issue>5</issue><spage>e024549</spage><epage>e024549</epage><pages>e024549-e024549</pages><issn>2044-6055</issn><eissn>2044-6055</eissn><abstract>ObjectivesVarious strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.DesignA qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period. Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.ResultsThree themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.ConclusionsThe current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality.DESIST registration number NCT01634451</abstract><cop>England</cop><pub>BMJ Publishing Group LTD</pub><pmid>31129576</pmid><doi>10.1136/bmjopen-2018-024549</doi><oa>free_for_read</oa></addata></record> |
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| subjects | Anesthesia Clinical medicine Codes Conscious Sedation - methods Critical care Critical Care - methods Critical Care Nursing Delirium Focus Groups Humans Intensive Care Intensive Care Units Medical research Nurses Pain Patients Physical Therapists Physicians Qualitative research Quality Quality Improvement Researchers Scotland Sleep Surgery Ventilators |
| title | Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units |
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