Phenomenological exploration of clinical decision making of Intensive Care Unit (ICU) nurses in relation to sedation management

Abstract

Driven by research studies and national targets, sedation practices in Intensive care Units (ICU) are undergoing change. Traditionally, ventilated patients in ICUs were kept deeply sedated and only gradually ‘weaned off’ sedation. However, current evidence supports a more ‘wakeful’ patient with the introduction of ‘sedation holds’ encouraging them to regain consciousness (Kress et al. 2000). There is little research exploring ICU nurses’ assessment and management of sedation. Employing a Heideggerian, hermeneutic phenomenological approach to enquiry, the study sought to provide insights into the world of the critical care nurse, nursing with technology, and specifically their beliefs surrounding sedation practices and how organisational factors, knowledge and personal experiences influence their clinical decisions in the care of the ventilated patient.

The setting was the Royal Infirmary of Edinburgh, ICU and the purposive sample consisted of 16 ICU nurses with diverse critical care nursing experience. Bedside interviews, utilising an aide memoir, elicited narratives about the nurses’ experiences of sedation practice and a novel sedation monitor (responsiveness). The phenomenological analysis drew upon a number of existing frameworks to guide enquiry. The researcher engaged with the ‘hermeneutic circle’, acknowledging her pre-understandings and using these as a platform to move between the whole of the research and the parts, the descriptions and narratives offered, to develop new knowledge. Themes emerged that demonstrated patients’ sedation status directly impacted upon the nurses’ ICU lived experiences and left them in a state of disequilibrium regarding the requirement to deliver research based care, the desire to deliver holistic care and the duty to deliver safe care. The nurses perceived sedation holds and ‘wakefulness’ as resulting in patient agitation and distress which affected patient safety and comfort. However, the nurses equally felt a pressure of obligation to the doctors to perform such evidence based sedation holds. They described the struggling to maintain patient safety and manage their own fears and anxieties and organisational constraints, whilst experiencing guilt, blame and failure associated with their behavioural discordance with the prescribed decisions and their own clinical decision making processes and strategies. Team work between the two professions and effective leadership is evidently less than ideal. Consequently the implementation of changes in sedation practice is failing to meet either the national targets or to respond to the nurses’ concerns regarding their patient’s short term wellbeing. On both counts this potentially impairs the pursuit of best practice.