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

Abstract

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.

KEY POINTS

Question: What are the interdisciplinary team members’ beliefs and attitudes about sedation when caring for mechanically ventilated patients in the ICU?

Findings: In this survey of interdisciplinary ICU team members, we observed interdisciplinary differences in their understanding of the appropriate sedation depth, psychologic effects, and preference for sedation. Physical therapists, occupational therapists, and physicians were more likely to guide their sedation management based on their understanding of post-intensive care syndrome and hold beliefs and attitudes contrasting those of nurses and respiratory therapists.

Meaning: Members of the interdisciplinary ICU team held different perspectives on sedation based on their professional backgrounds.

Deep sedation is an independent risk factor for delirium, prolonged mechanical ventilation, and death among mechanically ventilated patients in the ICU (1). Sedation is also a major barrier to early mobilization (2), leading to long-term cognitive impairment and decreased quality-of-life 1 year after ICU discharge (3). Clinical guidelines recommend minimizing sedation when caring for mechanically ventilated patients in the ICU (4), and an evidence-based implementation tool, the ABCDEF bundle (A, assessment of pain; B, Spontaneous Awakening Trials and Spontaneous Breathing Trials; C, choice of analgesia and sedation; D, delirium; E, early mobility and exercise; and F, family and patient engagement.) has been shown to decrease coma, delirium, mechanical ventilation, ICU readmission, discharge to a facility, and death in a dose-response manner (5). Yet, compliance with the ABCDEF bundle remains low (6), placing many patients at risk for preventable harm.

Barr et al (7) recently examined factors associated with the successful implementation of the ABCDEF bundle and found that the unit’s safety culture and interprofessional collaboration were among the strongest determinants. Thus, to minimize sedation in the ICU, every member of the ICU team must understand the sedation-related harms and consider sedation minimization a priority. To explore this further, we investigated the beliefs and attitudes regarding sedation use among members of the interdisciplinary ICU team.

MATERIALS AND METHODS

Study Design, Setting, and Subjects

This was a cross-sectional survey study of interdisciplinary team members in a 17-bed cardiothoracic ICU (CTICU) at a tertiary care academic hospital. More than 90% of the patients who receive mechanical ventilation in this ICU are admitted after cardiac surgery (60% elective and 40% urgent or emergent). One-third of patients require mechanical ventilation for greater than 24 hours postoperatively due to severe respiratory and cardiac insufficiency. Most patients receive at least one continuous sedative infusion while mechanically ventilated.

In June 2022, an online 28-item survey was distributed to all nurses, physicians, advanced practice providers (APPs), respiratory therapists, physical therapists (PTs), occupational therapists (OTs), and a pharmacist who routinely worked in the CTICU (n = 138). Each eligible subject received a prenotification email describing the survey’s purpose and context, followed by a separate email with a unique survey hyperlink. The study team tracked individual response status to monitor nonrespondents and multiple participation and sent up to 2 weekly reminder emails to nonrespondents. After 2 weeks, the study team approached nonrespondents in person to request participation. All responses were kept anonymous and confidential. We did not calculate the sample size because this survey was conducted as part of the quality initiative to understand the unit’s culture. The Colorado Multiple Institutional Review Board determined this study to be exempt from review (No. 22-0223). The reporting of this study adhered to the Checklist for Reporting of Survey Studies (8) (eTable 1, http://links.lww.com/CCX/B247).

Survey Instrument

The aim of this survey was to understand the beliefs and attitudes regarding sedation use in the ICU across training disciplines. After a literature review, we identified an existing instrument developed by Guttormson et al (9), the Nurse Sedation Practices Scale. We modified the instrument so that most survey items were relevant to every ICU team member. The draft survey was iteratively revised after cognitive pretesting by 10 members (three nurses, three physicians, two APPs, one respiratory therapist, and one PT) to refine the content and framing. The final version of the survey instrument is available in Supplemental Digital Content online (eFig. 1, http://links.lww.com/CCX/B247).

Each survey item asked respondents to choose their level of agreement with statements regarding their beliefs and attitudes related to the use of sedation when caring for mechanically ventilated patients on a 5-point Likert scale. One of the survey items asked whether the respondent had listened to a podcast called “Walking Home from the ICU” (10). This podcast was released in February 2020 to discuss the impact of ICU sedation and mobilization on patient outcomes through dialogues with ICU survivors, clinicians, and researchers. It was not shared at a unit level, but we included this survey item as we were aware that some had interest in this podcast. Given its rich content describing exemplary models of ABCDEF bundle implementation, we wished to preliminarily explore the potential influence of this podcast as an educational intervention in future works.

Statistical Analysis

To facilitate communication of our survey findings, we converted the responses into a binary outcome (strongly agree/agree vs neutral/disagree/strongly disagree) and examined the between-discipline differences. As an exploratory analysis, we examined whether the survey responses varied by listenership to the abovementioned podcast. We excluded the responses from the pharmacist due to only one person representing this discipline. Fisher exact test was used based on two-tailed testing with an alpha threshold of 0.05. We used the statistical software R Version 4.1.1 (R Foundation, Vienna, Austria) for analysis and its package “Likert” (11) for data visualization.

RESULTS

The overall survey response rate was 81% (112/138): nurses, 74% (66/89); physicians, 100% (16/16); APPs, 100% (13/13); respiratory therapists, 89% (8/9); PTs and OTs, 80% (8/10); and a pharmacist (1/1). Responses from 111 members were analyzed after excluding the pharmacist (eFig. 2, http://links.lww.com/CCX/B247). Seventy of 111 respondents (63%) were female. One-fourth reported less than 1 year, and two-thirds reported 2–10 years of ICU experience (Table 1). There were no missing responses in the completed surveys.

TABLE 1.

Characteristics of Survey Respondents

Characteristics	Survey Sent, n = 138, n (%)	Respondents, n = 112, n (%)	Podcast Listeners, n = 19, n (%)
Sex
Female		70 (63)	11 (58)
Discipline
Nurses	89 (64)	66 (59)	7 (37)
Physicians	16 (12)	16 (14)	3 (16)
Advanced practice providers	13 (9)	13 (12)	4 (21)
Respiratory therapists	9 (7)	8 (7)	2 (11)
Physical and occupational therapists	10 (7)	8 (7)	3 (16)
Pharmacist	1 (1)	1 (1)	0
Years of ICU experience, yra
≤ 1		29 (26)	3 (16)
2–5		46 (41)	9 (47)
6–10		20 (18)	2 (11)
11–15		9 (8)	4 (21)
≥ 16		7 (6)	1 (11)

^aPhysicians included 10 board-certified intensivists (nine anesthesiology-trained and one emergency medicine-trained) and six critical care fellows (four anesthesiology-trained and two emergency medicine-trained). Our survey did not include demographic information such as age, race, and ethnicity to maintain the anonymity of survey responses.

Most respondents across disciplines (94%) strongly agreed or agreed with the following statement: “My sedation practice can make a difference in patients’ outcomes.” (Fig. 1A) More nurses (47%) worried about patient safety when patients were awake and alert on the ventilator than physicians (13%) and PT/OT (13%) (p = 0.04) (Fig. 1A). When asked about the appropriate depth of sedation, more nurses (79%), physicians (94%), APPs (92%), and PTs/OTs (88%) perceived “patients responding only to noxious stimuli” as oversedation than respiratory therapists (25%) (p = 0.004) (Fig. 1B). When asked about the psychologic effect of sedation, more nurses (48%), APPs (62%), and respiratory therapists (50%) strongly agreed or agreed with the statement, “sedation can help alleviate psychologic stress that patients experience on the ventilator,” than physicians (19%) and PTs/OTs (0%) (p = 0.008) (Fig. 1A). More physicians (50%) and PTs/OTs (75%) strongly agreed or agreed that their patient management is guided by the understanding of post-intensive care syndrome (PICS) than nurses (29%), APPs (31%), and respiratory therapists (29%), although not statistically significant (p = 0.07) (Fig. 1B). Finally, the proportion of respondents that strongly agreed or agreed to the statement, “I would prefer to be sedated if I were mechanically ventilated,” varied widely by discipline: respiratory therapists (88%), nurses (83%), APPs (54%), PTs/OTs (38%), and physicians (19%) (p < 0.001) (Fig. 1A). Results of the remaining survey items are available online (eTable 2, http://links.lww.com/CCX/B247).

Figure 1.

Survey Results. A and B, Beliefs and attitudes toward sedation of intubated patients. Results of select survey items compared by disciplines. Fisher exact test resulted in the following p values for any between-group differences: “My sedation practice…” p = 0.80; “Sedating mechanically ventilated…” p = 0.52; “I worry about…” p = 0.04; “Sedation can help…” p = 0.008; “I would prefer…” p < 0.001; “Patients are oversedated… to noxious stimuli” p = 0.004; “Patients are oversedated… an eye contact” p = 0.07; “Sedation can decrease…” p = 0.06; and “My management of…” p = 0.07. APP = advanced practice provider, MD = physicians, OT = occupational therapist, PICS = post-intensive care syndrome, PT = physical therapist, RN = registered nurse, RT = respiratory therapist.

In our exploratory analysis, listeners of the podcast “Walking Home from the ICU” (n = 19; seven nurses, three physicians, four APPs, two respiratory therapists, and three PTs and OTs) were less likely to strongly agree or agree that “sedation can help alleviate psychologic stress that patients experience on the ventilator” (21% vs 47%; p = 0.04) or that “sedation can decrease the risk of anxiety, depression, and post-traumatic stress disorder” (21% vs 48%; p = 0.04) compared with nonlisteners. More podcast listeners strongly agreed or agreed that their patient management is guided by the understanding of PICS than nonlisteners (63% vs 29%; p = 0.008). Podcast listeners were less likely than nonlisteners to prefer to be sedated if they were mechanically ventilated themselves (37% vs 74%; p = 0.003) (eTable 3, http://links.lww.com/CCX/B247).

DISCUSSION

In this single ICU survey of interdisciplinary team members, we found that perspectives on sedation differed based on the respondents’ professional backgrounds. Most members, regardless of their discipline, believed that their sedation practice was impacting patient outcomes. Yet, only one-fourth of respiratory therapists recognized “responding only to noxious stimuli” as oversedation. Approximately half of the nurses, APPs, and respiratory therapists believed sedation had positive psychologic effects on patients, contrary to the evidence (12, 13). Furthermore, most nurses and respiratory therapists preferred to be sedated if they were mechanically ventilated, whereas only a handful of PTs, OTs, and physicians agreed with this statement. These findings imply that the definition of “best care” may differ depending on the individual.

When compared with a previous survey study of nurses (n = 177) published in 2019 (9), we found that nurses’ attitudes toward sedating patients receiving mechanical ventilation were similar in our study. In both studies, about 80% of nurses responded that they would prefer sedation if they were ventilated, more than half responded that it is easier to care for intubated patients who are sedated than those who are alert, and about a half responded that sedation is necessary for patient comfort. Interestingly, many nurses in the previous study (9) worked in community hospitals and specialized in medical-surgical or medical ICU, whereas 100% of our nurses worked in a CTICU at an academic hospital. The similarities in the response patterns despite the differences in study settings allude that nurses’ attitudes toward sedation may be consistent across different practice settings and patient populations.

Our study is the first to compare the mental models of sedation across multiple ICU disciplines and found that in general, PTs, OTs, and physicians had perspectives that contrasted those of nurses and respiratory therapists. Notably, PTs, OTs, and physicians were more likely to agree that their patient management is guided by the understanding of PICS. Since PICS is a downstream consequence of deep sedation and immobility in the ICU, there may be an association between the awareness of PICS and different perspectives on sedation. In our exploratory analysis, we found that listening to an educational podcast was associated with having beliefs and attitudes more aligned with the literature. Our findings suggest that education could play a role in future quality improvement efforts.

One important limitation of our study is the single-center design. Although the high response rate strengthens the internal validity, our findings are not generalizable given the differing ICU cultures and patient populations. For example, most physician respondents (81%) were anesthesia-trained, so our physician responses may not represent intensivists with other training backgrounds, such as medicine, surgery, emergency medicine, and neurology. Another limitation is the exclusion of the ICU pharmacist as there was only one person in this discipline category. In our exploratory analysis, we found that listeners of the podcast had response patterns different from nonlisteners. Still, since we did not require all staff to listen to the podcast, it is possible that a self-selection bias may exist wherein those individuals who voluntarily listened to the podcast already had different perspectives on sedation rather than the podcast impacting their mental models. Finally, we could not evaluate from this study whether the members’ beliefs and attitudes reflected their bedside practice.

Despite these limitations, the misaligned mental models we discovered are problematic since interprofessional collaboration and teamwork determine the effective delivery of high-value care in the complex ICU environment. Future research should investigate whether sharing the same beliefs and attitudes regarding sedation would help build an ICU culture necessary to implement evidence-based sedation practices.

CONCLUSIONS

While most team members believed that their sedation practices made a difference in patients’ outcomes, we observed interdisciplinary differences in their understanding of the appropriate sedation depth, psychologic effects, and preference for sedation. Since all ICU team members are involved in managing patients receiving mechanical ventilation in the ICU, aligning the mental models of sedation may be essential to enhance interprofessional collaboration and promote sedation best practices.

ACKNOWLEDGMENTS

We thank Dr. Jill Guttormson, PhD, for graciously granting us permission to use the survey instrument for this project, and Dr. Jack Pattee, PhD, for providing expertise on appropriate statistical analysis.

Supplementary Material

cc9-5-e0972-s001.pdf ^{(1.3MB, pdf)}