Procedural Sedation Practice: A Review of Current Nursing Standards

Abstract

Although administration of procedural sedation is a common practice among nurses, at present a unified consensus statement on Registered Nurse (RN) sedation core competencies or a consistent way in which RN sedation practice is regulated in the United States is lacking. In this article, the topic of RN sedation is discussed and includes current sedation standards by the American Society of Anesthesiologists and the Joint Commission. Examples of current regulations from State Boards of Nursing throughout the United States are also reviewed. Three major controversies related to RN sedation practice exist: variation in Board of Nursing regulation, lack of research on RN sedation practice, and lack of a national standard for RN sedation. Recommendations to address each of these areas are provided to inform regulators and nurse educators about current standards and knowledge gaps in sedation care. Strategies to improve sedation research in order to advance practice in this area are also discussed.

Over the last three decades, the administration of sedation for diagnostic and therapeutic procedures has increased dramatically; at the same time, these procedures have been recognized as an area fraught with potential risk for patients. Sedatives are often used to provide analgesia, allay anxiety, and increase comfort in patients that require procedures such as endoscopy and Magnetic Resonance Imaging (MRI). Sedation is used in a variety of patient populations and in various settings such as radiology, ambulatory care, and the emergency department. Anesthesia providers (APs) such as anesthesiologists and certified registered nurse anesthetists usually provide sedation, but the non-anesthesia providers, including non-AP physicians, nurse practitioners, and RNs also perform the procedure.

The demand for RNs to provide sedation has increased in recent years. A 2006 survey of United States gastroenterologists found the number of endoscopic procedures in adults increased exponentially (200% to 400%) over the fifteen years prior to the study and RNs are often called on to provide sedation during these procedures (Cohen et al., 2006). RNs also provide sedation for patients in critical care in order to maintain treatments, provide analgesia, and to minimize discomfort from therapies such as endotracheal intubation (Mason, 2012).

Sedation care protocols are often derived from standards of anesthesia care, developed by physician specialty organizations such as the American Society of Anesthesiologists (ASA). These guidelines have become the basis for sedation standards by accrediting agencies, specialty organizations and regulating agencies that influence sedation practice in the U.S.

Although the administration of procedural sedation, sometimes referred to, as “conscious” or “moderate” sedation, is a common RN practice there is no unified consensus statement on RN sedation core competencies or a consistent way in which RN sedation practice is regulated in the U.S. Several subspecialty nursing organizations such as the American Society of Perianesthesia Nurses (ASPN) and the Society of Gastroenterology Nurses and Associates (SGNA) have developed their own sedation-related standards and have published jointly with medical sub-specialty groups. Multiple contradictory standards published by various medical and nursing specialty organizations and different sedation regulations by Boards of Nursing exist. Table 1 is provided to assist the reader in navigating the various terms associated with sedation care that are referenced in this article, however it is not an exhaustive list of all organizations or terms associated with sedation care in the United States. The purpose of this paper is to describe the current state of RN sedation regulation in the United States and to identify RN related sedation practice controversies. The topic of RN sedation will be explored, focusing on three major components. The first component is to define sedation practice, describe qualifications of sedation providers and risks associated with sedation. Secondly, sedation standards and regulations by accreditors, professional organizations and Boards Of Nursing that impact RN sedation care will be presented. Lastly, major controversies in RN sedation practice and recommendations will be discussed.

Table 1.

Terms and abbreviations associated with sedation care and referenced in article

Term	Abbreviation	Description
American Society of Anesthesiologists1	ASA	Professional organization of anesthesia physicians, that have developed most of the standards regarding sedation in the United States
American Association of Nurse Anesthetists	AANA	Professional organization of Certified Registered Nurse Anesthetists
American College of Emergency Physicians2	ACEP	Professional organization representing emergency physicians, that have developed sedation standards for emergency medicine
American Nurses Association	ANA	Professional organization representing registered nurses in the United States
Anesthesia Provider(s)	AP(s)	Providers that are considered anesthesia providers Anesthesiologist and Certified Registered Nurse Anesthetists
Board of Nursing	BON	State boards that regulate nursing practice
Non-anesthesia provider(s) also called Non-anesthesiologists1	Non-AP(s)	Healthcare practitioners that are not specialists in anesthesiology for example radiologists, nurses, dentists, pediatricians, intensivists
Nurse Administered Propofol sedation3	NAPS	Practice of administration of propofol for deep sedation by nurses under the guidance of a physician not trained in anesthesia
The Joint Commission	TJC	An organization that establishes standards to accredit healthcare organizations

¹(American Society of Anesthesiologists [ASA] Task Force on Sedation and Analgesia by Non-Anesthesiologists, 2002)

²(American College of Emergency Physicians, 2005)

³(Vargo, et al. 2009)

Current Sedation Practice

Sedation Principles

Sedation defined.

The American College of Emergency Physicians (ACEP) defines procedural sedation as a technique of administering sedative or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia (PSA) is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently (American College of Emergency Physicians, 2005, p. 178).

There are four levels of sedation defined by the ASA (see table 2); sedation occurs on a continuum that ranges from minimal to full anesthesia. Sedation level classification depends on the patient’s assessed response to verbal commands, actual or potential impairment of the patient’s ability to maintain his/her own airway, spontaneous ventilation, and cardiovascular function after drug administration (American Society of Anesthesiologist [ASA] Taskforce on Sedation and Analgesia by Non-Anesthesiologists, 2002).

Table 2.

American Society of Anesthesia Sedation Level Definitions and Joint Commission Sedation Provider Qualifications

Level	1American Society of Anesthesia Definition	2Joint Commission Provider Qualifications
Minimal Sedation (anxiolysis)	A drug induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired ventilatory and cardiovascular function is usually maintained.	None
Moderate Sedation (formerly conscious sedation)	A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain the patient’s airway, and spontaneous ventilation is adequate. Cardiovascular function usually is maintained.	Individual administering moderate sedation are qualified and have credentials to manage and rescue patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.
Deep Sedation	A drug-induced depression of consciousness during which patients cannot be aroused easily; but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function usually is maintained.	Individual administering deep sedation are qualified and have credentials to manage and rescue patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.
Anesthesia	General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilator function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.	Anesthesiologist, Doctor of medicine or osteopathy other than a anesthesiologist, Doctor of dental surgery or dental medicine, Doctor of podiatric medicine, Certified Registered Nurse Anesthetist with supervision, Anesthesiologist assistant supervised by an anesthesiologist

¹(American Society of Anesthesiologists [ASA] Task Force on Sedation and Analgesia by Non-Anesthesiologists, 2002)

²(Joint Commission International, 2011)

Sedation levels.

Sedation begins with “minimal sedation” also referred to as anxiolysis, in contrast to “general anesthesia” which is considered the end point of the sedation-analgesia continuum and occurs when patients are unarousable with painful stimulation. There are two levels of sedation between minimal and general anesthesia: moderate and deep; they are the focus of this paper. Distinguishing between the two is difficult, but important, because regulations and standards of care differ depending on the patient’s sedation level.

Determining sedation level.

The level of sedation patients achieve is not solely predictable based on the medication administered or the dose used (ASA, 2002). The assessed level of sedation-analgesia may change throughout the procedure (Green & Mason, 2010). Sedation provider qualifications for each sedation level are set by the Joint Commission, and are presented in table 2 (Joint Commission International, 2011). Qualifications required for the sedation provider range from no specific qualifications for minimal sedation, to the ability to manage and rescue patients from whatever level of sedation or anesthesia is achieved when moderate and deep sedation levels are planned (Joint Commission International, 2011). The ability of RN sedation providers to be able to manage and rescue patients from a deep sedation level or anesthesia is widely debated. Conversely, some patients that receive sedative medications are exempt from meeting sedation monitoring requirements. Examples include patients receiving sedative medications for treatment of insomnia, anxiety or pain control. Patients who are not undergoing a diagnostic or therapeutic procedure, such as intubated and ventilated patients receiving continuous infusions of sedative agents, and patients at the “minimal” sedation level are also exempted from meeting sedation monitoring and provider guidelines (ASA, 2002).

Risks Associated with Sedation

Sedation Mortality and Adverse Event Surveillance

There is no national surveillance system to monitor sedation mortality or complications in the U.S. (Li, Warner, Lang, Huang, & Sun, 2009). Rather, numerous studies simply report patient-level data on sedation adverse events in one institution based on medications used, the health care setting in which sedation was provided, or the patient population being treated. Mortality and morbidity for moderate and deep sedation is unknown. Sedation mortality should theoretically be lower than anesthesia mortality rate, which was 1.1 per million population and 8.2 per million of hospital surgical discharges between 1999–2005 (Li et al., 2009).

Sedation Adverse Events

Sedation adverse event rates vary depending on the population being studied, the medication used, and how a sedation adverse event is defined. Most studies report on either adult or pediatric populations thus it is difficult to determine what the overall adverse event rate is; this is further complicated by the fact that adverse event results are often not comparable because they are defined differently. For example, there is no consistent definition for a common sedation adverse event, oxygen desaturation, leading to a range of reported rates for this complication depending on the population or circumstance (Cravero et al., 2006). Pino et al., (2007) reported 31 episodes (0.12%) of oxygen saturation less than 90% as an adverse event in a sample of 25,774 sedation cases including adults and children. Cravero et al. (2006) defined desaturation adverse events as an oxygen saturation less than 90% for greater than 30 seconds, reporting 470 episodes (1.6%) in a pediatric sample of 30,037 sedation cases. Miner, Gray, Stephens and Birso, (2009) reported on 150 adult patients undergoing sedation for painful procedures with propofol in the emergency department. In this study 74 patients received propofol alone and 71 patients received propofol in combination with alfentanil, an opioid analgesic (Miner, et al., 2009). Miner et al. (2009) reported oxygen saturation less than 92% at any time during the procedure as an adverse event; this was found in 9.5% of the propofol cases and 15.5% of the propofol with alfentanil cases. None of these studies presented any data related to RN sedation administration, although, Cravero et al. (2006) noted that sedation is sometimes performed by nurses and Pino, (2005) indicated that both physicians and RNs are formally credentialed to provide sedation.

Adverse events for RN administered sedation have generally been reported in cases with small sample sizes and specific patient populations. For example, a study of RN administered sedation for burn care procedures analyzed the results of 1,293 procedural sedations for wound care on 328 patients in a 12 month period (Thompson, Andrews, & Christ-Libertin, 2012). RNs administered fentanyl and midazolam using a procedural sedation order set without direct physician supervision during the wound care procedure (Thompson et al., 2012). A total of ten adverse events, all consisting of decreased oxygen saturation of less than 90% on eight patients were reported, yielding an overall adverse event rate of 0.77% (Thompson et al., 2012).

Managing Sedation Risk

Risks associated with sedation have led to the implementation of sedation standards by accrediting agencies such as the Joint Commission and several practice standards by professional organizations such as the ASA that guide the administration of sedation by all non-APs including RNs (Metzner & Domino, 2010). Despite the efforts of many professional organizations to define sedation practice in their specialty, the ASA has achieved an influential role in the development of standards of non-AP practice used by accrediting and regulatory agencies such as the Joint Commission, the Centers for Medicare and Medicaid Service and state boards of nursing. Following a discussion of regulations for Non-APs the article will focus on standards and regulation of sedation administered by RNs.

Sedation Standards and Regulations

American Society of Anesthesia Sedation Guidelines

The ASA has published several guideline documents defining the levels of sedation, practice standards for non-APs, statements for granting non-APs privileges to perform moderate sedation analgesia and an advisory document on deep sedation analgesia by non-APs (American Society of Anesthesiologists, 2009, 2010, 2011; American Society of Anesthesiologists [ASA] Task Force on Sedation and Analgesia by Non-Anesthesiologists, 2002). The ASA guidance document for Sedation and Analgesia by Non-Anesthesiologists (ASA, 2002) was developed by a ten-member taskforce using a systematic review of 357 articles with direct evidence related to sedation by non-anesthesiologist physicians (ASA, 2002). The guidance document does not address sedation by RNs, however, regulatory agencies including some state Boards of Nursing and specialty nursing organizations have used it to develop RN sedation standards. Sedation standards by the Joint Commission were developed using many of the recommendations set forth in the ASA guidance document.

Joint Commission Sedation Regulation

Sedation standards.

The Joint Commission sedation standards have been greatly influenced by the ASA guidance document for Sedation and Analgesia by Non-Anesthesiologists, (2002). The Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH) includes multiple standards in the Provisions of Care, Treatment and Services chapter (PC.03.01.01 to PC.03.01.07) that specifically address moderate and deep sedation with or without analgesia (Joint Commission International, 2011). These same standards apply to patients in any setting that receive general, spine or other regional anesthesia including ambulatory care settings (Joint Commission International, 2011).

The Joint Commission standards for sedation providers are detailed in table 2. These standards require perioperative patient assessment and development or concurrence with a plan of care by a licensed independent practitioner (Joint Commission International, 2011). Preprocedural education is required and continuous physiologic monitoring during and after the procedure is required depending on the depth of sedation achieved (Joint Commission International, 2011).

Joint Commission sedation regulation gaps.

The Joint Commission sedation standards do not address all sedation situations, such as non-verbal patients, procedures such as bronchoscopy that make it difficult to communicate with the patient, or circumstances in which monitoring the patient during sedation could interfere with completion of the procedure such as MRI. The Joint Commission does not state whether or not RNs can meet the qualifications for rescuing patients that slip from a moderate to deep level of sedation or from a deep level of sedation into general anesthesia. They also do not specify the manner in which RNs may be qualified or credentialed to provide sedation; instead the document references standards for medical staff credentialing. The Joint Commission also does not address or differentiate analgesia from sedation in their standards. Specialty nursing organizations, such as the Emergency Nurses Association, the American Association of Nurse Anesthetists (AANA) and boards of nursing have also developed RN sedation practice standards that offer conflicting guidance on the role, competencies, and scope of practice for RNs providing sedation.

Professional Organizations

Procedural Sedation Consensus Statement.

Several professional nursing organizations have published or collaborated on RN guidelines for the administration of sedation. The “Procedural Sedation Consensus Statement,” was last revised in 2008 and is endorsed by several medical and nursing professional organizations. The statement recognizes that interventions by RNs including administration of medications such as etomidate, propofol, ketamine, fentanyl and midazolam are used to manage a range of painful conditions including moderate to deep sedation (American Nurses Association, 2008). In contrast the ASA and AANA published a joint statement that propofol should only be administered by APs and that induction agents such as thiopental, methohexital, etomidate should be similarly restricted (American Association of Nurse Anesthetists, 2004).

RN sedation training and competency.

There is currently no uniformly accepted training for a sedation nurse (Centers for Medicare and Medicaid Services, 2012). The “Procedural Sedation Consensus Statement” supports that RNs can administer medications for procedural sedation in collaboration with any health care provider with privileges and credentials to administer sedation; the RN must be trained and competent in this role (American Nurses Association, 2008). Training and competencies such as demonstration of competence in airway management, ability to initiate CPR, demonstrated knowledge of pharmacology and the ability to recognize complications and intervene appropriately are recommended (American Nurses Association, 2008). Although this consensus statement is often cited in regulatory standards and is supported by several nursing organizations, it does not specify the standard of sedation practice outside of emergency settings. The majority of references cited to support the consensus statement come from the emergency medicine literature.

Gastroenterology RN Sedation Practice

The SGNA has two positions statements associated with procedural sedation. The first is on the use of sedation and analgesia in the gastrointestinal endoscopy setting. This statement recognizes the sedation levels developed by the ASA, supports the RN role of administering medication to provide moderate sedation and describes the RN role during deep sedation by APs as supportive to the endoscopy team (Society of Gastroenterology Nurses and Associates, 2010). It does not provide any further guidance related to the issue of deep sedation (Society of Gastroenterology Nurses and Associates, 2010).

The SGNA also published a joint statement with the American Society for Gastrointestinal Endoscopy (ASGE) describing the role of the RN during endoscopy procedures including monitoring, preparing and administering medications under the direct supervision of the physician, and expected RN training and competency (American Society for Gastrointestinal Endoscopy & Society of Gastroenterology Nurses and Associates, 2004). The ASGE and SGNA, (2004) joint position statement identifies the need for RNs to function within the limitation of their state licensure and practice act and organizational policies. The statement references prior guidelines from the ASGE regarding monitoring for moderate and deep sedation and the difference in monitoring by the RN during moderate versus deep sedation. It does not address whether the RN should administer medications leading to deep sedation (American Society for Gastrointestinal Endoscopy & Society of Gastroenterology Nurses and Associates, 2004).

Nurse administered propofol sedation in endoscopy

A statement on the use of RN-administered propofol sedation (NAPS) for endoscopy was issued jointly by the American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy, proposing that administration of propofol for deep sedation during endoscopies could be safely delivered by sedation trained nurses, under the supervision of a non-AP sedation credentialed gastroenterologists (Vargo, Cohen, Rex, & Kwo, 2009). Twentyeight studies with 460,651 cases were evaluated and found to have a similar safety profile to standard sedation for upper endoscopy and colonoscopy (Vargo et al., 2009). A four-pronged training approach for NAPS providers was described including didactic, airway workshop, simulation training, and a preceptorship (Vargo et al., 2009). NAPS for endoscopy has not been endorsed by the SGNA and the administration of propofol by the RN remains controversial with many boards of nursing opposing this activity (Vargo et al., 2009).

Regulators

Board of nursing regulation of sedation

State boards of nursing regulate nursing practice, including defining RN practice, determining scope of practice, taking disciplinary actions against licensees, and providing guidance on RN practice in their state. However, there is great variation in how boards of nursing regulate RN sedation practice and it is difficult to obtain information to determine requirements and restrictions in RN sedation practice depending on the state. The SGNA in cooperation with gastroenterology physician and nurse organizations developed a web site called SedationFacts (sgna.org/issues/sedationfactsorg.aspx), which was intended to provide an up-to-date and evidence- based resource for gastroenterology specialists to determine sedation regulations by states.

Determining Board of Nursing sedation regulations.

The SedationFacts site provided summaries of sedation regulations in each state including guidelines and links to the original state resource, however most of the information was last updated in 2011 and as of 2014 the site is unavailable with a notice that it is under construction. Despite its shortcomings, this site was perhaps the most readily available resource to obtain information on board of nursing sedation regulations in the United States. Variation in how some boards of nursing regulate RN sedation practice can be seen in table 3 which summarizes RN sedation regulations in non-intubated patients from one state from each of United States Census Bureau regional divisions (U.S. Department of Commerce Economics and Statistics Administration & U.S. Census Bureau, 2000).

Table 3.

Board of Nursing Guidance in Nine Census Bureau Divisions for Registered Nurse Administration of Moderate or Deep Sedation and Propofol in Non-Intubated Patients

U.S. Census Bureau Divisions	Conscious/Moderate Sedation	Deep Sedation	Propofol
New England
Massachusetts1	Advisory Ruling RN may administer if meets competency requirements. Organizational policies dictate acceptable meds, purpose, goals, techniques, doses/kg	April 2010 board meeting statement that RN may administer deep sedation in non-intubated requires organizational policies and anesthesia or airway expert present monitoring airway.	RN may administer following the deep sedation guidelines
Mid-Atlantic
New York2	RN competent may administer	IV anesthetics agents such as propofol, ketamine, etomidate, methohexital and thiopental are reserved for anesthesia providers	RN may not administer
East North Central
Wisconsin3	No specific guidance	No specific guidance	Specific policies by institutions are required. As in other IV meds RN must have appropriate education, skill level or monitoring and medical personnel available in the event of an emergency
West North Central
Missouri4	No specific guidance	No specific guidance	No specific guidance
South Atlantic
Delaware5	Position statement RN may administer, but must meet training requirements	No specific guidance	No specific guidance
East South Central
Kentucky6	Advisory opinion RN has right and obligation to administer meds in amount not to induce anesthesia or loss of consciousness	May not administer medications producing general anesthesia or for purpose of general anesthesia. Nitrous oxide may be given for sedation by competent nurse	No specific guidance
West South Central
Texas7	Position statement RN may provide moderate sedation using evidence based practice guidelines by professional organizations and as long as nurse is competent	Position statement administration of anesthetic agents is outside the RN scope of practice. The RN may only administer anesthetics such as propofol, methohexital, ketamine and etomidate when assisting in presence of CRNA or anesthesiologist, when assisting individual competent in advanced airway management including emergency intubation, when patient is intubated and mechanically ventilated in critical care, when in an advanced education program in preparation for licensure as nurse anesthetist.	Must meet the criteria in the deep sedation position statement
Mountain
Idaho8	Refers licensees to decision making model IDAPA 23.01.01.400 to consider scope of practice: 1. Does practice act prohibit 2. Possessing current knowledge and competency 3. Consistent with national specialty organization standards 4. Authorized through organizational policies and procedures 5. Would the same standard be provided by reasonable and prudent nurse	No Specific Guidance	No Specific Guidance
Pacific
Oregon9	Within scope of practice for RN under direction of LIP, meeting specific patient risk, RN knowledge and skill, practice setting, personnel and equipment or special circumstance criteria	Within scope of practice for RN under direction of LIP, meeting specific patient, knowledge and skill, practice setting, personnel and equipment or special circumstance criteria	Within scope of practice if meets deep sedation requirements

¹Advisory Ruling

http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/dhpl/nursing/nursing-practice/advisory-rulings/sedation-mild-to-moderate-sedationanalgesia.html

Newsletter July 2010

http://www.mass.gov/eohhs/docs/dph/quality/boards/nursing/nursing-news-july10.pdf

² http://www.op.nysed.gov/prof/nurse/nurse-ivsedation.htm

³ http://165.189.64.111/Documents/Board%20Services/Agenda%20Materials/Nursing/Nursing%2020120913%20Open%20Session%20Agenda%20Packet%201-42.pdf

⁴ http://pr.mo.gov/nursing-focus.asp

⁵ http://sedationcertification.com/uploads/states/Delaware.pdf

⁶Advisory Opinion #32http://kbn.ky.gov/practice/AOS/aosindex.htm

⁷ http://www.bon.state.tx.us/practice/position.html#15.8

⁸RN FAQ 2011-2013 http://ibn.idaho.gov/IBNPortal/IBON/FAQS/RN%20FAQ%202011-2013.pdf

⁹ http://www.oregon.gov/OSBN/pdfs/policies/sedation.pdf

Controversies in Nurse Sedation Care and Recommendations for Improvement

Variation in Board of Nursing Sedation Regulations.

Sedation regulations from nine boards of nursing are listed on table 3; these are presented as examples of the variation in how RN sedation is regulated. Note from the table that the boards of nursing in Wisconsin and Missouri do not provide any specific guidance on RN moderate or deep sedation practice. In Massachusetts, the board of nursing requires organizational policies for moderate and deep sedation and details areas the policies must address. In contrast the board of nursing in Texas requires the use of professional guidelines to determine appropriate care for moderate sedation, while in Idaho a decision making model requires the RN to use national specialty organization standards to determine RN scope of sedation practice. In New York and Texas the administration of propofol, methohexital, etomidate and ketamine by RNs for sedation is restricted which is in line with the AANA-ASA joint position statement on propofol administration (American Association of Nurse Anesthetists, 2004). However, current literature concerning sedation is rife with reports of RNs administering and monitoring propofol, ketamine and nitrous oxide, but little evidence on the skills and competence required to perform deep sedation safely is presented (Leroy, Schipper, & Knape, 2010; Metzner & Domino, 2010). Descriptions of organizational policies, institution specific training and outcomes such as patient satisfaction and adverse events concerning RN administered propofol generally consist of small sample sizes from individual institutions that provide little RN specific data (Ellett, 2010).

The AANA-ASA position statement conflicts with the “Procedural Sedation Consensus Statement” on the role of the registered nurse during sedation and the consensus statement on Nurse Administered Propofol Sedation (NAPS) for endoscopy (American Association of Nurse Anesthetists, 2004; American Nurses Association, 2008; Vargo et al., 2009). However, several physician specialty groups (Vargo et al., 2009) are promoting NAPS as safe and effective for use in endoscopy. The controversy related to the administration of propofol by nurses is emblematic of the difficulty in regulating RN sedation practice due to a lack of evidence about current sedation practice, lack of consistency in recommendations amongst nursing professional organizations, and the inconsistent or lack of board of nursing regulation about propofol administration (Ellett, 2010).

Recommendations

The National Council of State Boards of Nursing (NCSBN) is the organizing body of boards of nursing in the U.S. and provides a forum for the member boards to consult on matters of common interest (National Council of State Boards of Nursing, 2013). Part of the work of the NCSBN is to promote the uniformity of regulations and nursing practice. RNs are providing sedation services including deep sedation to many patients in a variety of specialties and settings and are seeking guidance on their role in this evolving area. Questions regarding scope of practice of RNs related to sedation have appeared in various publications such as newsletters (see table 3). In the past the NCSBN has developed guidelines to educate and inform RNs about practice matters that may be controversial or new, for example, the use of social media.

The NCSBN authored a white paper on social media to provide guidance to nurses on this topic (National Council of State Boards of Nursing, 2011). Recently the NCSBN also developed a uniform licensure requirement that sets a national standard for licensure in the U.S. (McDougal et al., 2011). It is recommended that similar steps be taken by the NCSBN to provide guidance on RN sedation practice including propofol administration. The first step in the process would be for NCSBN to work collaboratively with boards of nursing, professional organizations and experts in sedation care to develop a guidance document for RNs about sedation practice including the practice of deep sedation and administration of propofol. Secondly, recognizing that the need for sedation care continues to increase, a process similar to that used to develop uniform licensure requirements could be used to develop minimal requirements for RN sedation care (McDougal et al., 2011; Metzner & Domino, 2010).

Lack of Research on Nurse Sedation Practice

Research in the area of sedation is limited, due to the large sample sizes required to detect complications, the variety of settings, and procedures in which sedation is administered. In order to improve sedation research, collaboratives such as the Pediatric Sedation Research Consortium (PSRC) have been established. The PSRC consists of a group of more than 30 institutions that collect pediatric sedation data using a standard web based data collection instrument (Cravero et al., 2006). The PSRC database contains data on monitoring and medication practices, outcomes, and information on RNs as sedation providers (Cravero et al., 2006). While the PSRC has reported on many aspects of sedation care, including a focus on physician non-anesthesiologists, data on RN sedation providers has not been reported. The data collection methodologies and definitions of adverse events vary amongst researcher, so results are not comparable. The practice of sedation will continue to evolve as newer sedative medications become available and technology advances. However, the effectiveness of these advances in decreasing complications associated with RN delivered sedation will be difficult to evaluate given the current knowledge about the specific practices and risks of RN delivered sedation.

Recommendations

Collaboratives similar to the PSRC are necessary in order to develop samples of adequate size to research adult sedation care. In addition, the development of standard data collection methods and instruments for sedation care is necessary to determine possible differences between sedation providers and patient populations. Available data on RN sedation care must be studied to determine current RN sedation practice and outcomes that can inform sedation providers and regulators, in order to implement evidence based safety practices and regulations.

Lack of Unified RN Sedation National Standards

The myriad guidelines and statements from many sources make it difficult to develop national standards of practice including the scope, specific training requirements, and competencies necessary for RNs to safely provide sedation. The lack of national standards also make it difficult for RNs and consumers to make informed decisions as to the standard of care that should be provided for sedation with a variety of procedures. There are many reports of training requirements for RN providers, but current studies offer little information as to content, educational methods, competencies and outcomes of sedation training (Jest & Tonge, 2011).

In a recent systematic review investigating competence and skills necessary to provide sedation safely, only one study of nurse administered nitrous oxide was reviewed (Leroy et al., 2010). The authors were unable to find any well-designed prospective studies on sedation safety and the level of skill and competence of any non-anesthesia sedation providers (Leroy et al., 2010). Jest and Tonge (2011) used a learning-needs assessment in a sample of 55 RNs to find the knowledge gaps related to sedation practice of RNs already providing sedation in two different settings within an institution. RN responses to this assessment revealed that learning needs differed depending on the RNs specialty area (Jest & Tonge, 2011).

Recommendations

Most sedation national standards have been developed using a consensus method including a systematic review of evidence and expert panels to formulate recommendations for practice. The ANA has already started the process by endorsing the “Procedural Sedation Consensus Statement”(American Nurses Association, 2008). This consensus methodology should be applied to expand the scope of the “Procedural Sedation Consensus Statement” to other specialty areas or by patient population. Developing national standards addressing sedation competence will require further research, possibly using qualitative methods to determine competencies required by specialty, rather than attempting to apply a single level of training and competence across all specialties.

Conclusion

Sedation is a multispecialty discipline that will continue to evolve. Current RN sedation regulation in the U.S. remains fragmented and poorly documented. There are three major controversies related to RN sedation practice: variation in board of nursing regulation, lack of research on RN sedation practice, and a lack of RN sedation national standards. Collaboratives between researchers, sedation clinicians, professional organizations and regulators will be necessary to develop a unified strategy that will guide RN practice in the field of sedation. Improving sedation care will require developing evidence on sedation practices and outcomes in various populations that can inform educators, policymakers and clinicians.