Facilitators and barriers to optimizing sedation practices in critically ill adult patients: A qualitative study

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OBJECTIVES: To identify priority domains that influence healthcare provider sedation practices and to describe key sedation protocol elements reported by participants that serve as facilitators and barriers to sedation practice change. METHODS: We conducted qualitative individual semi-structured interviews with critical care healthcare providers, including physicians/nurse practitioners, nurses, pharmacists, respiratory therapists, and physiotherapists, to understand sedation practices and define key factors that limit the opportunity for optimization of ICU sedation practices. We analyzed responses with deductive content analysis using the Theoretical Domains Framework (TDF) to identify priority domains related to sedation practices and describe constructs within the priority domains. RESULTS: We conducted 29 semi-structured interviews virtually from April 29 to December 10, 2024, consisting of 12 physicians/nurse practitioners, 5 respiratory therapists, 8 nurses, 3 pharmacists, and 1 physiotherapist. We identified seven priority TDF domains across healthcare provider groups including: Beliefs about consequences, Beliefs about capabilities, Reinforcement, Memory, attention, and decision processes, Environmental context and resources, Social influence, and Social/professional roles. Participants reported sedation use for multiple purposes including patient and staff safety, unit culture, and to address environmental and organizational challenges (e.g., patient care efficiency). Participants reported several recommendations for optimizing sedation delivery including available nursing-driven sedation protocols for specific patient populations (e.g., alcohol withdrawal) and specific sedation weaning recommendations. CONCLUSIONS: Critical care healthcare providers identified several domains relevant to sedation practices, underpinned by patient and staff safety, key patient-specific factors, and socioenvironmental factors. In understanding priority domains and underlying factors that influence sedation practice, implementation strategies using protocol-driven sedation as a tool to improve guideline adherence should be designed targeting the identified priority domains and underlying driving factors. IMPLICATIONS FOR CLINICAL PRACTICE: Protocol-driven sedation strategies are more likely to succeed when interventions intentionally address the priority domains and driving factors that influence adherence to clinical practice guidelines during implementation processes.

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