Study design

This study adopted a qualitative descriptive methodology that provides a rich, and thick description30 of the participants’ perceptions that stays close to the data.31 Focus groups were used as a method of data collection. Focus groups are small groups of individuals who share common characteristics or experiences.32 They allow researchers to observe group dynamics and to explore what people think and how and why they think as they do.33

Objectives

The purpose of this study was to explore the experiences, beliefs and perceptions of ICU nurses on the management of PAD in critically ill patients.

Our two main research questions are as follows:

1. What are nurses’ perceptions and experience with PAD management in the ICU?

2. What are the barriers to evidence-based PAD management practices in the ICU?

Setting

This study took place in a community hospital located in a medium size Canadian city, where more than 90 part-time and full-time registered nurses provide ICU care. This centre has one adult 14-bed (all individual rooms) level-III medical-surgical ICU (where the intensivist acts as the primary physician during the patients’ ICU stay), with a nurse to patient ratio of 1:1 to 1:2. There is a dedicated ICU pharmacist, respiratory therapist, physiotherapist, dietitian and 24 hours in-house intensivist coverage. The ICU patient population includes general medical, cardiac, respiratory, nephrology, oncology, general surgical, orthopaedic and vascular surgical patients. The ICU is a locked unit but without restriction in family visiting hours. There is a nursing policy in place to stipulate that pain is assessed using the Numeric Pain Rating Scale at the beginning of each shift, after analgesic administration every 4 hours, and as needed. Sedation level is assessed using the Richmond Agitation Sedation Scale at the beginning of each shift and as needed and delirium is assessed using the Confusion Assessment for the ICU. The ICU nurses are responsible for titrating doses and frequency of analgesics and sedatives according to patients’ clinical status. There is no pre-existing protocol for medication titration.

Research team and reflexivity

A total of 10 researchers participated in this study. KR was a research assistant with a Masters’ degree in health sciences and experience in qualitative research. RM was a research volunteer with an undergraduate degree in health sciences. FM, PY and CM were medical students. MC was a research volunteer with a medical degree from Colombia. DF was a pharmacist in the ICU where the study was conducted. ML was a PhD scientist with qualitative research expertise. JLYT was an MD/PhD clinician scientist and intensivist in the ICU where the study was conducted. KR, RM, FM, PY, CM, MC and ML had no clinical involvement in the ICU and no relationship with study participants. Both DF and JLYT worked in the ICU where the study was conducted and had relationships with study participants.

During study design, the positioning of JLYT and ML, first author and senior author, respectively, was established regarding the researchers’ belief (suboptimal PAD management in the ICU) and motivation for the research (to improve PAD management in the ICU). Researchers based their approach on a constructivist paradigm with an assumption that knowledge is constructed based on personal experiences and hypotheses of environment.34 35

Participants and sampling

Purposeful sampling was conducted to select information-rich cases for study in depth. Information-rich cases are those from whom one can learn a great deal about issues of central importance to the purpose of the research.36 Moreover, the sampling for focus groups typically involves bringing together people of similar backgrounds and experiences. Therefore, purposeful sampling strategy was used.37 The inclusion criteria consisted of nurses who worked at full-time capacity in the community ICU (single ICU). There were no exclusion criteria.

An email was sent to invite nurses to participate in the study. A sign-up sheet was posted in the ICU where nurses who wished to participate could place their names. A few days before the focus group sessions, a reminder email was sent to participants. Participants were reimbursed on an hourly basis for their time spent in the focus group session. Of the 76 full-time ICU nurses who were eligible and invited, a total of 66 signed up and 46 participated. These included 43 women and three men. The gender ratio is representative of the nursing demographics in the ICU. There were 16 no shows.

Ethical considerations

We ensured participant confidentiality by anonymising our data. The participants were all informed of the purpose of the study and the voluntary nature of their participation.

Data collection

Semistructured focus group sessions were conducted in a hospital meeting room away from the ICU where participants worked. This data collection strategy was chosen to allow participants to discuss, explore, describe, explain, share and compare their thoughts, ideas and perceptions.30 There were five focus group session times that participants could choose from. At each session, there were 1–3 focus groups occurring with group sizes ranging from 3 to 7 participants (table 1). For each focus group, there was an experienced facilitator and a dedicated notetaker (FM, CM and PY) to take extensive notes in real time during the focus groups using a laptop. The notes include direct quotes from participants.

The facilitators (JLYT, DF and ML) conducted the focus groups with a semistructured interview guide with six open-ended questions (table 2) to guide discussions in English. The interview guide questions were informed by the responses to a nurse survey conducted prior to the design of this study38 together with sensitising concepts from existing literature. They were formulated to address the participants’ perceptions, beliefs and experience in PAD management and their perceived barriers to optimal PAD management in the ICU. The facilitators first explained the purposes of the focus groups and asked all participants to sign an informed consent form. The facilitators, then followed the semi-structured interview guide by posing one question at a time, allowing time for participants to voice their opinions and for discussion among the group. After all questions were posed, facilitators ended the focus groups with closing remarks (table 2). Since there was no audio recording, we did not have the exact duration of the focus groups. However, all focus groups lasted approximately 60 min. All the research data were anonymised and kept confidential.

Data analysis

Thematic analysis was adopted to search for themes and patterns in the focus group data.31 32 Initially, three independent analysts (FM, RM and CM) read the data sets multiple times to familiarise themselves with the data to generate and assign initial codes to units of meaning. Open coding (fracturing of the data and grouping/categorising) was performed, followed by axial coding (rearranging the data in new ways). All three of the analysts who generated and assigned initial codes (FM, RM and CM) did not have any clinical roles in the ICU; therefore, they did not have preconceived biases in regard to the quality of PAD management in the ICU. Moreover, one of the analysts (RM) had no prior involvement in the design and conduct of this study. This allowed RM to conduct the analysis with tabula rasa (blank slate). A total of 10 focus group data sets were analysed separately to create initial codes. Then two analysts performed thematic analysis by searching, reviewing, defining and naming themes. One analyst (JLYT) was an intensivist who is the first author of this manuscript and the other analyst (DF) was an ICU pharmacist. A total of 30 coded data sets were analysed individually and then discussed as a group to develop, define and name the themes. Finally, one analyst (ML), who is a qualitative researcher and the senior author of this study reviewed and finalised the themes (see figure 1). No qualitative software was used on the data.

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Figure 1

Data analysis scheme. ICU, intensive care unit.

Trustworthiness

The trustworthiness of this study was ensured by enhancing its credibility, transferability and dependability.39 Credibility was achieved using (1) a well-established research methodology (qualitative descriptive) and method (focus group), (2) triangulation as the focus of the interview questions was informed by results of a previous survey conducted by our group38 and (3) interview questions that were designed to collect descriptive data that reflected real experiences and perspectives of participants. Finally, despite the lack of audio recording, three transcribers were responsible for obtaining detailed transcripts including direct quotes in a total of 10 separate data sets. The credibility of the data sets was ensured by the similarity of the codes and themes that were generated and developed from these 10 separate data sets.

We addressed the transferability of this study by providing a detailed description of the setting (community ICU in a medium size Canadian city) and context (the aim of this study was to inform the development of PAD quality improvement interventions) in which this study took place. Further, reflexive insight from the researchers was noted, with the motives of researchers being to understand and improve PAD management, and the perception that PAD management in its current state was suboptimal within the community hospital setting. The dependability of this study was upheld by performing audit trails throughout the process of collecting, coding and thematising the data. We also performed member checking by asking four participants to review the results of our study. They felt that the results were consistent with their beliefs, perceptions and experiences. Our member checking validated the results of our study. Finally, we performed researcher triangulation by using multiple analysts to review data sets, generate codes and develop themes to reduce bias.

Patient and public involvement statement

The patients and the public were not involved in the design or planning of the study.

Theme: the professional perspectives on patient wakefulness state

This theme describes the divergent perspectives of nurses on optimal patient wakefulness state. Participants had polarised opinions on the appropriate wakefulness level of critically ill patients. The difference in perspectives appeared to stem from personal choice when thinking about how they would like to be treated as a patient.

Subtheme: when to worry?

Participants described divergent opinions on what is considered a harmful patient wakefulness state. Some reported that a patient who is deeply sedated would be very worrisome because it precludes proper assessment of neurological function. On the other hand, some participants reported that a patient who is awake and agitated could cause self-harm if the patient was ‘bucking the vent’, ‘pulling out lines and tubes’ or ‘banging, climbing in bed, [or] trying to extubate themselves.’ It was also perceived by the participants that agitated patients could be harmful to healthcare workers through violent outbursts. Therefore, an agitated patient would be more concerning than a deeply sedated patient.

Moreover, the divergent opinions also stemmed from the perspectives of patient care. Specifically, some participants felt that it is much easier to provide nursing care to a deeply sedated patient compared with an awake and agitated patient. Others felt that an awake and agitated patient is much more demanding of constant nursing attention, precluding the nurses from attending to other patient care matters.

Subtheme: the optimal patient wakefulness state

Participants expressed polarised views on what is considered an optimal patient wakefulness state. Some participants were adamant that a critically ill patient should be deeply sedated. This view stemmed from both professional beliefs and personal preferences. Professionally, some participants strongly believed that an ICU experience would lead to post-traumatic stress disorder (PTSD) in patients who are kept awake. Therefore, they were adamant that critically ill patients should be deeply sedated. Moreover, some participants clearly voiced their demand of being deeply sedated should they become a critically ill patient. Their rationale primarily surrounded the risk of PTSD development from an ICU stay.

On the other hand, some participants felt that patients should be kept calm and awake. They believed that the most important thing is to manage the patients’ pain. Once that is achieved, patients could be comfortably kept more awake. Some participants stated that they would prefer to be more awake should they become critically ill because they would like to be able to participate in medical decision making as a patient.

Theme: the professional perspectives on PAD management of critically ill patients

The second main theme that emerged from our data related to the professional perspectives on PAD management that were dependent on both patient status and healthcare providers’ preferences, resulting in significant variability. This variability occasionally became the source of healthcare providers’ frustrations.

Clinical conditions of patients

Participants reported that PAD management should be tailored to individual patients. The patient factors that need to be considered include severity of illness, underlying comorbidities such as cognitive impairment, drug metabolism (response to analgesics, sedatives and antipsychotics) and preferences. The participants highlighted that all patients respond differently to various medications and environmental stimuli. They also reported that patients have varying severity of illness which further complicates care regarding PAD. Some participants also reported the influence of response to therapy by pre-existing medical conditions or previous exposure to pharmacotherapy. The recognition of the need to individualise PAD management also contributes to frustrations as it precludes the use of uniform clinical PAD protocol.

Preferences of healthcare providers

Our participants reported that healthcare providers often have varying knowledge about PAD and individual preferences for specific medications, sedation levels, use of restraints, earplugs and care process. They also highlighted the problem of inconsistencies in PAD management provided by healthcare providers. Moreover, they reported that the choices of pharmacotherapy vary significantly among intensivists resulting in instances where patient’s analgesics, sedatives or antipsychotics were changed drastically without proper patient assessment when there was a change-over of intensivist. Participants were also frustrated by inconsistent PAD management approaches among nurses and they recognised a difference in PAD management between day shifts and night shifts. They felt that night nurses tend to sedate patients more deeply compared with day nurses. These perceptions exist despite the fact that most nurses work both day and night shifts. They felt that these care differences impacted on how patients were managed over the duration of their ICU stay and potentially may contribute to prolonged ICU length of stay. Some participants reported that the variability of PAD care provided by healthcare professionals could negatively impact patient care and it became a constant frustration of bedside nurses.

Theme: the factors impacting PAD management

The third main theme that emerged from the data centred on factors that impact PAD management. The participants reported that PAD management was complex and healthcare providers need to consider many factors when they cared for their patients from the perspective of PAD.

Interprofessional dynamics

The participants reported that healthcare team dynamics, communications between multidisciplinary healthcare teams and with the patients and family could positively or negatively influence patient care. For example, the participants felt that physicians should assess the patients and communicate with the bedside nurses before altering PAD pharmacotherapy. Bedside nurses often have a better understanding of the patients’ clinical state compared with intensivists who often spend only a short time with the patients precluding them from recognising the trend of patients’ clinical status. Moreover, participants felt it would be beneficial for the intensivists to explain the rationale of changing pharmacotherapy to the bedside nurses, therefore promoting education and understanding among healthcare professionals.

More importantly, the participants reported that it is important for the healthcare team to effectively communicate with patients and patients’ family to promote their understanding, facilitate therapeutic rapport and build trust. It would also reduce patient and family anxiety. Moreover, effective communication with patients and family could provide clues to appropriate and individualised non-pharmacological PAD therapy.

Environmental factors

The participants reported many aspects of the environment that they felt could impact the patient well-being. These included overhead announcements, monitors, patient positioning in the room, bright lighting and constant healthcare professional interaction with the patients. As noted by multiple participants, there were a variety of distractions and disruptions to the patient that were felt to negatively impact PAD. Participants suggested ways to minimise the negative environmental effects on patient well-being, such as clustering medical procedures, turning lights off at night and minimising overhead announcements in patient rooms.

Family input

The participants reported that family members could be helpful in the care processes or may be disruptive to the patient and healthcare teams that could be stress inducing for the patients. This relates to interactions that healthcare providers had with the patients and/or how the family engaged with the patient. The participants also felt that healthcare providers could better incorporate family members into care through education on how best to interact with the patients, while also involving family members to further understand patient’s baseline conditions and care preferences.