The experience of bedside nurses delivering and intensive care sedation study: a process evaluation within the A2B study

Abstract

Background: This process evaluation explored delivery of a complex sedation intervention within the Alpha-2 Agonists for Sedation to Produce Better Outcomes from Critical Illness (A2B) trial, which compared dexmedetomidine- and clonidine-based sedation with propofol (usual care). All groups targeted lighter sedation levels. The objective was to understand bedside nurses’ experiences delivering the interventions and identify factors influencing protocol adherence and implementation. Methods: A qualitative study using semi-structured interviews was conducted with intensive care unit (ICU) staff (consultants, bedside and research nurses) from A2B trial sites. Thematic analysis explored how participants experienced and delivered trial interventions, with particular focus on bedside nurses’ abilities to manage sedation in line with the protocol. Results: Nurses with greater ICU experience described more confidence and adaptability in using alpha-2 agonists, while less experienced staff required support due to limited familiarity with lighter sedation. Hesitancy to up-titrate alpha-2 agonists was common, driven by concerns about bradycardia and hypotension. Reluctance to down-titrate propofol was shaped by fears of agitation and self-extubation. Deep sedation norms, especially amongst nurses trained during the COVID-19 pandemic, further hindered protocol adherence. Research nurses were instrumental in supporting implementation and bridging knowledge gaps. Conclusion: Despite all three trial groups targeting lighter sedation, nurse confidence, safety concerns, and ingrained cultural practices limited adherence to alpha-2 agonist-based protocols. Addressing these barriers through training, support, and cultural change will be essential for future trials and practice shifts involving lighter sedation strategies in ICU. Trial registration number: ClinicalTrials.gov NCT03653832 https://clinicaltrials.gov/study/NCT03653832

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