Influence of clinicians' values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation.
BACKGROUND
Although popular, clinical practice guidelines are not universally accepted by healthcare professionals.


OBJECTIVE
To compare nurses' and physicians' actual and perceived rates of adherence to practice guidelines used in sedation of patients receiving mechanical ventilation and to describe nurses' and physicians' perceptions of guideline use.


METHODS
Pairs of fellows and nurses caring for 60 eligible patients were asked separately about their rationale for medicating patients, effectiveness of medication, and their perceived adherence to the guidelines. Actual adherence was determined independently by review of medical records. An additional 18 nurses and 11 physicians were interviewed about perceptions of guideline use.


RESULTS
Use of mechanical ventilation was the most common reason given by physicians (53%) and nurses (48%) for medicating patients, although reasons for administering medication to a given patient differed in up to 30% of cases. Physicians and nurses disagreed on the effectiveness of medication in 42% (P = .01) of cases. Physicians reported following guidelines in 69% of cases, but their actual adherence rate was only 20%. Clinicians sometimes had difficulty distinguishing among anxiety, pain, and delirium. Clinicians justified variations from guidelines by citing the value of individualized patient care. Nurses and physicians sometimes had different goals in the use of sedation.


CONCLUSIONS
Physicians may think they are following sedation guidelines when they are not, and they may prescribe incorrect medications if the cause of agitation is misdiagnosed. Differences between physicians and nurses in values and perceptions may hamper implementation of clinical practice guidelines.
Slomka
J
J
Cleveland Clinic Foundation, Ohio, USA.
Hoffman-Hogg
L
L
Mion
L C
LC
Bair
N
N
Bobek
M B
MB
Arroliga
A C
AC
D000328:Adult; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D016292:Procedural Sedation / Q000592:standards*; D003422:Critical Care; D003951:Diagnostic Errors; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital / Q000193:education / Q000523:psychology*; D008875:Middle Aged; D019148:Neuromuscular Blockade; D009741:Nursing Staff, Hospital / Q000193:education / Q000523:psychology*; D018579:Patient Selection; D017410:Practice Guidelines as Topic / Q000592:standards*; D011446:Prospective Studies; D011595:Psychomotor Agitation / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology; D012121:Respiration, Artificial / Q000009:adverse effects; D011795:Surveys and Questionnaires; D016896:Treatment Outcome