The influence of intensive care unit culture and environment on nurse decision-making when managing vasoactive medications: A qualitative exploratory study.

Abstract

Nurses working in intensive care units make autonomous decisions to manage high-risk vasoactive medications in critically ill patients. Noradrenaline (norepinephrine) is a vasoactive medication commonly administered to patients in intensive care units. The influence of unit culture and environment on nurse-decision-making on noradrenaline (norepinephrine) management is unknown. The study aimed to investigate nurses' perceptions of the impact of interpersonal interactions, socialisation, and the intensive care environment on decision-making when managing noradrenaline (norepinephrine). An exploratory qualitative study applied thematic analysis to focus group data. A purposive sample of nineteen nurses participated in four focus groups at two intensive care units in Melbourne, Australia, from March to June 2021. The COREQ checklist was used to guide study development and no patients or members of the public were involved in focus groups. Three themes were generated from the researcher's interaction with data, Nursing and Medications; Culture and Decision-making; and a Safe Practice Environment. Nurses reported decision-making challenges associated with learning to manage noradrenaline (norepinephrine) early in their intensive care career and discussed feelings of isolation due to staffing resources, and the configuration of the intensive care environment. Nurses developed titration and weaning strategies to support decision-making in the absence of evidence-based algorithms. Empathetic patient allocation early in nurses' intensive care careers facilitated a safer learning environment, and reduced isolation inherent in single room intensive care units. Nurses developed and used titration and weaning strategies, often learnt from other clinicians to manage practice uncertainty. Management of noradrenaline (norepinephrine) is core business for intensive care nurses worldwide. Development of titration and weaning strategies by nurses indicated unmet need for guidelines to support decision-making. Identifying contextual elements that impact nurse management of high-risk medications can guide development of environments, resources and policies that support nurse decision-making, and reduce nurse anxiety and disempowerment.