Date of Award

Spring 6-9-2023

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Amy J. Howells

Faculty Reader

Darryl DuVall

Executive Summary

Title: Program Evaluation of an Online RASS Score Training Module and its Effects on Sedation Management of Pediatric Intensive Care Patients

Background and Significance: Across intensive care medicine, sedation poses a challenge to providers and nurses who struggle to balance agitation and pain against optimal levels of comfort and sedation. Pediatric patients are hard to sedate due to their complexity, variability in communication skills, and narrow therapeutic range. Across the country dexmedetomidine (precedex) is widely used in PICUs to aid in sedation. Dosage, titration, and weaning of this medication vastly differs from institution to institution (Thompson et al., 2019). Use of the Richmond Agitation Sedation Scale (RASS), a standardized tool, can help guide nurses and providers in setting appropriate sedation goals and assessing the appropriate achievement of optimal sedation. Greater education of nurses and providers on RASS scores can help guide practice change for more reliable sedation scores that can guide more effective patient sedation and management (Kerson et al., 2016). Targeted RASS scores can help providers and nurses maintain an appropriate level of sedation, as well as cue the initiation of weaning continuous medications sooner (Kerson et al., 2016).

Problem and Purpose Statements: Nurses and providers agree that optimal sedation should be achieved while utilizing the smallest amount of drug possible. However, understanding of RASS scores and management goals varies between nurses and providers. Nurses are focused on maintaining comfort and safety, whereas providers are focused not only on sedation but also on overarching goals. Providers and nurses both want to use the least amount of sedation to achieve the most comfort and optimal sedation. However, best practices around sedation management and the variability of precedex doses and titration algorithms used make this difficult to achieve. The goal of this program evaluation is to assess the effectiveness of the Grow summer 2021 RASS training module for nurses, to assess provider and nurse attitudes and views related to RASS scores, and to identify barriers to sedation achievement.

Methods: All nursing and provider staff in the Pediatric Intensive Care Unit (PICU) received education on RASS scores. Nurses completed an online module while providers had variable education ranging from informal discussion to classes. The education module included a PowerPoint outlining the RASS tool and a knowledge assessment quiz at the end and was completed by all nursing staff in October of 2021. Two surveys composed of Likert scale questions and two free text questions were sent out for anonymous participation. One survey invited nurses to participate, and the other survey invited all PICU providers to participate. Both surveys shared the same questions except the nursing survey included additional questions to assess nursing-specific components of sedation management. Descriptive statistics of the paired data between nurses and providers were analyzed for significant mental models of nurses and providers regarding using RASS scores to attain appropriate sedation, appropriate ordered goals, discussions between nurses and providers, and knowledge of RASS scores. Qualitatively data was collected from two open-ended questions to assess barriers or ideas for improvement of current sedation practices. Chart audits were conducted over a three-month period to assess for compliance with RASS documentation, titration with RASS scores, and appropriate initiation of continuous sedative medications.

Results/Outcomes: Qualitative data gathered from open-ended questions identified key areas such as communication/discussion, lack of knowledge/education, and comfort with sedative medication as areas where improvements would benefit staff in helping to attain better sedation management. Differing mental models between nurses and providers was a central element to contributing to improper sedation management. Nurses focused on maintaining more immediate comfort and safety whereas providers also focus on comfort and safety and additionally must anticipate long-term goals. Quantitative data demonstrated that most nurses found their knowledge of RASS scores improved post Grow summer 2021 module. Most nurses agreed that RASS scores alone were not a good enough marker for optimal sedation management as PICU patients are complex and ever-changing.

Sustainability: All the data collected from this program evaluation will be shared with the PICU CNS and microsystem council to help guide evidence-based practice changes to the existing Comfort protocol. Findings from this program evaluation can be utilized to better understand the different mental models that exist between providers and nurses that lead to suboptimal sedation achievement. This evaluator recommends a discussion of RASS scores on each shift to occur between nurses and providers every 12 hours to assess appropriate target sedation achievement and barriers to achievement that should be addressed. The findings from this program evaluation will be utilized to create improved education for nurses and providers on RASS scores and bring more awareness to the continual need for discussion between providers and nurses using the shared language of RASS scores.

Implications: Understanding barriers to appropriate RASS score utilization and barriers that exist for nurses and providers can guide practice change that results in effective management of patient sedation. In identifying barriers such as different mental models or provider nurse goals, the program evaluator and PICU CNS can work to create educational materials and tools to help guide more cohesive communication. Nurses may feel more confident in using the RASS scores to initiate discussions with providers around safe and appropriate sedation goals. Both providers and nurses can use RASS scores as a common language to outline sedation goals and as a reliable marker to measure the achievement of these goals. In understanding barriers to optimal sedation that exist between nurses and providers, more appropriate and better clinical outcomes can be achieved in PICU patients who require continuous sedation medications.