Research

The Nurse’s Role in Mechanical Ventilation Weaning Introduction Weaning from mechanical ventilation is an essential and universal element in the care of critically ill intubated patients receiving mechanical ventilation. Weaning covers the entire process of liberating the patient from mechanical support and from the endotrachael tube, including relevant aspects of terminal care. (Boles et al 2007). Weaning from mechanical ventilation is the role of the critical care nurses. Transferring this role from physicians to nurses is not without challenges. The aim of this study is to how to improve the nurse’s role in mechanical ventilation weaning, and to inherit the skills, experience and willingness to accept the level of responsibility. Weaning in the context of critical care can be challenging. To wean the difficult-to wean or the long-term weaning patient requires great skills and expertise. Weaning from mechanical ventilation is not a new problem but has now gained a higher priority in the critical care largely as a result of the economic impact of caring for long-term weaning patients in a critical care settings. Hence this study reveals the nurses role in mechanical ventilation weaning. Literature Review Search Strategy An extensive search of five major databases such as Medline, ProQuest, Science Direct, CINAHL, Cochrane was utilised to identify relevant articles published from 1998 to the present time. Search terms used include ‘critical care’ ‘decision making’ ‘nurse led weaning’ ‘mechanical ventilation weaning’ ‘nursing role and weaning’ and ‘protocolised nurse led weaning’. The total subject matter is based on the result of individual search on articles and studies which are relevant to this article review. Electronic Journals also provided relevant information, however, protocolised nurse led weaning would be difficult because of the frequent turnover of medical and nursing staff also the level of ICU experience. Themes The discontinuation or withdrawal process from mechanical ventilation is an important clinical issue. Mechanical Ventilation Weaning is used for intubated patients in the intensive care unit. Hanneman (1999) states that most patients can be extubated or weaned from mechanical ventilation without difficulty, while approximately 20 percent represent a complex challenge for the intensive care unit staff. Marelich et al (2000) suggested that it has been estimated that weaning takes up 40 percent of the mechanical ventilator trajectory. Tobin and Alex (1994) stated prolonged mechanical ventilation weaning is often associated with life threatening complications, which means that weaning should be carried out as expeditiously as possible. In the UK the process of discontinuing mechanical ventilatory support (weaning) is normally directed by intensive care unit (ICU) medical staff. Nurses’ engagement in this process is dependent upon their experience, personal preference and / or unit culture. The combined effect of individual preference and variability in experience may result in inconsistencies in weaning practice. Nurses have not traditionally been considered to be part of the decision making in relation to mechanical ventilation weaning, but recent studies are emerging which suggest that nurses do participate in the decision making and that this may positively influence the process. Crocker (2002); Marelich et al (2000) states that studies of nurse – led protocol weaning in England and United States, have demonstrated a reduction in the duration of mechanical ventilation weaning. Martensson and Fridlund (2002) states that a national survey in Sweden of weaning from mechanical ventilation shows that critical care nurses are in a unique position for adapting a holistic approach to weaning, and the study identifies a number of measurable parameters which improve the quality of care. Bucknall (2000) states that although nurses participate in decision making, there is a high degree of variability in nurses participation, as it is found that decision frequencies are linked to nurses’ critical care experience, appointment level, and nursing shifts. Norton (2000), Anderson and O’Brien (1995), Harris (2001) Fulbrook et al, (2003) stated that historically that the process of weaning from mechanical ventilation has been the responsibility of intensive care physicians or other medical staff, with nurses involved in the process but not responsible for the initiation of ventilator changes. Increasingly responsibility for weaning is been taken over by nurses, especially within the framework of weaning protocol. Harris (2001) notes that the role nurses in weaning practices is difficult to quantify in the Untied Kingdom settings due to wide variation of practice in individual intensive care units. Aikan et al (2003) stated that critical care nurses have an important role in the management of mechanical ventilation weaning. They have been described as an around-the-clock surveillance system and, as such are in the excellent position to access physiological and psychological indicators of readiness and failure to wean, ‘interpret patients’ changing pathophysiology, and titrate ventilation and monitor responses to corresponding ventilator adjustments. Blackwood (2003) acknowledges that weaning readiness assessment has unique pathophysiological and emotional components that maybe only be recognised by the close contact of bedside practitioners. Henneman et al (2002) and Cohen et al (1991) argues that most effective clinical making about the process of weaning from mechanical ventilation is derived from effective communication and planning by multidisciplinary teams. It is imperative therefore, that ventilation and weaning should be performed as a collaborative process between bedside nurses and physicians. As per Mancebo (1996) Weaning refers to the transition from ventilatory support to spontaneous breathing).Hess (2002) argued that the overall aim of the weaning process is to enable the patient to assume a greater ventilatory workload by reducing the support given by the ventilator .Kollef et al (1998) stated that depending on the patient's response, this transition may occur rapidly such that the patient undergoes a short trial of spontaneous breathing and is then extubated, or it may take the form of a gradual withdrawal with slow decrements in the level of support given by the ventilator. Some authors prefer the term ‘liberation’, as this signifies the release from a restrictive, potentially dangerous process, whilst weaning implies the withdrawal from a nurturing life support system. Esteban A et al (2002) suggested that Prolonging mechanical ventilation may increase the risk of adverse events, particularly nosocomial pneumonia. Conversely, extubation failure is also associated with adverse outcomes, including higher hospital mortality, longer hospital stay, higher costs, and greater need for tracheotomy and transfer to post-acute care. Ely et al. (2001) suggested that there is strong evidence that the use of weaning protocols by nurses and respiratory therapists can safely and expeditiously liberate patients from ventilator support. Hess (2002) believes that the positive outcomes of weaning protocols may be due to early recognition by bedside clinicians, e.g. nurses and respiratory therapists, of the patient's ability to breathe without support. Blackwood (2003) argued that early studies of the use of weaning protocols in the 1970s focused on postoperative cardiac surgery patients. Blackwood (2003) stated that these patients, however, differ in important ways from general ICU patients as they usually only require short-term ventilation to overcome the effects of anaesthesia, surgery and bypass. Weaning strategies Weaning strategies are mainly divided as Wean as able and Weaning method Wean as able The decision to move from a pre weaning phase to a weaning phase was made by the medical staff either in the morning assessment of the patient or at the ward round. The doctors documented that decision as to ‘wean as able’ and they often gave parameters (desired level of PO2 or PCO2) for the nurses to follow. Then, nursing staff decided on the manner and time to start reducing the ventilatory support. More experienced nurses either would initiate weaning or would prompt the doctor to give a weaning plan after the morning assessment, whereas more junior nurses were reluctant to proceed with the weaning until a formal decision was made at the ward round. The ‘wean as able’ did not provide the nurse with a definite plan for the day; it was interpreted differently and was attributed to the nurse's skills, knowledge and experience in weaning. For some nurses, weaning meant a reduction of pressure support by 2 cm H2O for the day or a reduction of the fraction of oxygen by 10%. Nurses stated during informal interviews that they followed their clinical judgment when adjusting the ventilatory parameters and based their decisions on their observation and on blood gas analysis. This quite often resulted in great variations of the ventilatory support during the day or in total weaning inactivity. Observation in practice and interview analysis revealed that changing the level of ventilator support was variable and doctor dependent, despite the existence of a weaning protocol. Nurses agreed that the lack of a weaning plan resulted in inconsistency of decisions among nurses and doctors regarding the duration and frequency of spontaneous breathing trials (SBTs), the modes of ventilation for spontaneous breathing and the rest periods during the night. According to nurses, this irregularity had an impact on the patient's weaning trajectory and response to changes of the ventilatory support. Moreover, nurses' interpretation of the ‘wean as able’ approach did not provide a systematic approach to the management of ventilation. Krishnan et al (2004) and Blackwood et al (2009) stated that studies until now have shown that protocolised weaning can improve the outcome of weaning patients because it offers a more standardized conduct . Blackwood et al (2005) argued that protocols can impede the clinical judgment, because they over simplify weaning and concentrate on physiological responses of the patients without considering the heterogeneity of these patients . Weaning is more complicated than just following an algorithm; therefore, long-term ventilated patients would benefit from an individualized dynamic weaning plan that would incorporate nurses' expertise. Weaning protocols are available to assist less experienced staff in their decision-making, whilst junior nurses are allocated to the weaning patients. Crocker and Scholes (2009) stated that the nurse allocation system and shift patterns were inhibiting factors in knowing the patient and maintaining a continuity of the weaning process,. Logan and Jenny, (1997) argued that Senior nurses and critical care managers should consider the skill mix when allocating nurses to the patients to preserve continuity of care and to allow junior nurses learn from experts, if they are to develop skills in weaning the patient .Further research is required in investigating ways to maintain and enhance the continuity of care for the complex long-term ventilated patients. Weaning Method Terminal extubation is characterized by ceasing ventilatory support and removing the endotrachael tube in one step. Mayer S A, Kosseoff S B (1999) and O Mahonys et al (2003) revealed in their studies that Extubation was the only method used. Terminal weaning is a process of step-wise, gradual reductions in oxygen and ventilation, terminating with placement on a t-piece or with extubation. Campbell ML et al (1999) stated that rapid terminal weaning was the only method used in one study with an average weaning interval of 15 minutes. Faber – Langendoen K (1994) stated that in a survey of physician practices related to ventilator withdrawal, investigators found that surgeons and anaesthesiologists preferred terminal weaning compared with internists and paediatricians who preferred extubation. It is interesting to note that physician rather than patient characteristics contributed to choice of method. There are no known investigations that compare these methods. Aims and Objective The aim of this study is to gain consensus among panel of experts, concerning the role of critical care nurses in the management of mechanical ventilation weaning.  The literature circumscribed many aspects of mechanical ventilation weaning. The Objectives are: To set up a panel who are expertise, knowledgeable and experienced and to explore experts conceit and assumption based on their knowledge and experience concerning the nurse’s role in mechanical ventilation weaning. Methodology Giacomini MK and Cook DJ(2000) stated that Qualitative Analysis aims to interpret the data to develop theoretical insights that describes and explains phenomena such as interactions, experiences, roles, perspectives, and organizations. The aim of this research proposal is to explore the issues of nurse-led mechanical ventilation weaning. The research is undertaken in a NHS hospital within the North West region of England. The study aims to identify the factors which influence the decision to commence nurse-led weaning from physician guided mechanical ventilation weaning. Qualitative methodology is adopted as an appropriate research approach. Qualitative research reports as best understood as empirically based contributions to the ongoing dialog and exploration of social phenomena. These qualitative studies primarily used in- depth personal interviews as a data collection method and grounded theory analytic approach. The studies in this review captured some important experiences of Intensive care unit nurses who are involved in the mechanical ventilation weaning, including their experience, skills, their role, knowing the patient (which was the basis for expert nurses judgement) acknowledging the work of weaning and physicians approach to this method. Nobit GWand Hare RD (1988) described that Individual Qualitative research reports can richly describe and explain social phenomena, and can be synthesised using meta- ethnography whereby the participants are observed in their practice environment. Phenomenology and philosophy is concerned with seeing things without making value judgements (Robert N and Philip B 2006) .Hence Phenomenological research approach is used to explore the nurse’s role in mechanical ventilation weaning. Phenomenologist use depth interviews, diaries, journals, poetry, and art as the data sources for insight into the human experience (Halloway and Wheeler S 2002) This intends to explore nurse’s perceptions implication and their interventions. Sample A Sample is the proposition of the defined population who are selected to participate in the study and is intended to reflect all characteristics of that population. Cormack D (2000) stated that how a sample is selected is an important aspect of any study. Qualitative interviews are planned to conduct with purposive sample of 15 intensive care unit nurses adopted for this study, they consist of a mixture of nurses from nursing bands 5, 6, and 7 with nursing experience ranging from 1to 20 years. Purposive sampling is a strategy in which the researcher’s knowledge of the population and its element is used to handpick the case to be included in the sample (LoBiondo-Wood Haber). In this purposive sampling, the nurses are to be included. Recommendations for group size vary amongst authors (Cormack D 2000, Holloway and Wheeler 2002). A small group is better for controversial or complex topics, while larger groups tend to have lower levels of involvement with less highly intense topic areas (Holloway and Wheeler 2002). Data collection There are different types of data collection methods; physiological, observational, interviews, questionnaires, records or available data. Data’s are collected through participant observation, informal interviews, and the collection of field notes and documentary analysis of weaning protocols and educational packages. Critical care nurses with a range of experience caring for long- term ventilated patients Will be invited to participate in the interview. Approximately 15 nurses will be observed in routine weaning practice for 3-5 hours each day on selected patient cases. The observation will occur during the day shift between 8 am – 8 pm, because the unit’s practice is not to wean patients at night as patients need rest. Long term ventilation is defined as a patient who has been ventilated for more than 4 days and had an unsuccessful trial of extubation within that period. Patients will be selected for the study from a computerized Intensive Care Unit data base and inclusion criteria’s are adults aged > 18 years, ventilated in the unit for more than 4 days, patients who are admitted with head injury and spinal problems. Exclusion criteria’s are patients who had already been weaning when the observation period started, patients who were planned to be extubated in the morning, patients who were ventilated for less than 3 days. Focus group Interview Aiming for 3 month prospective cohort study in a 20 bedded Intensive care unit. All the nurses are included in this study, irrespective of juniors and seniors. All the patients admitted to Intensive care unit who received mechanical ventilation need to be included in this study. Approximately 100 patients per month receive mechanical ventilation in this Intensive Care Unit. Focus group interview (see table 1 below) were planned to conduct in one of the side room within the Intensive care unit. 20-40 minutes of duration is allocated and it should be audio taped. According to Pope et al (2000) the recording were transcribed and the textual data’s are analysed systematically using a variant content analysis which entailed the following. Questions need to be open in order to obtain their great values and ideas. Focus group interview were guided by a semi- structured interview schedule. Questions are concentrated on nurse’s knowledge about the mechanical ventilation weaning. (Table -1) Interview schedule 1. How do you decide that the patient is ready for weaning' 2. What are the methods used to wean the patient' 3. Would you explain the role of a nurse in mechanical ventilation weaning' 4. What are the main issues in mechanical ventilation weaning' 5. What is your perception about the use of protocols in weaning a patient' 6. Are you confident in weaning a patient from ventilator' Aiming to use ‘survey monkey ‘also in order to obtain all the nurses perception who were not able to participate in the interview on the day. Data Analysis Data’s are analysed using the method of content analysis (Glaser and Strauss, 1967) In content analysis researcher establish a set of themes. These themes are also shaped by the existing literature (Silverman, 2001).The analysis of data followed several steps commencing with careful reading and re-reading of transcripts in their entirety. For this study two themes were emerged. These were: wean as able and weaning method. Reliability and Validity Reliability is defined as the accuracy of the data in terms of their stability or repeatability where as validity is the extent to which an instrument actually does what it purpose to do (Cormack D 2000).A number of methods are used to assure truthfulness and consistency in data collection and analysis. The usage of tape recording and transcribed textual data assured consistent accurate recording of data. Summarising points at the study’s conclusion is also beneficial to ensure validity. Ethical consideration All research’s are planned to conduct within the auspices of the National Health Service and involving human subjects or proposal information relating to them requires the approval of the local ethical committee. Ethical approval required from National Health Service Research Ethics Committee and the hospital Research and Development office, which includes approval to the setting and to the patient’s medical notes. Patient’s consent is not considered necessary because patients were not directly involved in the data collection. Patient’s privacy and confidentiality is to be respected at all times, all data is anonymous and observation is to be discontinued if the nurse thinks that it is predisposed patient’s condition. Written Consent is to be obtained from participating nurses on the onset of study, no personal information is revealed during the transcription and analysis and all data is to be stored in the researcher’s personal computer in a locked file. Limitation The study aimed to rely on bedside nursing staff to identify and categorise ventilator decisions compliance with documentation of the frequency of changes in ventilator settings is to be checked on a twice-daily basis by inspection of the bed-side clinical record and supplementary further clarification with bedside staff. However, the accuracy of the documentation of the indication for each decision episode and the identity of the initiator and implementer of each ventilator change could not be confirmed due to the size of the Intensive Care Unit (20 beds) and the 24hours a day, nature of decision making for ventilatory support. Another limitation is nurses changing duty rota, most of the nurses prefer to do long days and it is not suitable for getting their continuity of care. The researcher chose to undertake the research in her own unit, and as such it can be argued that this is a source of bias. Conclusion Nurse’s role in mechanical ventilation weaning was implied during the interviews as essential to the delivery of patient-centred care there were two themes were presented in order to present nurses role in mechanical ventilation weaning. Top of page Abstract BACKGROUND METHODOLOGY 1. 2. 3. 4. 5. FINDINGS 6. DISCUSSION 7. CONCLUSION 8. WHAT IS KNOWN ABOUT THIS TOPIC 9. WHAT THIS PAPER ADDS 10. ACKNOWLEDGEMENTS 11. REFERENCES This study showed that there was lack of a systematic approach to weaning, because of the different interpretations of weaning strategies by the clinicians and of the alternating shift pattern and nurse to patient allocation, which compromised the continuity of care that long-term ventilated patients require. Weaning should be based on a methodical cooperation between doctors and nurses to maintain consistency in decision-making and avoid behaviours that can result in the patient's deterioration. Nurses are knowledgeable than clinicians because they spend more hours by the bedside and are in the position to know the patient's weaning behaviour. Increasing their autonomy with the appropriate support, and guidance by the medical and senior nursing staff and by adequate education would increase their confidence in decision-making during the weaning process and therefore, facilitate the patient’s sooner discontinuation from the ventilatory support. Moreover, developing a flexible ‘wake and wean’ tool would offer a standardized approach to the management of weaning patients. Knowing the patient was further impeded by the lack of continuity afforded by the patient needs to be developed. The weaning protocol has its place but nurses need to ‘champion’ its implementation in mechanical ventilation weaning. Junior nurses need to learn from experts, if they are to develop skills in knowing the patient. Education in the use of protocols should be provided for all staff. Due to frequent turnover of medical and nursing staff, experience levels are varied. A designated, experienced nurse specifically to oversee weaning may be helpful in alleviating concern about this. However, individual units will need to consider carefully their recourses, particularly personnel time and commitment (Blackwood 2003). Further research may need to concentrate on skill mix, weaning outcome and investigating ways to maintain and enhance the continuity of care for the complex long-term ventilated patients.