RESEARCH doi: 10.1111/nicc.12092
Critical care nurses management of prolonged weaning: an interview study ¨ Carl-Johan Cederwall, Kaety Plos, Louise Rose, Amanda Dubeck and Mona Ringdal ABSTRACT Background: For most critically ill patients requiring mechanical ventilation in the intensive care unit (ICU) weaning is uncomplicated. For the remainder, weaning is a challenge and may result in further complications and increased risk of mortality. Critical care nurses (CCNs) require substantial knowledge and experience to manage patients experiencing prolonged weaning. Aim: The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU. Design: A descriptive qualitative design. Methods: Semi-structured interviews with 19 experienced CCNs were conducted. Data were analysed using content analysis. Results: Participants used various strategies for weaning that were grouped into four categories: individualized planning for the weaning process, assessing patient’s capacity, managing the process and team interaction. The overall theme that emerged was: CCNs drive the weaning process using both a patient centred and targeted approach. Conclusion: CCNs in these ICUs performed weaning using a patient centred approach to plan, initiate, assess and establish a holistic weaning process. Team collaboration among all health care practitioners was important. CCNs have a key role in prioritizing weaning and driving the process forward. Relevance to clinical practice: Closeness to the patient and a key role in management of the mechanical ventilated patient in ICU gives the CCN unique potential to develop and create models and tools for prolonged weaning. These tools, specially designed for patients undergoing prolonged weaning, would give focus on continuous planning, collaborating, managing and evaluation in the process of liberating patients from mechanical ventilation. Key words: Intensive care unit • Mechanical ventilation • Nursing • Prolonged weaning • Weaning
BACKGROUND
Authors: C.-J. Cederwall, Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; Intensive care unit, Sahlgrenska University Hospital, ¨ straket ˚ 2, 413 45 Gothenburg, Sweden; K Plos, Institute of CIVA, Grona Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; L Rose, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 276, Toronto, ON M5T 1P8, Canada; Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital, Toronto, Canada; Mount Sinai Hospital and the Li Ka Shing ¨ Knowledge Institute, St Michael’s Hospital, Toronto, Canada; A Dubeck, Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; M Ringdal, Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden Address for correspondence: Carl-Johan Cederwall, MSc, CCN, RN, ¨ straket ˚ 2, Sahlgrenska University Hospital, Intensive care unit, CIVA, Grona 413 45 Gothenburg, Sweden E-mail: [email protected]
236
Although mechanical ventilation is life-saving, it can cause physiological and psychological complications for the patient. An important priority for critical care clinicians is therefore to discontinue mechanical support as soon as possible (Boles et al., 2007). Weaning is described as a gradual reduction of ventilatory support until the patient no longer requires ventilatory assistance or a reduction is neither feasible or realistic (Crocker, 2009). On average, patients spend 40–50% of the total ventilator time weaning. For most critically ill patients weaning is uncomplicated (classified as simple weaning) but approximately one third experience difficult (≤7 days) or prolonged (>7 days) weaning. Prolonged weaning increases the risk for further complications and death (Boles et al., 2007). Critical care nurses (CCNs) provide round the clock monitoring and develop substantial knowledge about the patient enabling adaptation of weaning to the patient’s abilities while taking in to consideration © 2014 British Association of Critical Care Nurses • Vol 19 No 5
Prolonged weaning
fatigue and anxiety (Crocker and Scholes, 2009). Weaning protocols help guide the weaning process by promoting increased awareness of weaning and by making the process more systematic (Blackwood et al., 2011). Protocols may enable CCNs to act in the physician’s absence, help nurses feel secure by legitimizing their actions, provide motivation to wean and promote continuity (Hansen and Severinsson, 2009; Kydonaki, 2010). However, protocols, which frequently contain objective criteria for initiation and progression of weaning, may focus CCNs attention towards such objective data and detract from subjective or abstract data gained from knowing the patient. Strategies to optimize weaning should be holistic and focus on both objective physiological and subjective assessment of the patient (Blackwood, 2000). CCNs require substantial knowledge and experience to manage ventilated patients experiencing prolonged weaning. Strategies such as specialized weaning teams, involving only the most experienced and qualified nurses and physicians, and weaning plans facilitating collaborative decision-making and interprofessional communication may decrease ventilator time and intensive care unit (ICU) length of stay (Henneman et al., 2002; Egerod, 2003). For patients requiring difficult or prolonged weaning, the weaning process should be individualized using a patient centred approach while partnering with the patient (Crocker and Scholes, 2009). A prerequisite for individualized care is that the nurse gets to know the patient (Jenny and Logan, 1994). This knowledge occurs during continuous close contact. Patients are individuals and therefore there is no algorithm, guideline or set of rules that fits all (Crocker and Scholes, 2009); prolonged weaning is very much about trial and error (Crocker, 2009). Therefore, we designed a study to answer the following question: what strategies do CCNs use for patients experiencing prolonged weaning and how do they approach and handle problems associated with management of these patients?
medical-surgical ICU in a regional hospital. Inclusion criteria were CCNs with at least 5 years experience in the ICU. In consultation with each manager, 20 CCNs were asked of whom, 19 chose to participate.
Data collection Semi-structured interviews were conducted by the first author between May 2011 and September 2012. In accordance with methods described by Polit and Beck (2012), we piloted the interview guide with three participants and modified the interview guide as a result of the pilot. The pilot interviews were also included in the analysis. Interviews took place in a quiet room close to the ICU, were 10–50 min in length, and were digitally audio recorded and later transcribed verbatim. Interviews commenced with requesting the participant to describe his or her strategies when managing patients experiencing prolonged weaning. Subsequent questions addressed: CCNs main tasks in relation to weaning, strategies they used to reduce the duration of ventilation and optimize weaning success, usual problems experienced during weaning and strategies to promote efficiency and continuity during the weaning process.
Data analysis Qualitative content analysis according to the methods described by Graneheim and Lundman (2004) was chosen because of its flexible and structured method for processing and interpretation of text material. Analysis began with the first author reading the transcripts. This reading guided the structural analysis where the whole text was read by the first author again. The most suitable meaning units to answer the aim were selected. These meaning units were then condensed and abstracted into subcategories and categories. The tentative categories were then discussed by the entire research team and revised until consensus was reached. Finally the categories were formulated into a theme which described the underlying meaning of the text.
AIM
Ethical considerations
The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU.
Participants were given both written and verbal information about the study, informed that participation was voluntary, and they could terminate participation anytime without consequence. The study was approved by the Ethical Review Board of the University of Gothenburg (2012-03-08 Dnr 121–12).
METHOD Sample and setting Nurse managers from three ICUs in western Sweden were provided with study information and permission was sought to recruit nurses. Two of the ICUs were located in university hospitals and admitted surgical, medical, trauma patients. The third was a © 2014 British Association of Critical Care Nurses
RESULTS Demographic characteristics are shown in Table 1. Strategies reported for managing a patient experiencing prolonged weaning included using a 237
Prolonged weaning
team should be well versed and in agreement with the plan to ensure consistency.
Table 1 Participant demographics Variable (n = 19) Age (years) Years of practice in ICU Female/male Specialist in critical care∗
Median
Range
46 15
32–60 5–35
%
89/11 100
ICU, intensive care unit. ∗ One year of university studies in advanced level.
Creating continuity
Table 2 Subcategories, categories and theme Subcategories
Categories
Theme
Creating an individual plan Creating continuity Evaluating the process Conditions Respiratory function Well-being Resources Reactions Initiating the process Prioritizing time for weaning Driving the process forward Collaborative planning Collaboration with the enrolled nurse Dialogue with the physician
Individualized planning
CCNs drive the weaning process using both a patient centred and targeted approach
Assessing patient capacity
Managing the process
Managing the team interaction
CCN, critical care nurse.
patient-centred and targeted approach with the clinical team to achieve the best outcomes for the patient. The main theme was CCNs drive the weaning process using both a patient centred and targeted approach. Table 2 shows the four categories and their subcategories associated with the main theme. The theme highlights the complexity of the weaning process. Weaning was described from two perspectives; as patient centred with individualized weaning incorporating assessments of how the patient responds while viewing the patient as a person with resources and capacity. The second perspective was structuring weaning using a plan to focus on specific targets. CCNs drove the weaning process while interacting with the interprofessional team.
Individualized planning Creating an individual plan Participants reported problems with standardized weaning protocols and strived to establish individual plans, both for the longer term and for the day’s shift. They thought that all members of the interprofessional 238
‘So I think it should be . . . tailored to patients, and individual in this way, but it should not be individualized and tailored to who happens to work this particular shift’. /5
To create continuity in the weaning process during the day or from day to day, participants reported that shorter plans were written on the observation sheet and reported verbally. Long-term plans were more difficult to document as there was no obvious writing space to document this. When several different physicians were involved in patient management decisions during a week, participants perceived CCNs took on extra responsibility to make sure that plans were upheld. ‘I write it down, I try so that it is on the observation sheet . . . then sometimes it is not possible, not the shorter plans but longer plans I write them in the medical record and try to report it to the next shift’. /16
Evaluating the process Continuous evaluation of various parameters and interventions were deemed important by participants to be able to make decisions about how to move forward with the weaning process. Vital signs and patient’s response to weaning were evaluated, and necessary ventilator changes were made so that weaning could be as effective as possible. ‘You have to stop and think about it; otherwise there is not much point in taking your blood gas. Does he need this much oxygen, can I go down or should I go up or how much pressure support, should he have this much?’ /15
Assessing patient capacity Conditions Participants reported they checked the patient’s capacity for weaning at each shift. An assessment of the patient’s conditions and capabilities such as oxygen requirements, age, admission diagnosis, medical history and comorbidities was performed to evaluate how demanding the weaning process was going to be for the patient. Older patients and patients with respiratory comorbidity were perceived to be a greater weaning challenge. The preceding duration of mechanical ventilation was perceived to have an impact on weaning. Patients © 2014 British Association of Critical Care Nurses
Prolonged weaning
experiencing ventilation for a longer duration of time placed higher demands on the nurse as they are more difficult to wean ‘A younger person is easier to wean than a person with previous pulmonary disease and if he has been in the ventilator for a longer period it will of course be more difficult’./7
Respiratory function To assess the patient’s respiratory function, participants looked at current ventilator settings with regards to oxygen and pressure support levels, respiratory rate, breathing pattern and work of breathing. The goal of this assessment was to ensure patients were not pushed too hard during weaning. Objective data such as arterial blood gas analyses were used to assess the patient’s response to weaning. ‘Far too rapid respiratory rate, rising pCO2 , you can see that he is not comfortable at all on the ventilator that can affect not only the respiration but it also affects circulation and other things. But often it is increasing respiratory rate and gasping for air and you can see that it is not comfortable on the ventilator’./16
Well-being Participants reported they assessed the patient’s psychological response including looking for signs of discomfort, fear, anxiety, pain or stress associated with weaning. They tried to be responsive to patient’s needs, read body language, breathing pattern and to find out the cause of discomfort, anxiety or pain. ‘To see that the patient is well . . . that he is not . . . grimacing or looking strained somehow . . . with wheezing or respiratory pattern or so’ . . . /4
Resources Careful assessment was made of the resources and abilities of the patient. Participants felt it was important to assess whether the patient was physically and mentally strong enough to cope with moving forward in the weaning process or proceed more carefully and slow down the weaning tempo. ‘I think first and foremost on whether he can do it. Also mentally, does he want to – does he feel like getting out?’ /10
Reactions Participants identified the need to take notice and assess the patient’s reactions to treatment and changes © 2014 British Association of Critical Care Nurses
in ventilator settings. As well as making an assessment of how long the patient can tolerate breathing without the ventilator, participants monitored patient reactions to other nursing interventions such as mobilization and changing body position. ‘What happens when we do nursing care? How does the patient react what is difficult? On which side do they oxygenate better?’ /12
Managing the process Initiating process As soon as the patient was intubated, participants perceived they had to be active in the weaning process by assessment of the patient’s weaning potential, and by raising the question of weaning to physicians early in the patient’s course of ventilation. ‘As soon as the patient is on the ventilator I try to think about being active with us changing ventilator settings so the patient can breathe more spontaneously if it works’ . . . /16
Prioritizing time for weaning Participants identified that they often cared for two patients at the same time together with an enrolled nurse and saw problems with prioritizing weaning as they were often busy with other tasks. Participants actively tried to prioritize weaning over other examinations or treatments. ‘Weaning may draw the short straw because you are so busy with the other patient’ /7 ‘When we are about to wean one of the patients we may choose a time when we are not doing a bronchoscopy and inserting a CVC on the other patient in the room, then maybe we try to fit in that we have made it so that it is quiet on that side’. /14
Driving the process forward Participants reported competing priorities, the need to attend to more urgent events as well as a perceived lack of interest prevented physicians from paying full attention to moving the weaning process forward. In these cases, they often assumed this responsibility. ‘As a nurse you get to control the weaning quite a lot, prescriptions are insufficiently addressed and weaning is not super interesting enough’. /2 ‘Yes, I drive the weaning . . . I point out that I will do it and do it now, that is to say I initiate when I see that nothing is happening’. /12 239
Prolonged weaning
Managing the team interaction Collaborative planning Participants reported that they took responsibility for creating an effective interprofessional team where all members worked with the patient, developed a mutual understanding, and knew how to move forward with the weaning process. They saw it as important that everyone collaborated to work out when it would be most suitable to focus on weaning and to coordinate other tasks such as mobilizing the patient. They did this by involving the interprofessional team early in the weaning process and by setting goals and targets during each shift. Participants indicated made sure that different tasks were distributed in an appropriate manner to make the best use of available skills. ‘So it is important that everyone is involved and feel engaged in the whole process’. /6
Collaboration with the enrolled nurse Several participants described how they depended on good collaboration and communication with the enrolled nurse in terms of how the weaning would proceed and to keep track of how patients coped during weaning. ‘I am keen to inform my enrolled nurse who is actually there with the patient all the time, communication with the enrolled nurse is incredibly important’. /3
Dialogue with the physician Almost all participants emphasized the importance of constructive dialogue with physicians. Participants stated they needed to be able to defend their assessment of appropriate weaning strategies and patients’ responses especially in cases where physician’s instructions were not working satisfactorily. They perceived they were better placed to see how patients respond to and cope with weaning and to make sure the weaning plan was optimized. ‘That I am much more at the patient’s side than the physician so then I can tell them, when they are there for five minutes they may not get the whole picture then I can recount the whole day and how I perceive that the patient is doing’. /16 Some participants believed it was the physicians’ responsibility to select all ventilator settings while others made small changes and then reported these to the physician. Participants perceived experienced 240
CCNs had more freedom to take charge of the weaning process as they were trusted by physicians. ‘It is the physician who tells me how much I should reduce; this is how I do it at least. I don’t go and make changes by myself. I actually don’t because it is their responsibility’. /7
DISCUSSION The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU. The main findings of our study were that CCNs took a great responsibility and drove the weaning process using both patient centred and target orientated approaches to achieve the best patient outcome. Participants described the importance of having a clear and individual weaning plan but identified problems with adherence. In patients experiencing prolonged ventilation standardized protocols may not work and need adapting to the individual patient (Crocker, 2009). Several participants in our study described issues associated with creating continuity and evaluating the process. Problems with continuity of care were also identified by Kydonaki (2010) who saw shift work patterns and late ward rounds as a reason for delayed weaning. Participants in our study expressed difficulty in adhering to a long-term weaning plan over the multiple shifts emphasizing the importance of communicating established weaning plans to all team members and ensuring adherence. Participants reported the CCN as opposed to other members of the interprofessional team had responsibility for ongoing assessment of the patient. CCNs performed assessments before and during weaning, and after any adjustment of ventilator settings. Participants focused on patient’s conditions and resources, both before weaning was commenced and also their responses during weaning. Rose et al. (2007) found that patient’s respiratory function and arterial blood gases were factors frequently assessed by nurses during weaning. Lavelle and Dowling (2011) also found assessment as a central theme before commencement and during conduct of weaning. CCNs in our study focused on the patient as a whole, physical and mental response during weaning, on titration of ventilator settings, and how the patient managing weaning during mobilization. Assessment of patients’ well-being included assessment of fear, stress, fatigue and breathing pattern. Participants tried to ascertain if the patient wanted to be weaned from the ventilator. This is also discussed by Crocker and Scholes (2009) who argue that © 2014 British Association of Critical Care Nurses
Prolonged weaning
weaning must be patient centred and psychological aspects should be valued. Participants reported making significant effort to know the patient to promote the patients’ own resources and to be aware of what the patient can do without generating excessive fatigue. The importance of knowing the patient in weaning situations is well-recognized (Jenny and Logan, 1994; Crocker and Scholes 2009). Participants described that they felt responsible for initiating the weaning as soon as possible. Several authors suggest CCNs have a unique role for decision-making during weaning due to their proximity to, and knowledge about, the patient thus enabling identification of the most appropriate time to commence and progress weaning (Jenny and Logan, 1994; Rose et al., 2007; Hansen et al., 2008). Our results indicate that decision-making in weaning is a central part of the CCNs role as they make important decisions in the process to initiate weaning and drive the process forward. In this study, participants also identified difficulty in giving priority to weaning. This finding is in concordance with other studies (Blackwood et al., 2004; Crocker and Scholes, 2009) that report CCNs and physicians often give low priority to patients during weaning as they are being perceived as less challenging and sicker patients are prioritized. Finally collaborative planning was described as essential so that all team members know and accept their responsibilities for managing the weaning process. This team interaction was led and promoted by CCNs. The importance of team collaboration is recognized in other studies as a key aspect of optimizing weaning success (Henneman et al., 2002; Egerod, 2003). The need for effective dialogue with physicians was described by our participants. Physicians have overall decisional responsibility but CCNs have better knowledge of the patient and first-hand experience of the patient’s responses during weaning. Collaboration between physicians and CCNs has been previously highlighted as an essential part to progress
weaning (Pettersson et al., 2012) and to improve patient outcomes (Rose et al., 2008). Our study shows that CCNs can play a significant role in the weaning process and are in a unique position to assess the patient’s weaning capacity, create a plan and drive the process forward. Team interaction is essential with CCNs playing an important role in establishing individualized weaning targets.
Limitations This study comprises data from 19 semi-structured interviews describing CCNs’ perception of the weaning process as opposed to observation of the actual process in real time. Participants were identified by the nurse manager based on meeting the inclusion criteria which may have biased as not all eligible nurses were invited to participate. Six of the participants were known to the first author which could have influenced their responses
CONCLUSIONS This study shows that CCNs have a key role in prioritizing weaning and driving the process forward. CCNs performed weaning using a patient centred approach by individualized planning, and assessing patients’ physical and emotional resources while recognizing the patient as a person. Further, CCNs acknowledged a targeted approach was important to manage the weaning process by initiating, prioritizing time and driving the process forward. Finally CCNs emphasized collaboration of the team was important planning for weaning with the CCN in a unique position due to her/his knowledge of the patient and their response to weaning.
ACKNOWLEDGEMENTS Support and funding was received from Sahlgrenska University Hospital, Gothenburg and Selma Andersson research foundation, Uppsala University.
WHAT IS KNOWN ABOUT THIS TOPIC? • Prolonged weaning means increased risk for complications and death. • Prolonged weaning requires individualized planning and a high level of knowledge and experience. WHAT THIS PAPER ADDS • Critical care nurses (CCNs) have a key role in management of patients experiencing prolonged weaning by prioritizing and driving the process forward. • CCNs should use a patient centred and targeted approach to weaning to optimize patient outcomes.
© 2014 British Association of Critical Care Nurses
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REFERENCES Blackwood B. (2000). The art and science of predicting patient readiness for weaning from mechanical ventilation. International Journal of Nursing Studies; 37: 145–151. Blackwood B, Wilson-Barnett J, Trinder J. (2004). Protocolized weaning from mechanical ventilation: ICU physicians’ views. Journal of Advanced Nursing; 48: 26–34. Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O’Halloran P. (2011). Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: cochrane systematic review and meta-analysis. BMJ (Clinical research ed.); 342: c7237. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, Pearl R, Silverman H, Stanchina M, Vieillard-Baron A, Welte T. (2007). Weaning from mechanical ventilation. The European Respiratory Journal; 29: 1033–1056. Crocker C. (2009). Weaning from ventilation–current state of the science and art. Nursing in Critical Care; 14: 185–190. Crocker C, Scholes J. (2009). The importance of knowing the patient in weaning from mechanical ventilation. Nursing in Critical Care; 14: 289–296. Egerod I. (2003). Mechanical ventilator weaning in the context of critical care nursing. In: The University Hospitals Centre for Nursing and Care Research, Volume Ph.D. Copenhagen: The University of Copenhagen. Graneheim UH, Lundman B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today; 24: 105–112. Hansen BS, Severinsson E. (2009). Physicians’ perceptions of protocol-directed weaning in an intensive care unit in Norway. Nursing & Health Sciences; 11: 71–76. Hansen BS, Fjaelberg WT, Nilsen OB, Lossius HM, Soreide E. (2008). Mechanical ventilation in the ICU–is there a gap between the time available and time used for nurse-led
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weaning? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine; 16: 17. Henneman E, Dracup K, Ganz T, Molayeme O, Cooper CB. (2002). Using a collaborative weaning plan to decrease duration of mechanical ventilation and length of stay in the intensive care unit for patients receiving long-term ventilation. American Journal of Critical Care; 11: 132–140. Jenny J, Logan J. (1994). Promoting ventilator independence: a grounded theory perspective. Dimensions of Critical Care Nursing; 13: 29–37. Kydonaki K. (2010). Observing the approaches to weaning of the long-term ventilated patients. Nursing in Critical Care; 15: 49–56. Lavelle C, Dowling M. (2011). The factors which influence nurses when weaning patients from mechanical ventilation: findings from a qualitative study. Intensive & Critical Care Nursing; 27: 244–252. Pettersson S, Melaniuk-Bose M, Edell-Gustafsson U. (2012). Anaesthetists’ perceptions of facilitative weaning strategies from mechanical ventilator in the intensive care unit (ICU): a qualitative interview study. Intensive & Critical Care Nursing; 28: 168–175. Polit DF, Beck CT. (2012). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Rose L, Nelson S, Johnston L, Presneill JJ. (2007). Decisions made by critical care nurses during mechanical ventilation and weaning in an Australian intensive care unit. American Journal of Critical Care; 16: 434–444. Rose L, Nelson S, Johnston L, Presneill JJ. (2008). Workforce profile, organisation structure and role responsibility for ventilation and weaning practices in Australia and New Zealand intensive care units. Journal of Clinical Nursing; 17: 1035–1043.
© 2014 British Association of Critical Care Nurses
Critical care nurses management of prolonged weaning: an interview study ¨ Carl-Johan Cederwall, Kaety Plos, Louise Rose, Amanda Dubeck and Mona Ringdal ABSTRACT Background: For most critically ill patients requiring mechanical ventilation in the intensive care unit (ICU) weaning is uncomplicated. For the remainder, weaning is a challenge and may result in further complications and increased risk of mortality. Critical care nurses (CCNs) require substantial knowledge and experience to manage patients experiencing prolonged weaning. Aim: The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU. Design: A descriptive qualitative design. Methods: Semi-structured interviews with 19 experienced CCNs were conducted. Data were analysed using content analysis. Results: Participants used various strategies for weaning that were grouped into four categories: individualized planning for the weaning process, assessing patient’s capacity, managing the process and team interaction. The overall theme that emerged was: CCNs drive the weaning process using both a patient centred and targeted approach. Conclusion: CCNs in these ICUs performed weaning using a patient centred approach to plan, initiate, assess and establish a holistic weaning process. Team collaboration among all health care practitioners was important. CCNs have a key role in prioritizing weaning and driving the process forward. Relevance to clinical practice: Closeness to the patient and a key role in management of the mechanical ventilated patient in ICU gives the CCN unique potential to develop and create models and tools for prolonged weaning. These tools, specially designed for patients undergoing prolonged weaning, would give focus on continuous planning, collaborating, managing and evaluation in the process of liberating patients from mechanical ventilation. Key words: Intensive care unit • Mechanical ventilation • Nursing • Prolonged weaning • Weaning
BACKGROUND
Authors: C.-J. Cederwall, Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; Intensive care unit, Sahlgrenska University Hospital, ¨ straket ˚ 2, 413 45 Gothenburg, Sweden; K Plos, Institute of CIVA, Grona Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; L Rose, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 276, Toronto, ON M5T 1P8, Canada; Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital, Toronto, Canada; Mount Sinai Hospital and the Li Ka Shing ¨ Knowledge Institute, St Michael’s Hospital, Toronto, Canada; A Dubeck, Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden; M Ringdal, Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30 Gothenburg, Sweden Address for correspondence: Carl-Johan Cederwall, MSc, CCN, RN, ¨ straket ˚ 2, Sahlgrenska University Hospital, Intensive care unit, CIVA, Grona 413 45 Gothenburg, Sweden E-mail: [email protected]
236
Although mechanical ventilation is life-saving, it can cause physiological and psychological complications for the patient. An important priority for critical care clinicians is therefore to discontinue mechanical support as soon as possible (Boles et al., 2007). Weaning is described as a gradual reduction of ventilatory support until the patient no longer requires ventilatory assistance or a reduction is neither feasible or realistic (Crocker, 2009). On average, patients spend 40–50% of the total ventilator time weaning. For most critically ill patients weaning is uncomplicated (classified as simple weaning) but approximately one third experience difficult (≤7 days) or prolonged (>7 days) weaning. Prolonged weaning increases the risk for further complications and death (Boles et al., 2007). Critical care nurses (CCNs) provide round the clock monitoring and develop substantial knowledge about the patient enabling adaptation of weaning to the patient’s abilities while taking in to consideration © 2014 British Association of Critical Care Nurses • Vol 19 No 5
Prolonged weaning
fatigue and anxiety (Crocker and Scholes, 2009). Weaning protocols help guide the weaning process by promoting increased awareness of weaning and by making the process more systematic (Blackwood et al., 2011). Protocols may enable CCNs to act in the physician’s absence, help nurses feel secure by legitimizing their actions, provide motivation to wean and promote continuity (Hansen and Severinsson, 2009; Kydonaki, 2010). However, protocols, which frequently contain objective criteria for initiation and progression of weaning, may focus CCNs attention towards such objective data and detract from subjective or abstract data gained from knowing the patient. Strategies to optimize weaning should be holistic and focus on both objective physiological and subjective assessment of the patient (Blackwood, 2000). CCNs require substantial knowledge and experience to manage ventilated patients experiencing prolonged weaning. Strategies such as specialized weaning teams, involving only the most experienced and qualified nurses and physicians, and weaning plans facilitating collaborative decision-making and interprofessional communication may decrease ventilator time and intensive care unit (ICU) length of stay (Henneman et al., 2002; Egerod, 2003). For patients requiring difficult or prolonged weaning, the weaning process should be individualized using a patient centred approach while partnering with the patient (Crocker and Scholes, 2009). A prerequisite for individualized care is that the nurse gets to know the patient (Jenny and Logan, 1994). This knowledge occurs during continuous close contact. Patients are individuals and therefore there is no algorithm, guideline or set of rules that fits all (Crocker and Scholes, 2009); prolonged weaning is very much about trial and error (Crocker, 2009). Therefore, we designed a study to answer the following question: what strategies do CCNs use for patients experiencing prolonged weaning and how do they approach and handle problems associated with management of these patients?
medical-surgical ICU in a regional hospital. Inclusion criteria were CCNs with at least 5 years experience in the ICU. In consultation with each manager, 20 CCNs were asked of whom, 19 chose to participate.
Data collection Semi-structured interviews were conducted by the first author between May 2011 and September 2012. In accordance with methods described by Polit and Beck (2012), we piloted the interview guide with three participants and modified the interview guide as a result of the pilot. The pilot interviews were also included in the analysis. Interviews took place in a quiet room close to the ICU, were 10–50 min in length, and were digitally audio recorded and later transcribed verbatim. Interviews commenced with requesting the participant to describe his or her strategies when managing patients experiencing prolonged weaning. Subsequent questions addressed: CCNs main tasks in relation to weaning, strategies they used to reduce the duration of ventilation and optimize weaning success, usual problems experienced during weaning and strategies to promote efficiency and continuity during the weaning process.
Data analysis Qualitative content analysis according to the methods described by Graneheim and Lundman (2004) was chosen because of its flexible and structured method for processing and interpretation of text material. Analysis began with the first author reading the transcripts. This reading guided the structural analysis where the whole text was read by the first author again. The most suitable meaning units to answer the aim were selected. These meaning units were then condensed and abstracted into subcategories and categories. The tentative categories were then discussed by the entire research team and revised until consensus was reached. Finally the categories were formulated into a theme which described the underlying meaning of the text.
AIM
Ethical considerations
The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU.
Participants were given both written and verbal information about the study, informed that participation was voluntary, and they could terminate participation anytime without consequence. The study was approved by the Ethical Review Board of the University of Gothenburg (2012-03-08 Dnr 121–12).
METHOD Sample and setting Nurse managers from three ICUs in western Sweden were provided with study information and permission was sought to recruit nurses. Two of the ICUs were located in university hospitals and admitted surgical, medical, trauma patients. The third was a © 2014 British Association of Critical Care Nurses
RESULTS Demographic characteristics are shown in Table 1. Strategies reported for managing a patient experiencing prolonged weaning included using a 237
Prolonged weaning
team should be well versed and in agreement with the plan to ensure consistency.
Table 1 Participant demographics Variable (n = 19) Age (years) Years of practice in ICU Female/male Specialist in critical care∗
Median
Range
46 15
32–60 5–35
%
89/11 100
ICU, intensive care unit. ∗ One year of university studies in advanced level.
Creating continuity
Table 2 Subcategories, categories and theme Subcategories
Categories
Theme
Creating an individual plan Creating continuity Evaluating the process Conditions Respiratory function Well-being Resources Reactions Initiating the process Prioritizing time for weaning Driving the process forward Collaborative planning Collaboration with the enrolled nurse Dialogue with the physician
Individualized planning
CCNs drive the weaning process using both a patient centred and targeted approach
Assessing patient capacity
Managing the process
Managing the team interaction
CCN, critical care nurse.
patient-centred and targeted approach with the clinical team to achieve the best outcomes for the patient. The main theme was CCNs drive the weaning process using both a patient centred and targeted approach. Table 2 shows the four categories and their subcategories associated with the main theme. The theme highlights the complexity of the weaning process. Weaning was described from two perspectives; as patient centred with individualized weaning incorporating assessments of how the patient responds while viewing the patient as a person with resources and capacity. The second perspective was structuring weaning using a plan to focus on specific targets. CCNs drove the weaning process while interacting with the interprofessional team.
Individualized planning Creating an individual plan Participants reported problems with standardized weaning protocols and strived to establish individual plans, both for the longer term and for the day’s shift. They thought that all members of the interprofessional 238
‘So I think it should be . . . tailored to patients, and individual in this way, but it should not be individualized and tailored to who happens to work this particular shift’. /5
To create continuity in the weaning process during the day or from day to day, participants reported that shorter plans were written on the observation sheet and reported verbally. Long-term plans were more difficult to document as there was no obvious writing space to document this. When several different physicians were involved in patient management decisions during a week, participants perceived CCNs took on extra responsibility to make sure that plans were upheld. ‘I write it down, I try so that it is on the observation sheet . . . then sometimes it is not possible, not the shorter plans but longer plans I write them in the medical record and try to report it to the next shift’. /16
Evaluating the process Continuous evaluation of various parameters and interventions were deemed important by participants to be able to make decisions about how to move forward with the weaning process. Vital signs and patient’s response to weaning were evaluated, and necessary ventilator changes were made so that weaning could be as effective as possible. ‘You have to stop and think about it; otherwise there is not much point in taking your blood gas. Does he need this much oxygen, can I go down or should I go up or how much pressure support, should he have this much?’ /15
Assessing patient capacity Conditions Participants reported they checked the patient’s capacity for weaning at each shift. An assessment of the patient’s conditions and capabilities such as oxygen requirements, age, admission diagnosis, medical history and comorbidities was performed to evaluate how demanding the weaning process was going to be for the patient. Older patients and patients with respiratory comorbidity were perceived to be a greater weaning challenge. The preceding duration of mechanical ventilation was perceived to have an impact on weaning. Patients © 2014 British Association of Critical Care Nurses
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experiencing ventilation for a longer duration of time placed higher demands on the nurse as they are more difficult to wean ‘A younger person is easier to wean than a person with previous pulmonary disease and if he has been in the ventilator for a longer period it will of course be more difficult’./7
Respiratory function To assess the patient’s respiratory function, participants looked at current ventilator settings with regards to oxygen and pressure support levels, respiratory rate, breathing pattern and work of breathing. The goal of this assessment was to ensure patients were not pushed too hard during weaning. Objective data such as arterial blood gas analyses were used to assess the patient’s response to weaning. ‘Far too rapid respiratory rate, rising pCO2 , you can see that he is not comfortable at all on the ventilator that can affect not only the respiration but it also affects circulation and other things. But often it is increasing respiratory rate and gasping for air and you can see that it is not comfortable on the ventilator’./16
Well-being Participants reported they assessed the patient’s psychological response including looking for signs of discomfort, fear, anxiety, pain or stress associated with weaning. They tried to be responsive to patient’s needs, read body language, breathing pattern and to find out the cause of discomfort, anxiety or pain. ‘To see that the patient is well . . . that he is not . . . grimacing or looking strained somehow . . . with wheezing or respiratory pattern or so’ . . . /4
Resources Careful assessment was made of the resources and abilities of the patient. Participants felt it was important to assess whether the patient was physically and mentally strong enough to cope with moving forward in the weaning process or proceed more carefully and slow down the weaning tempo. ‘I think first and foremost on whether he can do it. Also mentally, does he want to – does he feel like getting out?’ /10
Reactions Participants identified the need to take notice and assess the patient’s reactions to treatment and changes © 2014 British Association of Critical Care Nurses
in ventilator settings. As well as making an assessment of how long the patient can tolerate breathing without the ventilator, participants monitored patient reactions to other nursing interventions such as mobilization and changing body position. ‘What happens when we do nursing care? How does the patient react what is difficult? On which side do they oxygenate better?’ /12
Managing the process Initiating process As soon as the patient was intubated, participants perceived they had to be active in the weaning process by assessment of the patient’s weaning potential, and by raising the question of weaning to physicians early in the patient’s course of ventilation. ‘As soon as the patient is on the ventilator I try to think about being active with us changing ventilator settings so the patient can breathe more spontaneously if it works’ . . . /16
Prioritizing time for weaning Participants identified that they often cared for two patients at the same time together with an enrolled nurse and saw problems with prioritizing weaning as they were often busy with other tasks. Participants actively tried to prioritize weaning over other examinations or treatments. ‘Weaning may draw the short straw because you are so busy with the other patient’ /7 ‘When we are about to wean one of the patients we may choose a time when we are not doing a bronchoscopy and inserting a CVC on the other patient in the room, then maybe we try to fit in that we have made it so that it is quiet on that side’. /14
Driving the process forward Participants reported competing priorities, the need to attend to more urgent events as well as a perceived lack of interest prevented physicians from paying full attention to moving the weaning process forward. In these cases, they often assumed this responsibility. ‘As a nurse you get to control the weaning quite a lot, prescriptions are insufficiently addressed and weaning is not super interesting enough’. /2 ‘Yes, I drive the weaning . . . I point out that I will do it and do it now, that is to say I initiate when I see that nothing is happening’. /12 239
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Managing the team interaction Collaborative planning Participants reported that they took responsibility for creating an effective interprofessional team where all members worked with the patient, developed a mutual understanding, and knew how to move forward with the weaning process. They saw it as important that everyone collaborated to work out when it would be most suitable to focus on weaning and to coordinate other tasks such as mobilizing the patient. They did this by involving the interprofessional team early in the weaning process and by setting goals and targets during each shift. Participants indicated made sure that different tasks were distributed in an appropriate manner to make the best use of available skills. ‘So it is important that everyone is involved and feel engaged in the whole process’. /6
Collaboration with the enrolled nurse Several participants described how they depended on good collaboration and communication with the enrolled nurse in terms of how the weaning would proceed and to keep track of how patients coped during weaning. ‘I am keen to inform my enrolled nurse who is actually there with the patient all the time, communication with the enrolled nurse is incredibly important’. /3
Dialogue with the physician Almost all participants emphasized the importance of constructive dialogue with physicians. Participants stated they needed to be able to defend their assessment of appropriate weaning strategies and patients’ responses especially in cases where physician’s instructions were not working satisfactorily. They perceived they were better placed to see how patients respond to and cope with weaning and to make sure the weaning plan was optimized. ‘That I am much more at the patient’s side than the physician so then I can tell them, when they are there for five minutes they may not get the whole picture then I can recount the whole day and how I perceive that the patient is doing’. /16 Some participants believed it was the physicians’ responsibility to select all ventilator settings while others made small changes and then reported these to the physician. Participants perceived experienced 240
CCNs had more freedom to take charge of the weaning process as they were trusted by physicians. ‘It is the physician who tells me how much I should reduce; this is how I do it at least. I don’t go and make changes by myself. I actually don’t because it is their responsibility’. /7
DISCUSSION The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU. The main findings of our study were that CCNs took a great responsibility and drove the weaning process using both patient centred and target orientated approaches to achieve the best patient outcome. Participants described the importance of having a clear and individual weaning plan but identified problems with adherence. In patients experiencing prolonged ventilation standardized protocols may not work and need adapting to the individual patient (Crocker, 2009). Several participants in our study described issues associated with creating continuity and evaluating the process. Problems with continuity of care were also identified by Kydonaki (2010) who saw shift work patterns and late ward rounds as a reason for delayed weaning. Participants in our study expressed difficulty in adhering to a long-term weaning plan over the multiple shifts emphasizing the importance of communicating established weaning plans to all team members and ensuring adherence. Participants reported the CCN as opposed to other members of the interprofessional team had responsibility for ongoing assessment of the patient. CCNs performed assessments before and during weaning, and after any adjustment of ventilator settings. Participants focused on patient’s conditions and resources, both before weaning was commenced and also their responses during weaning. Rose et al. (2007) found that patient’s respiratory function and arterial blood gases were factors frequently assessed by nurses during weaning. Lavelle and Dowling (2011) also found assessment as a central theme before commencement and during conduct of weaning. CCNs in our study focused on the patient as a whole, physical and mental response during weaning, on titration of ventilator settings, and how the patient managing weaning during mobilization. Assessment of patients’ well-being included assessment of fear, stress, fatigue and breathing pattern. Participants tried to ascertain if the patient wanted to be weaned from the ventilator. This is also discussed by Crocker and Scholes (2009) who argue that © 2014 British Association of Critical Care Nurses
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weaning must be patient centred and psychological aspects should be valued. Participants reported making significant effort to know the patient to promote the patients’ own resources and to be aware of what the patient can do without generating excessive fatigue. The importance of knowing the patient in weaning situations is well-recognized (Jenny and Logan, 1994; Crocker and Scholes 2009). Participants described that they felt responsible for initiating the weaning as soon as possible. Several authors suggest CCNs have a unique role for decision-making during weaning due to their proximity to, and knowledge about, the patient thus enabling identification of the most appropriate time to commence and progress weaning (Jenny and Logan, 1994; Rose et al., 2007; Hansen et al., 2008). Our results indicate that decision-making in weaning is a central part of the CCNs role as they make important decisions in the process to initiate weaning and drive the process forward. In this study, participants also identified difficulty in giving priority to weaning. This finding is in concordance with other studies (Blackwood et al., 2004; Crocker and Scholes, 2009) that report CCNs and physicians often give low priority to patients during weaning as they are being perceived as less challenging and sicker patients are prioritized. Finally collaborative planning was described as essential so that all team members know and accept their responsibilities for managing the weaning process. This team interaction was led and promoted by CCNs. The importance of team collaboration is recognized in other studies as a key aspect of optimizing weaning success (Henneman et al., 2002; Egerod, 2003). The need for effective dialogue with physicians was described by our participants. Physicians have overall decisional responsibility but CCNs have better knowledge of the patient and first-hand experience of the patient’s responses during weaning. Collaboration between physicians and CCNs has been previously highlighted as an essential part to progress
weaning (Pettersson et al., 2012) and to improve patient outcomes (Rose et al., 2008). Our study shows that CCNs can play a significant role in the weaning process and are in a unique position to assess the patient’s weaning capacity, create a plan and drive the process forward. Team interaction is essential with CCNs playing an important role in establishing individualized weaning targets.
Limitations This study comprises data from 19 semi-structured interviews describing CCNs’ perception of the weaning process as opposed to observation of the actual process in real time. Participants were identified by the nurse manager based on meeting the inclusion criteria which may have biased as not all eligible nurses were invited to participate. Six of the participants were known to the first author which could have influenced their responses
CONCLUSIONS This study shows that CCNs have a key role in prioritizing weaning and driving the process forward. CCNs performed weaning using a patient centred approach by individualized planning, and assessing patients’ physical and emotional resources while recognizing the patient as a person. Further, CCNs acknowledged a targeted approach was important to manage the weaning process by initiating, prioritizing time and driving the process forward. Finally CCNs emphasized collaboration of the team was important planning for weaning with the CCN in a unique position due to her/his knowledge of the patient and their response to weaning.
ACKNOWLEDGEMENTS Support and funding was received from Sahlgrenska University Hospital, Gothenburg and Selma Andersson research foundation, Uppsala University.
WHAT IS KNOWN ABOUT THIS TOPIC? • Prolonged weaning means increased risk for complications and death. • Prolonged weaning requires individualized planning and a high level of knowledge and experience. WHAT THIS PAPER ADDS • Critical care nurses (CCNs) have a key role in management of patients experiencing prolonged weaning by prioritizing and driving the process forward. • CCNs should use a patient centred and targeted approach to weaning to optimize patient outcomes.
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