Weaning from mechanical ventilation is physically and psychologically demanding for patients, and requires nurses with expertise who can give continuity of care
Cheryl Crocker, PhD, MSc, BA, RNT, RGN, is fellow, NHS Institute for Innovation and Improvement and formerly consultant nurse, critical care, Nottingham University Hospitals Trust; Julie Scholes,DPhil, MSc, DANS, DipN, RN, is professor of nursing, Centre for Nursing and Midwifery Research, University of Brighton.
Crocker C, Scholes J (2010) Weaning from ventilation needs to be tailored to individual patients and involve them. Nursing Times; 106: 4, early online publication.
Aim To understand how nurses use technology to wean patients from mechanical ventilation.
Background The literature tends to focus on weaning indices, predictors of success or weaning methods. Few papers address patients’ experiences of weaning.
Design An ethnographic approach was adopted to understand how nurses used technology to wean patients.
Methods Data was gathered by participant observation and interviews over six months. In total 250 hours of field notes were recorded.
Results Data was analysed using the content analysis method. A central theme of knowing the patient was identified, as well as three sub-themes: ways of knowing; continuity of care; and patients’ role in the weaning trajectory.
Conclusion Participants implied during interviews that “knowing the patient” was essential to delivering patient centred care. Two main factors are necessary for nurses to know their patients: continuity of care and expertise. “Ways of knowing” relied on gaining information about patients and their role was as passive recipients of treatment.
Implications for practice Staff allocation systems should enable them to learn from experienced nurses, while work schedules should be organised to ensure nurses begin weaning when they can offer continuity of care. Knowing the patient has been defined as a characteristic of expert nursing. To be truly patient centred, nurses need to address the barriers that prevent them from getting to “know” patients.
Keywords Ventilation, Weaning, Patient centred, Patient involvement
- This article has been double blind peer reviewed
- Units need to develop allocation systems that encourage continuity of care and help nurses to get to know patients being weaned from mechanical ventilation.
- Weaning protocols have their place but may oversimplify the process and concentrate on physiological responses.
- Weaning should be tailored to individual patients’ psychological and physical needs and promote patients’ active involvement in the process.
- Junior staff need to learn from experts in order to develop skills in knowing patients.
- Patients undergoing long term weaning may be better served in weaning centres rather than critical care settings.
Weaning from mechanical ventilation is defined in the literature as the process of assisting patients to breathe unaided (Knebel, 1991). It is undertaken when the patient has adequate gas exchange, appropriate neurological and muscular status, and stable cardiovascular function. However, the patient’s psychological readiness should also be taken into account. Knowing the patient has been identified as an important factor in the weaning process (Blackwood, 2000), and this requires expertise (Tanner et al, 1993) and continuity of care (Henderson, 1997).
The nursing literature on ventilation has addressed aspects such as: patients’ experience of communication (Hafsteindottir, 1996); patients’ recollections of stressful experiences (Rotondi et al, 2002); and their perceptions of fatigue (Higgens, 1998). However, few studies have concentrated on the weaning process itself (Johnson, 2004; Logan and Jenny, 1997).
Knowing the patient is important in all aspects of nursing (Ball and McElligott, 2003). Many studies have been conducted to define the exact meaning of knowing and attempts have been made to describe and analyse how this is achieved in nursing (for example: Luker et al, 2000; Sandelowski, 1998; Scholes, 1998; Henderson, 1997).
The whole study aimed to improve understanding of how nurses use technology in the workplace, and explored this by focusing on observing nurses weaning patients from mechanical ventilation.
An ethnographic approach was adopted, which has been defined as a description of culture or selected aspects of culture (Spradley, 1980). Fieldwork was conducted in a large teaching hospital over six months. Data was collected through participant observation, focused interviews, collecting field notes and documentary analysis of weaning protocols and educational packages. The researcher was a consultant nurse working in the unit under investigation. Further details on the method are available in Crocker and Scholes (2009).
Observation focused on nurses caring for patients who were being weaned from mechanical ventilation. Although patients were not the subject of observation and their details were never collected, they and their relatives were asked permission for care to be observed. Written consent to be observed and to take part in informal interviews was obtained from the nurse participants at the beginning of the study, and again verbally at every new episode of observation during the six month period.
The local research ethics committee granted approval for the study and the hospital’s research and development department approved the governance arrangements before the fieldwork started.
Data was analysed using content analysis (Glaser and Strauss, 1967), in which researchers identify a set of categories or themes emerging from the data, then code the body of data to see how many instances fall into each category. Four themes emerged: knowing the patient; the division of labour in weaning; nursing visibility; and the nursing-technology relationship. This article explores the theme of knowing the patient in relation to the literature on nursing expertise.
Knowing the patient
This overall theme is divided in to three sub-themes: ways of knowing; continuity of care; and patients’ role in weaning. For full details see Crocker and Scholes (2009).
Ways of knowing
Nurses implied during interviews that knowing the patient was essential to delivering individualised care. They believed they “knew their patients” in different ways to other healthcare professionals, as the following extract demonstrates:
“…nurses are more holistic. Doctors come along and they see the organs and the rate and the numbers; as nurses we see the overall picture, we see the psychological, emotional and all that kind of stuff and that is good. It is important that at handover we pass that over because that is important to weaning, so that is why it is more beneficial” (interview).
This illustrates how nurses assimilate different types of information about patients to inform practice. Nurses also recognised there were barriers that prevented them from getting to know patients. They described these in terms of difficulty communicating with them, problems in communicating about them between staff, such as relying on using paper or charts; and being busy attending to patients’ needs. Observation in practice revealed a reliance on technology-generated information.
Ways of knowing refer to how information about patients was gathered and what information was elicited. Most, but not all, junior nurses relied on biomedical facts and tended to concentrate on patients’ illness and past medical history. Analysis of transcripts revealed that nurses spent a considerable amount of time finding information on patients through various records and documentation, rather than getting to know them through interaction.
Continuity of care
Most nurses on the unit worked 12 hour shifts (known as “long days”), resulting in fewer working days per week. There was a lack of agreement among participants about whether this prevented them from offering continuity of care.
“…long days are beneficial to all of us [nurses] but they can have a bit of a detrimental effect on patients. Nurses on today may not come back for three days so you don’t see the flow and you can lose some continuity of patient care. For example, the patient had his pressures reduced by two and he did not tolerate it, this mistake may be repeated again whereas someone will say ‘we did that yesterday and it didn’t work’” (interview).
Although longer shifts allowed nurses to plan their work, observation revealed they delayed weaning ventilated patients until the afternoon so they could perform other caring duties in the morning. This reduced the length of time they were available to provide continuity of care through the weaning process, yet some felt weaning was often delayed due to lack of continuity. Lack of time and multiple caregivers have also been identified as inhibiting factors in getting to know patients (Morse, 1991).
Patients’ role in weaning
Although patients’ psychological readiness to come off mechanical ventilation will affect their experience of the process and may also affect its success, no incidents were observed in which nurses engaged with patients when writing a weaning plan:
“He [the patient] has a learning disability and is prone to getting anxious so I would not tell him [about changes in his weaning], which some people say is unethical, but he has been here for 21 days and knowing him as I do, I feel it is not worth upsetting him” (interview).
An analysis of field notes revealed a lack of involvement of patients as active partners in weaning. There appeared to be little partnership between patients and the staff caring for them. Nurses saw patients’ progress in terms of a “weaning trajectory”, a concept taken from Lawler’s (1991) “recovery trajectory, and interview data revealed that those being weaned were not considered stimulating or exciting:
“Weaners are not so interesting, nurses do not volunteer to go back to the patient. Critical care staff want the sick patients. Weaners are not very sick, they do not have many pumps or infusions” (interview).
The condition of patients being weaned from ventilation can change rapidly, and knowledge and skills are essential to ensure that cues of fatigue or deterioration are recognised and acted on promptly. However, many of the nurses in this study who were allocated to care for this group of patients were advanced beginners rather than experienced practitioners.
The literature suggests that knowing the patient requires expertise (Manley et al, 2005; Benner, 1984) and is related to positive outcomes (Radwin, 1996). Benner (1984) defined and explored expert practice, while Benner et al (1992) examined the Dreyfus model of skill acquisition, which suggests advanced beginners focus on what needs to be done for patients during the time they spend with them. These nurses feel the need to organise and prioritise tasks, and become anxious if they are unable to do this (Benner et al, 1992).
Advanced beginners do not feel responsibility for advanced planning and preventing critical incidents in their patients, but feel responsible for completing the tasks that are ordered. Consequently, they miss subtle cues that indicate problems and continue to care in a way that does not detect them in the early stages (Benner et al, 1992).
The fact that a number of staff in critical care are advanced beginners goes some way to explain the findings in this study. Their ways of knowing were limited to that which was technologically framed and depicted by the biomedical data, and continuity of care was limited. Since weaning protocols are available to support less experienced nurses’ practice, it is likely that junior staff will continue to be allocated to weaning patients, meaning patients are not supported through the weaning process by more expert nurses. This leads us to conclude that “protocolised” weaning systems that drive a technically satisfactory process may inadvertently become barriers preventing nurses from acquiring the expertise necessary to devise individualised weaning programmes that take account of patients’ psychological readiness to wean (Blackwood, 2000) and physical capacity to support the “work” of weaning (Logan and Jenny, 1997).
This study was conducted in one critical care unit and therefore results cannot be generalised to other units. The researcher chose to undertake the study in her own unit and it could be argued that this is a source of bias.
Participants implied during interviews that “knowing the patient” was essential to delivering patient centred care. Two main factors are necessary for nurses to know their patients: continuity of care and expertise, yet the allocation system used in the unit prevented continuity by fragmenting episodes of care, while the use of weaning protocols prevented the nurses from developing expertise. If patients are to become active partners in the weaning process and advanced beginners are to develop expertise in tailoring weaning to individual patients, allocation systems should enable them to learn from experienced nurses, while work schedules should be organised to ensure nurses begin weaning at a time when they will be able to offer continuity of care.
- The full results of all aspects of this study were first published in Nursing in Critical Care (Crocker and Scholes, 2009).
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