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Intensive and Critical Care Nursing (2007) 23, 196—205
ORIGINAL ARTICLE
Intensive care nurses’ perceptions ofprotocol-directed weaning—–A qualitative study
Britt Sætre Hansena,b,∗, Elisabeth Severinssonc,d,1
a University of Stavanger, Norwayb Acute Clinic of Intensive Care, Stavanger University Hospital, Box 8100, N-4068 Stavanger,Norwayc Department of Health Studies, Faculty of Social Sciences, University of Stavanger,N-4036 Stavanger, Norwayd University Hospital of Stavanger, Box 8100, N-4068 Stavanger, Norway
Accepted 4 March 2007
KEYWORDSCollaboration;Communication;Interdisciplinary;Intensive care nurses;Protocol-directedweaning
Summary The aim of this study was to identify intensive care nurses’ perceptionsof protocol-directed weaning, by means of focus group interviews and qualitativecontent analysis.
The results showed that the nurses perceived the protocol as useful. When pre-scribed, it represented interprofessional agreement that allowed them to act in theabsence of a physician. It focused on weaning, saved time, was easy to use andled to a feeling of safety and continuity in the weaning process. Barriers to its usewere related to lack of instructions from physicians. Nurses reported three ways ofhandling the situation in the absence of a weaning plan: taking action, waiting, andgiving weaning low priority, which could lead to undesired variations. Nurses in this
study reported that they would like an interdisciplinary approach to weaning andexpressed the need for a shared ‘‘language’’ or knowledge base in order to improvecommunication. It is important that different disciplines meet to share each other’sknowledge. Contact is vital in order to learn about and respect different types ofprofessional knowledge.© 2007 Elsevier Ltd. All righI
Tb
∗ Corresponding author at: Kong Haraldsgate 49, N-4041 Hafs-fjord, Norway. Tel.: +47 51519138; fax: +47 51519932.
E-mail address: [email protected] (B.S. Hansen).1 This study was developed when I was a visiting professor at
the Centre for Midwifery, Child & Family Health, Faculty of Nurs-ing, Midwifery and Health, University of Technology Sydney, POBox 123, Broadway NSW 2007, Australia.
Kae1
0964-3397/$ — see front matter © 2007 Elsevier Ltd. All rights reservdoi:10.1016/j.iccn.2007.03.001
ts reserved.
ntroduction
he provision of safe, error-free care is the num-er one priority of all health care professionals.
nowledge development in the area of medicalnd nursing practice has increasingly focused onvidence-based action (Rosswurm and Larrabee,999). However, a gap exists between best evidenceed.
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nd best practice (Cook et al., 2002). Therefore,uidelines and protocols based on best practicend research have been developed to reduce unde-irable variations and improve the quality of careWeingarten, 2000). The value of such protocolss determined by their impact on patient care,or example improvements in the quality of carend enhanced patient satisfaction. Research onreatment methods has, however, focused on physi-ians rather than the care team (Berenholtz andronovost, 2003). There has been relatively littleesearch on how the care team can work togethero improve the quality and safety of care. ICU caren particular depends on teamwork, which has beenhown to be in need of improvement (Berenholtznd Pronovost, 2003).
The best approach to rapidly weaning patientsrom ventilator support has been a subject ofebate for many years. Several studies indicatehat protocol-directed weaning is quicker, resultingn reduced costs, shorter ICU stays and mechani-al ventilation times without an increased rate ofomplications (Krishnan et al., 2004). The maineason is that the staff members responsible formplementing the protocol are constantly presentt the patient’s bedside and employ a specific, evi-ence based approach without any variations due toractitioner bias (Kacmarek, 1998). Nevertheless,here are significant barriers to the use of evidence-ased clinical guidelines, including the fact thatroviders may be unaware of their existence, a lackf agreement between, and inability on the partf providers to implement them (Cabana et al.,999). Those not in favour of such protocols viewheir introduction as a restriction on clinical discre-ion and autonomy (Rose and Nelson, 2006). Theyrgue that protocols restrict analytical and criticalhought, clinical innovation as well as individualisedare in both medical and nursing practice (Tobin,004).
It has been estimated that as many as 50%f all ICU patients receive mechanical ventila-ion and almost half of intubated time is devotedo weaning, which therefore constitutes a heavyorkload for staff (Tobin, 2001). Patients beingeaned from ventilatory support thus occupy a
ignificant number of ICU beds and have a majormpact on resources. Mechanical ventilation canause life-threatening complications and should beiscontinued as early as possible (Tobin, 2001).
ICU practice often involves a high workloadOates and Oates, 1996). Nurses have to con-
tantly respond to the needs of patients and familyembers as well as interacting on a regular basisith the most emotional aspects of life. Researchhows that workload is one of the main deter-
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weaning 197
inants of patient safety and quality of care inCUs (Carayon and Gurses, 2005). A high work-oad appears to influence a care provider’s decisiono perform various procedures (Griffith et al.,999) and to impair nurse-physician collaborationBaggs et al., 1999). The professional nurse haso combine technical competence with a compas-ionate approach. The weaning process requiresot only technical competence, knowledge of lunghysiology and mechanical ventilation, but alsohe capacity to focus on the patient as a wholeerson, provide safety by means of a structuredeaning process, supply information and moni-
or facial expressions and behaviour in additiono allowing the patient some degree of influ-nce. The weaning process can be complex, andmproved outcomes are often due to the coordi-ated efforts of a skilled, multidisciplinary teamHenneman, 2001). Unfortunately, despite muchhetoric, collaboration still remains the exceptionather than the rule (Henneman, 2001). Physiciansnd nurses are trained separately, keep separateatient records, report to different hierarchies,ead different journals, and use different jargonBlickensderfer, 1996). Lindeke and Sieckert (2005)tate that collaboration is a complex multidimen-ional process that requires knowledge-sharing andoint responsibility for patient care. Standards androtocols serve as important structures for facili-ating a team approach (Henneman, 2001) as wells integrating research findings into daily care.
ethods
qualitative descriptive exploratory researchesign (Polit and Beck, 2006) was employed.
linical setting
he study was carried out in a 12-bed mixed inten-ive care unit (ICU) with two bay areas, each ofhich contain four beds and four single rooms. Oneundred and twenty-five nurses (90% with a 16-onth intensive care training in addition to general
ursing education) are employed in 88 positionsotating between the ICU and two post-operativenits (30 beds). The ICU serves all units and is thenly ward in the hospital that provides ventilatorreatment apart from the neonatal ward.
In 1999, a weaning protocol (a fixed, standard-
sed plan that guides the nurse in a stepwise mannerowards extubation, and includes a T-piece trial)as implemented in an attempt to enhance thetaff members’ weaning efforts. The protocol was
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based on previous research and designed for theunit by an interprofessional group of ICU nursesand physicians. It was introduced to the physi-cians by physicians and to the nurses by physiciansand nurses, as all presentations of new knowledgeand information in the ICU are organised in sep-arate groups. In spite of the fact that since 1999all nurses have to go through a yearly ventila-tor knowledge certification involving use of theprotocol (not a part of this study) it was rarelyreferred to or used as intended. Anaesthetists,rotate between the ICU and operating theatres, allexcept from two who have their daily practice inthe ICU only. The anaesthetist on duty is responsiblefor prescribing the weaning protocol or furnish-ing an individual plan (tailored to each individualpatient for a planned period of time). As nursesalso rotate, very few deal with weaning on a dailybasis. A qualitative study was designed to explorethe reasons behind the failure to use the weaningprotocol.
Sample
A total of 24 nurses, 21 women and 3 men, partic-ipated in the study. The participants’ age rangedfrom 26 to 60 years. Their experience of intensivecare nursing ranged from 6 months to 30 years and16 of them had completed the 16-month intensivecare training. The nurses were randomly selectedin the sense that the ward manager (who waswell aware of the importance of mixed experienceamong the participants) decided how many and whoshould participate in the interviews, in order toensure that the ward was adequately staffed. Thusnot all nurses who had been informed about thestudy participated. The sample was considered rep-resentative of the intensive care unit in which thenurses were employed.
Ethical considerations
The study was approved by the head of the Clinicat the University Hospital and by The Norwe-gian Social Science Data Services (no. 11437). Therespondents were provided with information aboutthe purpose and method of the study, the factthat participation was voluntary, that they werefree to withdraw at any time (The World MedicalAssociation Declaration of Helsinki, 2000) and thatfull confidentiality was guaranteed. They wereinvited by the Nurse Manager to participate, as
she organises daily activities on the ward as wellas the nurses’ working schedule. The participantswere also asked for permission to tape-record theinterviews. In addition, the data were handled con-atft
B.S. Hansen, E. Severinsson
dentially and all names were removed from theranscripts.
ocus group interviews
ata were collected from three typical ‘‘one shot’’ocus group interviews, described by Morgan (1997)s one of several focus group methods. Whatetermines the value of these methods is theiruitability for answering the research question inays that go beyond what could be accomplishedy other approaches (Morgan, 1997). The nurses inhis study were familiar with the topic and thereas no difficulty obtaining rich data. According
o the literature (Morgan, 1998), there is little toe gained by arranging more focus group inter-iews when the point of ‘‘theoretical saturation’’as been reached. The second focus group inter-iew provided less new information and, at theonclusion of the third group interview, it wasgreed that ‘‘theoretical saturation’’ had beeneached.
The following areas were focused on during theata collection: the informants’ experiences of theeaning protocol, the implementation process, and
nterdisciplinary collaboration. The key questionas the nurses’ perception (attitudes and beliefs)f the weaning protocol. The focus group partici-ants were asked to describe their initial thoughtsn hearing the term ‘weaning protocol’ and allowedo talk freely about it.
An external moderator served to reduce theias, which could occur in the case of a researchernvolved in the implementation of the protocol.he interviews were conducted in 2003 in a pri-ate room at the hospital. The interviews lastedetween 50 and 60 min and were audio-taped andranscribed by the first author (BSH) and a nursingolleague.
easons for choosing the focus groupethod
organ (1997) states that if the aim is to go beyondrocesses, such as attitude and opinion formationnd decision making, learning about participants’xperiences and perspectives through self reportedehaviour is more useful than opinions that haven unknown basis. The process of sharing and com-aring self-reported behaviour and experiences tond out what the participants think about an issue,
nd why they think the way they do, is one ofhe most valuable aspects of focus groups. Theocus group method was chosen to provide the par-icipants with an opportunity for discussing their
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erceptions of protocol directed weaning and allowhe researcher to observe group interaction. Groupiscussions provide direct evidence about similar-ties and differences in the participants’ opinionsnd experiences (Morgan, 1997). However, if theim is to learn more about each informant in detail,
he individual interview has an obvious advantage.ocus groups provide less depth and detail abouthe opinions and experiences of the participants. Inhis study, depth and detail were considered of lessAuIi
Table 1 Nurses’ perceptions of the usefulness of protocol-
Meaning units Cu
‘‘Guidelines and protocols are important. Very oftenwe have to look after patients we do not know.With protocols it is easier to continue the weaningprocess in such situations’’. ‘‘I feel I have tocontinue the weaning process when the nurse onthe shift before me has started. I feel acommitment, an obligation to follow the plan’’
Co
‘‘It is important for new nurses, as they are afraid ofmaking mistakes. They lack knowledge and havelittle experience of the ICU and thus the weaningprotocol may improve patient safety. I don’t needit, because I am very experienced, but it is mucheasier for the next nurse to continue when I use itin the report’’. ‘‘Without the protocol I would nothave the courage to do anything to the ventilator,as I lack experience. The protocol is valuable, as itis easy to understand and makes me feel safe.Safety is important. It is not only what I do thatmatters, but also what I don’t do . . .’’
Imsptf
A plan makes me focus on weaning, progress isfaster, we want to do a good job and shorten thepatient’s time on the ventilator. It is good, I don’thave to ask the physician about every change tothe ventilator, a common weaning plan leads to afeeling of safety. ‘‘It enables me to act. It isimportant to be active in the weaning process as, ifnot, no decisions are made and nothing happens’’
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Use of a protocol makes it easier to continue theweaning process with an unfamiliar patient, as itprovides a set procedure and facilitatesunderstanding of the process. ‘‘When the protocolis not prescribed, there is no plan and decisionsare made ‘‘by chance’’ or not at all. This feelsde-motivating. When the protocol has beenprescribed, I can act. It is very motivating to beable to wean without having to ask for permissionall the time. It is also motivating to know that thenext nurse on duty will also have to follow theprescribed plan’’
CupMnf
‘‘I have had some positive experiences with theprotocol, it just guided me through the processand one patient was extubated the same evening!It was fun!’’
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weaning 199
mportance than the process of sharing and com-aring experiences of the weaning protocol in aroup.
ualitative content analysis
qualitative content analysis in several steps wassed (Graneheim and Lundman, 2004, Table 1).mmediately after the conclusion of the focus groupnterview, the moderator and observer discussed
directed weaning
ondensed meaningnit
Category Theme
ommitmentbligation
Easy Useful
portant for newtaff. Improvesatient safety. Easyo understand. Aeeling of safety
Patient safety.Nurse safetycontinuity
Useful
ocus on more rapidrogress. Good job.on’t have to ask Aeeling of safetyction
Focus on progresspatient care. Jobsatisfaction.Time-savingautonomy action
Useful
ontinuenderstand. A setrocedureotivating Nexturse will have toollow the plan
Progress inweaning.Commonunderstandingmotivatingcontinuity
Useful
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the significance of the data. After reading thetranscribed text, its content was organised intomeaning units, condensed meaning units, cate-gories and themes. Furthermore, common patternswere identified from the respondents’ differentapproaches to problems related to the use of theprotocol. The patterns were compared in orderto identify similarities and divergences in the ICUnurses’ perceptions of the use of the weaning pro-tocol, after which the researcher reflected uponthem.
Results
The results showed that the respondents perceivedthe protocol as useful since, when prescribed, itrepresented an interprofessional agreement allow-ing the nurse to act in the absence of a physician.Some barriers to its use were also identified, such asthe fact that it was not prescribed or referred to ona regular basis by the physicians and that weaninghad low priority among some physicians and nurses.In the absence of a prescribed weaning plan (a gen-eral weaning protocol or an individual plan) thenurses reported three different approaches: takingaction, waiting and giving weaning low priority.
Usefulness
The respondents perceived the protocol as effec-tive as it provided continuity, saved time, enhancedfeelings of safety and, when prescribed, repre-sented a goal that motivated staff (Table 1).
Barriers
The nurses’ perceptions of the weaning protocolindicated that it was used when it was new, afterwhich its use gradually decreased. Several barri-ers to its use were reported: as lack of interest,continuity, collaboration and information.
Lack of interestThe protocol was prescribed ‘‘by chance’’ or whenrequested by the nurses. It was not referred to,reported on or discussed at interdisciplinary levelduring physicians’ rounds. The nurses describeda lack of interest among the physicians as wellas among some nurses, which frustrated thosewho favoured a multidisciplinary approach and a‘‘shared language’’.
Lack of continuityLack of continuity implied that a nurse and a physi-cian might be assigned to other patients on their
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B.S. Hansen, E. Severinsson
ext shift, instead of following the same patient(s)ver time. One nurse reported.
‘It takes a day to learn to know everything and feelafe when the patient is new to me. Weaning has toait until I know the patient. There is also a lack ofontinuity among the physicians’’ (Group 2, Nurse,).
ack of collaboration and informationack of interprofessional collaboration as well asnformation frustrated the nurses. They stated thatome physicians preferred other ways of weaningnd failed to inform the bedside nurse or werenaware of the protocol’s existence.
‘Sometimes the physician makes changes on theentilator without any explanation and leaves. Its very frustrating (Group 3, Nurse I). We need aystem where physicians and nurses collaborate andiscuss whether or not it is time to use the protocolr not, the important thing is to agree to somethingnd get started’’ (Group 3, Nurse H).
The respondents expressed a need for a weaninglan they could use when there was no physicianvailable. A multidisciplinary approach to weaningssessment which takes advantage of the uniquekills and expertise of the bedside nurses wasegarded as very important.
‘We need a system where physicians and nursesgree to a common plan’’ (Group 3, Nurse B).
ifferent approaches to problems related toarriers
he nurses reported several ways of dealing withroblems and dilemmas that arise in the absencef a weaning plan and added that physicians didot have a common approach to weaning.
‘What we are allowed to do depends on the physi-ian on duty. Some give us a lot of responsibility,hile others decide everything themselves (Group, Nurse C). The physician governs how much or howittle we can decide and do without their permis-ion’’ (Group 2, Nurse G).
The nurses believed that their responsibility washat which was ‘‘left over’’ when the physicianad finished—–sometimes nothing and sometimes‘too much’’. This ‘‘never knowing what will hap-en’’ situation influences the weaning process.
urses and physicians have their own ways ofealing with weaning based on personal interest,nowledge and experience, leading to variationshat can prolong the process. Three different
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pproaches were reported: action, waiting and lowriority.
ctionoth experienced and inexperienced nurses werection oriented. The degree of action varied fromocusing on weaning all the time to hardly thinkingbout it at all.
‘I am constantly aware of the need to start theeaning process. It has to do with age and experi-nce. I firmly believe that if we did not act, very fewatients would be started on the weaning process’’Group 2, Nurse C).
Some nurses were very confident and used theirnteractive talent to get things done their way.
‘We have our ways and means of dealing withhysicians who disagree with us; we know howo ask the right questions in order to obtain thenswers we want’’ (Group 2, Nurse F).
The expression: ‘‘It is easier to seek forgive-ess than acceptance’’ was mentioned. Nursesere marginalised in decision making associatedith the weaning process and had to ‘‘play theame’’ in order to gain some opportunity to influ-nce decisions. They described how physicians areesponsible for weaning yet failed to make usef the nurses’ knowledge and familiarity with theatients. Other nurses knew when it was appro-riate to start weaning, but did not have theonfidence to go ahead, and thus only made smallhanges to the ventilator. This group of nurses wel-omed the protocol because it legitimised whathey already did.
aitingurses need physicians’ permission to startrotocol-directed weaning. Some nurses chose toait for the physician to arrive before takingction. They needed to discuss every move andeaning was discontinued when nobody was there.
‘We cannot use the protocol alone, and when usingt I need the approval of the physician every nownd again’’ (Group 1, Nurse M).
‘I suggest weaning when I see the patient is readyor it. I have to ‘remind’ the physicians, but if theyay no, there is nothing I can do. It is a dilemmahen I have observed things that he has not. He
s at the bedside for 5 min while I am there for 8 h
Group 2, Nurse F).These nurses have knowledge and experiencend thus know when it is time for weaning. Theard routine, however, only allows weaning to
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weaning 201
ake place when the physician has given his/herpproval. The respondents clearly underlined themportance of communication and collaborationith physicians and specialist nurses.
‘Weaning is difficult, I need someone to discusst with especially at the beginning of the pro-ess’’ (Group 1, Nurse M). ‘‘It is not easy, aso two patients are alike’’ (Group 1, Nurse K).‘Interprofessional discussions are important duringhe weaning process’’ (Group 3, Nurse H).
The respondents described collaboration as rang-ng from non-existent to very good:
‘Sometimes we don’t see them at all, they writeown their orders and leave’’ (Group 1, Nurse B).‘Collaboration is sometimes good, it is acknowl-dged that we have to urge the physician to set aaily goal for weaning, and in such cases he/sheay provide some written respiratory guidelines asell’’ (Group 3, Nuse B). ‘‘We work closely with
he physicians, collaboration is good, some listen tos, others don’t’’ (Group 2, Nurse F). ‘‘Weaning ismportant to us, but not to them’’ (Group 2, Nurse).
Lack of communication leads to a slow weaningrocess as illustrated by the following statements:
‘When the physician makes a change without com-unicating the reasons behind it or the plan, I don’t
nderstand and am unable to continue’’ (Group 1,urse B). ‘‘Weaning depends on teamwork, but dur-
ng evening, night and weekend shifts we rarelyee a physician. They have responsibility for manyatients, I have one or two’’ (Group 1, Nurse F).
The use of standards and protocols could reducehe discrepancy between the time available foreaning and the actual time used. The weaningssessments or lack of them depend on the individ-al physician and/or nurse on duty and not alwaysn the patient’s ‘‘readiness for weaning’’. Theespondents believed that weaning has low prior-ty among physicians and consider it the nurse’sesponsibility to suggest it, as if not, nothing willappen. The respondents expressed a need for aeaning plan that they could use in the physician’sbsence.
ow priorityhe third approach reported was the low priorityiven to weaning.
‘We have many things to do and it is easy to giveeaning low priority. It is nice to see the patient
elaxed, because weaning is stressful (Group 2,urse A). Weaning is difficult and easier to leave
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until the next shift (Group 2, Nurse C). Weaningrequires a great deal of energy, which is sometimesthe reason why it receives low priority’’ (Group 2,Nurse F).
An intensive care patient demands a great dealof the nurse’s time. Some days are so busy thatthe physician and nurse have to give priority tolife-saving interventions, which leaves no time toconcentrate on weaning. Several of the respondentsadmitted that even if a patient is ready, they some-times choose not to start. They feel uncomfortablewith the weaning process because they lack confi-dence, knowledge or there is nobody available toask and discuss it with. They focus on other impor-tant duties instead. Furthermore, weaning resultswere not required, discussed, reported or measuredon an interdisciplinary basis.
Discussion
The aim of this study was to identify ICU nurses’perceptions of protocol-directed weaning. Focusgroups were chosen in order to reflect the nurses’perception of protocol-directed weaning. Qualita-tive content analysis (Graneheim and Lundman,2004) was used to analyse the transcripts ofthe interviews. The content and classificationof themes were discussed and validated by theauthors. According to Blaikie (2000), the reflexivecharacter of qualitative research means that indi-vidual researchers inevitably contribute somethingof themselves to the research process and therebythe outcome. In addition, social situations are neversufficiently similar across time and space to makereplication possible. One of the authors is an expertin intensive care nursing and thus possesses thecontextual knowledge that makes it possible tounderstand the intensive care environment.
The overall results showed that the nursesperceived the protocol as useful, since it rep-resented a common, interdisciplinary knowledgebase and plan. When prescribed by a physician,it enabled the nurse to start and continue theweaning process within safe limits. The nurses per-ceived the protocol as motivating and time-savingas well as providing a feeling of independence. Theydescribed it as stressful to be unable to wean apatient who is ‘‘ready to wean’’ due to the lackof a plan or protocol.
Barriers to weaning were associated with the
absence of an interdisciplinary weaning plan. With-out a plan on which there is consensus, weaningsometimes happened by chance or not at all. Nurseshave a difficult role in weaning due to the mix ofip
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B.S. Hansen, E. Severinsson
kills within the profession and between profes-ional categories, in addition to professional rolesnd boundaries. The nurses considered themselveso be in an excellent position for assessing physi-logical indicators of readiness to wean as well asor titrating ventilation and monitoring responses toentilator adjustments. However, they expressed aeed for a collaborative process to discuss a com-on plan and goal. These findings are in accordanceith Blackwood (2000), who emphasises that thessessment of readiness for weaning has uniquehysiological and emotional components that cannly be recognised by those in close contact withhe patient, i.e. bedside nurses. Lack of interestn and individual attitudes towards weaning amongealth care professionals can have a critical influ-nce on a patient who is ready for weaning.
The nurses expressed a feeling of irritation abouthe fact that the protocol was rarely prescribednd therefore hardly used, which they perceived aseing due to a lack of communication and collabo-ation on the part of physicians but also among theurses themselves. They mentioned several factorshat can combat barriers to using the protocol andromote the protocol as a standard. They also iden-ified three approaches to problems that arose as aesult of failure to focus on weaning and prescribe
weaning plan. Depending on the patient’s con-ition and lack of physicians’ prescription, the ICUurses either chose to act, wait or give weaning lowriority. Several studies from a variety of settingsave reported that physicians and nurses have dif-erent perceptions of clinical pathways (McDonaldt al., 2005). McDonald et al. (2005) state that,hile nurses advocate standardisation and viewhysicians as rule breakers, physicians may not nec-ssarily regard guidelines as legitimate or identifyith the rules written for them by members ofther social groups. The different approaches toandling weaning described by the nurses may leado undesirable variations such as some nurses giv-ng weaning high priority while others hardly weant all. Caring for an intensive care patient is hardork as the nurse has to focus on and give priority toany important tasks. Interprofessional discussions
nd plans may help the health care team to agreen priorities and work towards the same goals.ariations in weaning might benefit the patient ifased on expert knowledge and communicated tohe team as a part of an interprofessional plan. Ifhe weaning outcome is not discussed on a regularasis, it may easily receive low priority. The nurses
n this study considered the protocol useful, as itut weaning on the agenda and represented a plan.Pronovost et al. (2005) state that mistakesnclude failure to complete a planned action as
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ntended and the use of a wrong plan as a result ofn action taken (error of commission) or not takenerror of omission). Accordingly, lack of protestbout the fact that the ready-to-wean patient hasad no protocol or individual weaning plan pre-cribed is an error of omission. Teaching peopleow to speak up and creating an environmenthere they can express their concerns is a key
afety factor. Adaptation of standardised tools andehaviours is a very effective strategy for enhanc-ng teamwork and reducing risk (Leonard et al.,004).
The lack of collaboration between health carerofessionals revealed in this study agrees withther findings (McDonald et al., 2005). Accordingo Henneman (2001), many of the structures androcesses used in ICUs today continue to promoteierarchical and discipline specific decision making,hich hinders the development of combined skillsnd expertise in multidisciplinary teams. Standardsnd protocols are important structures for facili-ating a team approach as well as improving theuality of care by translating new research findingsnto practice (Wollersheim et al., 2005). However,t is difficult to effect a change in attitudes, pro-essional habits and work practices.
Effective professional collaborative relation-hips require mutual respect and may seemdealistic or even unrealistic, but are well worthhe effort involved, as they lead to a better out-ome for patients as well as personal growth forhe professional categories concerned (Kramer andchmalenberg, 2003). It is not what people have inommon but their differences that make collabo-ation more powerful than working individually, ashe questions and challenges that arise from theseifferences are important (Davis, 2000). Thus, col-aboration begins when different disciplines meeto share each other’s knowledge. Each health carerofessional has information the other needs inrder to practise successfully (Lindecke and Sieck-rt, 2005).
A major change in nursing and medical educations necessary for the development of collaborativeehaviours (Finch, 2000) but, until this happens,t may be beneficial to develop collaborativeethods for the introduction of new procedures.hile waiting for the emergence of organisational
nd educational changes there is a need to actow and focus on already established ‘‘meetingoints’’ (rounds, simulation, discussions, debrief-ng) in order to improve staff collaboration. It is
lso necessary to implement new structures withinhich health care workers from different profes-ions can learn, discuss and evaluate. When newrocedures involving more than one discipline are
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weaning 203
ntroduced, it might be worthwhile creating annterdisciplinary forum, where different profes-ions can listen to each other’s questions, learnrom each other’s differences and evaluate dailyractice. Due to their socialisation into differentaradigms, nurses and physicians have comple-entary skills. It is important to start focusing
n the health care team and how its memberseal with the discrepancy between time availableor protocol-directed weaning and the actual timeevoted to it (Fjælberg et al., 2005). Interdis-iplinary agreement to a weaning plan (generalrotocol or individual plan) could reduce this dis-repancy, as it would allow nurses to act within safeimits while the physicians attend to other patients.here is a need for goal-directed, dynamic, patiententred communication with focus on assessment,are planning and progress (Arfjord, 2005).
The nurses also stated that they had different,ndividual ways of handling the situation depend-ng on the existence or lack of physicians’ orders.t was reported that disagreements were aired,lthough there was no specific reference to con-rontations with physicians or that the matter hado be brought to the attention of the ward manager.urses have been accused of developing specificehaviours to resolve conflicts and attempting tovoid disputes between themselves and physiciansCoombs, 2003). Nurses must be empowered to con-ribute to teams from a position of strength. Theyeed not strive to control teams, but should never-heless provide strength, innovation and integrity inollaboration. Nurses have become more assertive,ompetent and better educated than ever before.n view of their role as the patient’s advocate, its important that they speak up if they feel thatoutines and collaboration could be improved.
Clinical nurses need to integrate research find-ngs into daily clinical care in order to maintainigh standards. Nursing also involves pioneering thencorporation of integrating evidence derived fromualitative research studies into practice. Otherisciplines such as medicine have doctoral and post-octoral programmes. However, within nursing, theesearch tradition is short. It can be assumed thatntensive care nurses’ knowledge of research is lim-ted, since nursing research education is a relativelyew discipline. It is necessary to study nurses’ atti-udes to and knowledge of research education inrder to carry out more research in this area, par-icularly in acute settings. It is possible to identifyreas of perceived low and high competence as well
s areas in which nurses would like to improve theiresearch skills. Improved skills would make it eas-er to speak up on interdisciplinary teams, in theatient’s best interest.
B
B
B
B
B
C
C
C
C
D
F
F
G
G
H
K
K
K
L
L
M
M
204
Conclusion
When the protocol was employed, the nursesperceived it as an asset, as it represented an inter-professional agreement allowing them to act in thephysicians’ absence. It focused on weaning, savedtime, motivated them and led to safety and conti-nuity in the weaning process. Barriers to using theprotocol were associated with failure on the partof physicians to prescribe it. In the absence of aweaning plan (protocol or individual plan), nursesreported three ways of handling the situation: tak-ing action, waiting and giving weaning low priority.
It is necessary to have a weaning plan basedon interdisciplinary understanding, research andteam communication about the patient’s situationand goal, as without it, there will be undesiredvariations in weaning. Nurses would like an interdis-ciplinary approach as well as a shared ‘‘language’’or knowledge base. New procedures involving morethan one discipline could be introduced by meansof an interdisciplinary approach, using one roomas a ‘‘meeting point’’, where health care work-ers can listen to each other’s questions and utiliseeach other’s specialist knowledge for the benefit ofpatients. The outcome of using the weaning pro-tocol should be discussed, reported and measuredon an interdisciplinary basis. Nursing research is animportant means of improving nursing skills, whichin turn will strengthen the nurse’s voice in the inter-disciplinary team and enhance patient care. Forfurther research it is important to focus on inter-professional collaboration and to interview otherICU team categories.
Acknowledgements
The authors would like to thank the respondentsfor sharing their experiences. Special thanks toWenche Fjaelberg, intensive care nurse at Sta-vanger University Hospital, and Anne Norheim,associate professor at the University of Stavanger,for their assistance with the data collection, and toSvein Harboe, our senior physician, who constantlyencourages and motivates us by means of discus-sions, advice and keeping us informed about newresearch articles. The Laerdal Foundation of Nor-way provided support in the form of a grant for thedevelopment of this study.
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