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RESEARCH doi: 10.1111/nicc.12055 Paediatric intensive care nurses’ and doctors’ perceptions on nurse-led protocol-directed ventilation weaning and extubation Lyvonne N Tume, Alison Scally and Bernie Carter ABSTRACT Background: Nurse-led (protocol-directed) ventilation weaning (NLVW) is utilized in adult intensive care and has shown to be safe and reduce ventilation times. Our paediatric intensive care unit (PICU) implemented a NLVW (and extubation) protocol in 2004, yet it was observed that some NLVW-trained nurses were not undertaking the role in practice. Aims: To explore PICU nurses’ and doctors’ perceptions of and barriers to NLVW on a UK PICU, with the aim of facilitating more NLVW on our PICU by reducing these barriers. Methods: A cross-sectional electronic survey was used to collect data from both nurse ventilation weaners and all medical staff and advanced nurse practitioners (ANPs) on one PICU. Results: Our survey response rates were 90% (36/40) nursing and 54% (20/37) medical. The four top reasons cited for nurses not being able to wean by protocol were not being allocated to a ‘weanable’ patient, being in an in-charge or runner role, high clinical workload and a perceived lack of support from medical staff/ANPs. The restrictive nature of our protocol also emerged as a key issue by all staff. The medical survey revealed an overwhelming positive response to NLVW with 90% believing that experienced PICU nurses should be allowed to wean ventilation. In contrast to the nurses perceived lack of support or encouragement for NLVW, medical staff rated their encouragement for the nurses to undertake this role as high. Conclusions: NLVW is a complex process, and factors that impair or facilitate this process relate not only to the weaning protocol itself, but also organizational processes and structural factors in a PICU. Relevance to clinical practice: This paper highlights the complexities involved in instituting and establishing a nurse-led, protocol-driven ventilation weaning process within a PICU. Further, in depth research is required to examine both PICU nurses and doctors attitudes to NLVW both in the UK and across Europe. Key words: Advanced nursing roles Developing/Evaluating nursing roles Paediatric intensive/Critical care Weaning from mechanical ventilation Weaning protocols Weaning ventilation INTRODUCTION Mechanical ventilation (MV) is a fundamental com- ponent of children’s intensive care unit admission. Authors: LN Tume, RN RSCN RNT Dip App Sci (Nurs), B Nurs, M Clin Nurs (Crit Care), PGDE, PhD, Senior Nursing Research Fellow PICU, Alder Hey Children’s NHS Foundation Trust and University of Central Lancashire, Liverpool L12 2AP, UK; A Scally, RNC Dip HE (Nurs), BA (Nurs), BSc (Hons), Sister PICU, Alder Hey Children’s NHS Foundation Trust, Liverpool L12 2AP, UK; B Carter, PhD, PGCE, BSc, RSCN, SRN, Professor of Children’s Nursing, University of Central Lancashire, Preston PR1 2HE, UK Address for correspondence: LN Tume, Alder Hey Children’s NHS Foundation Trust and University of Central Lancashire, Eaton Road, Liverpool L12 2AP, UK E-mail: [email protected] On average 18 300 children per year are admitted to UK paediatric intensive care units (PICUs) and 66·5% require MV (PICANET 2012). Weaning from MV is a major step in the child’s recovery and pro- gression towards PICU discharge. Delays in weaning from MV and extubation impact of patient mor- bidity prolong PICU stay and bed availability. In light of accumulating adult evidence (Kollef et al., 1997; Krishnan et al., 2004; Marelich et al., 2000), we implemented a nurse-led protocol-directed ven- tilation weaning (and extubation) process on our PICU in 2004, yet this was observed to be inconsis- tently initiated and utilized; thus the authors sought explanations. © 2013 British Association of Critical Care Nurses 1

Paediatric intensive care nurses' and doctors' perceptions on nurse-led protocol-directed ventilation weaning and extubation

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Page 1: Paediatric intensive care nurses' and doctors' perceptions on nurse-led protocol-directed ventilation weaning and extubation

RESEARCH

doi: 10.1111/nicc.12055

Paediatric intensive care nurses’ anddoctors’ perceptions on nurse-ledprotocol-directed ventilationweaning and extubationLyvonne N Tume, Alison Scally and Bernie Carter

ABSTRACTBackground: Nurse-led (protocol-directed) ventilation weaning (NLVW) is utilized in adult intensive care and has shown to be safe andreduce ventilation times. Our paediatric intensive care unit (PICU) implemented a NLVW (and extubation) protocol in 2004, yet it was observedthat some NLVW-trained nurses were not undertaking the role in practice.Aims: To explore PICU nurses’ and doctors’ perceptions of and barriers to NLVW on a UK PICU, with the aim of facilitating more NLVW onour PICU by reducing these barriers.Methods: A cross-sectional electronic survey was used to collect data from both nurse ventilation weaners and all medical staff and advancednurse practitioners (ANPs) on one PICU.Results: Our survey response rates were 90% (36/40) nursing and 54% (20/37) medical. The four top reasons cited for nurses not beingable to wean by protocol were not being allocated to a ‘weanable’ patient, being in an in-charge or runner role, high clinical workload and aperceived lack of support from medical staff/ANPs. The restrictive nature of our protocol also emerged as a key issue by all staff. The medicalsurvey revealed an overwhelming positive response to NLVW with 90% believing that experienced PICU nurses should be allowed to weanventilation. In contrast to the nurses perceived lack of support or encouragement for NLVW, medical staff rated their encouragement for thenurses to undertake this role as high.Conclusions: NLVW is a complex process, and factors that impair or facilitate this process relate not only to the weaning protocol itself, butalso organizational processes and structural factors in a PICU.Relevance to clinical practice: This paper highlights the complexities involved in instituting and establishing a nurse-led, protocol-drivenventilation weaning process within a PICU. Further, in depth research is required to examine both PICU nurses and doctors attitudes to NLVWboth in the UK and across Europe.

Key words: Advanced nursing roles • Developing/Evaluating nursing roles • Paediatric intensive/Critical care • Weaning from mechanical ventilation • Weaningprotocols • Weaning ventilation

INTRODUCTIONMechanical ventilation (MV) is a fundamental com-ponent of children’s intensive care unit admission.

Authors: LN Tume, RN RSCN RNT Dip App Sci (Nurs), B Nurs, M ClinNurs (Crit Care), PGDE, PhD, Senior Nursing Research Fellow PICU, AlderHey Children’s NHS Foundation Trust and University of Central Lancashire,Liverpool L12 2AP, UK; A Scally, RNC Dip HE (Nurs), BA (Nurs), BSc (Hons),Sister PICU, Alder Hey Children’s NHS Foundation Trust, Liverpool L122AP, UK; B Carter, PhD, PGCE, BSc, RSCN, SRN, Professor of Children’sNursing, University of Central Lancashire, Preston PR1 2HE, UKAddress for correspondence: LN Tume, Alder Hey Children’s NHSFoundation Trust and University of Central Lancashire, Eaton Road,Liverpool L12 2AP, UKE-mail: [email protected]

On average 18 300 children per year are admittedto UK paediatric intensive care units (PICUs) and66·5% require MV (PICANET 2012). Weaning fromMV is a major step in the child’s recovery and pro-gression towards PICU discharge. Delays in weaningfrom MV and extubation impact of patient mor-bidity prolong PICU stay and bed availability. Inlight of accumulating adult evidence (Kollef et al.,1997; Krishnan et al., 2004; Marelich et al., 2000),we implemented a nurse-led protocol-directed ven-tilation weaning (and extubation) process on ourPICU in 2004, yet this was observed to be inconsis-tently initiated and utilized; thus the authors soughtexplanations.

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BACKGROUND AND PROTOCOLDEVELOPMENTIn our PICU, around 85% of children admitted areinvasively ventilated (PICANET). Of these, approx-imately 21% children are successfully weaned fromventilation within 2–3 days of admission, 15% requireventilator support for 4–7 days and 9% require >7 daysof ventilator support (PICANET, 2012). Although MVis essential, the longer the duration of ventilation,the risks of infection, airway problems and sedation-related issues increase. The use of weaning protocolsas a strategy for guiding the process of discontin-uing MV has developed over the last two decades(Kollef et al. 1997; Krishnan et al., 2004; Marelichet al., 2000). Blackwood et al.’s (2011) systematic reviewof adult studies showed significant but inconsistentreductions in the duration of MV across studies. Yetnurse-led ventilation weaning (NLVW) protocol usein UK PICUs is still uncommon, with only around18% of PICUs currently using ventilation weaningprotocols (Tume and Blackwood, 2013). The processof ventilator weaning is complex and dependent ona number of interrelated and interdependent compo-nents including organizational structure and contextand relationships; and professional practice such asstaffing, multidisciplinary team working, professionalaccountability, clinical experience, professional judg-ment and autonomy (Blackwood et al., 2013).

In 2004, a protocol and training day for nurse(and physiotherapist)-led protocol-directed ventilationweaning and extubation was instituted in our PICU.The aims of this training were to improve theexperience of care for children and their families byreducing the child’s length of MV time, maximizingthe efficiency of the ICU and improving the knowledgeand skills of the nursing staff around ventilation so theunit could progress to the introduction of autonomousventilation management by nurses. Staff eligible toundertake the course were paediatric intensive-carecourse certified and had expressed an interest totake on this role. The one-day training consisted ofinteractive lectures, case presentations and problem-based learning as well as practical demonstrations.There was a written exam at the end of the day(The pass mark was set at 70%). Following thisstudy day, staff kept a practice log and had toundertake five supervised ventilation weans andextubations (including one cuffed endotracheal tube).This ‘supervised training’ period was intended to becompleted within 6 months. A policy and local protocol(weaning algorithm) was developed by a senior nurse(Rebecca Hill) after a systematic review of the literature(Hill, 2003) and expert consensus of PICU consultantsand senior nurses in the PICU. Initially, NLVW

was only undertaken in uncomplicated post-operativechildren (without any underlying lung pathology) andthen expanded to all patient groups on PICU, afteran audit showing there were no more adverse events(emergency re-intubations) than with standard medicalextubation. There remained some contraindications fornurse extubation, for example, a grade II intubationand above (indicating a problematic or potentiallyproblematic airway). The protocol allows the nurseto alter single ventilation parameters at one time,check an arterial blood gas and then re-wean untilpatient-specific, pre-extubation ventilation settings arereached (Figure 1). There was essentially no flexibilityin the protocol and if a patient needed to be weanedmore quickly, then they had to come off the protocoland be weaned by the medical and advanced nursepractitioner (ANP) staff as per standard practice. Afterimplementation of the protocol, a prospective auditwas conducted to detect any adverse events or safetyissues. Thirty-five nurse-led weans and extubationaudits were completed and no adverse events wereobserved. No formal audit of ventilation times beforeand after NLVW was introduced was undertaken.However, audit data showed no change in medianventilation days from 2003 to 2005 (after the protocolwas introduced in 2004) (PICANET data).

SettingA 23-bed PICU in the North West of England wasselected for this study. The hospital has a separate15-bed high-level HDU adjacent to the PICU which isstaffed and managed as a separate unit. The PICU has170 whole time equivalent (WTE) nurses, 9 consultantmedical staff, 4 specialist PICU training doctors(registrars), 1 permanent associate specialist/clinicalmedical fellow, 7 paediatric doctors in training(who rotate through the PICU every 6 months)and 9 rotating anaesthetic training doctors. Four,clinical MSc-qualified ANPs and a nurse consultantwork clinically on the medical rota (undertakingan advanced role similar to the specialist PICUtraining doctors). Some nurses (60%) have a specialistintensive care nursing course qualification. The unitaccepts all specialist referrals including burns, cardiacsurgery, neurosurgical admissions and is a cardiacand respiratory surge Extra Corporeal MembraneOxygenator (ECMO) centre. It does not undertakespecialist liver or heart/lung transplant services.Intubated patients are nursed with a nurse: patientratio of 1:1. The PICU accepts patients aged 0–17 yearsof age; however 60% of patients are aged less than12 months of age. The median length of PICU stay andventilation is 3 days (PICANET, 2012) which is similar

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Figure 1 Weaning algorithm BIPAP (ASB) Draeger Evita.

to other UK PICUs, and the percentage of invasivelyventilated children is around 85%.

Although 45 nursing staff had been trained toundertake NLVW between 2004 and 2012, in dailyclinical practice it was apparent that many of thesenurses were not undertaking this skill. The aim of thestudy was to explore the perceptions of and possiblebarriers to NLVW and to explore why the nurses whohad been trained and assessed to wean ventilation andextubate (within a directed protocol) did not undertakethis role in practice. We also wanted to ascertainthe perceptions of medical staff and ANPs aboutnurse ventilation weaning and extubation, becauseventilation weaning is a collaborative process. The

overall aim of which was to address some of thesebarriers and increase the amount of NLVW on ourPICU.

METHODSA cross-sectional electronic survey design (SurveyMonkey™) was used to collect the data and explorePICU nurses’ and doctors’ perceptions of nurse-led(protocol-directed) ventilation weaning in one PICU.Survey one (Figure 2) was sent to all nurse weaners stillworking on the PICU (n = 40; five previously trainednurses had since left the unit). Survey two (Figure 3)was sent to all medical (and ANPs) staff working on the

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Nurse ventilation weaners survey questions 1. What band nurse are you?

a. Band 5b. Band 6c. Band 7

2. How many hours per week do you work?3. What is your shift pattern?

a. Mixture of days and nightsb. Permanent nights

4. When did you complete the protocol ventilation weaning study day?a. 2012b. 2011c. 2010d. 2009e. earlier

5. What was your MAIN reason for choosing to undertake the weaning ventilation study day?a. I wanted to take on the extended role of weaning ventilation and extubationb. I didn’t want nurses more junior than me doing a role that I couldn’t doc. I wanted to learn more about ventilation weaning and extubationd. I wanted to ensure timely weaning and extubation for my patientse. I don’t knowf. Other please specify

6. Have you completed your ventilation weaning competences yet?a. Yesb. No

7. If so how long has it taken you to complete your competencies?a. 3-6 monthsb. 6-12 monthsc. >1 yeard. >2 years

8. If it has taken you more than 6 months to complete your competencies, please rank the importance ofeach of these factors below.a. The type of patient allocated to me (they were too sick and not weanable)b. My role (I am always team leader or runner)c. My workload (I just find I am too busy with my patient)d. I still don’t feel confident in weaning and extubatinge. I feel the medical staff or ANPs don’t support mef. I never really worked with my mentor

9. Can you describe any other barriers you have encountered that stop or prevent you from weaningventilation and extubating patients on the PICU?

10. If you undertake less than 3 extubations a month what are the main reasons? Please rate the factorsbelow in order of importancea. My workload being highb. The patients I am allocatedc. The restrictive nature of the protocold. My perceived lack of support from the medical and ANP staffe. My perceived lack of support from other nurses on the unitf. My shift patterng. My role (always being team leader)h. Other please specify

11. Please rate the factors below in terms of their importance in preventing you from weaning by theprotocol:a. It takes too longb. It is too restrictivec. The doctors don’t encourage itd. I often just forget to get the weaning guideline filled out

Figure 2 Survey instrument of nurse ventilation weaners.

PICU (consultants, specialist PICU training doctors,rotating paediatric training doctors and anaesthetictraining doctors) between September and December2012. In our PICU the ANPs work on the medical rotain a medical role, thus for the purpose of this surveywere included in the medical staff survey.

These surveys were anonymous requiring only jobtitle. The content of the surveys was different. The18-item nurse and 18-item medical surveys were amixture of multiple choice, Likert scale and freetext question types. No validated surveys could beidentified that would address our specific aim, so two

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e. I don’t feel confident to do itf. Other nurses on the unit don’t support meg. The ANPs don’t encourage me to do ith. Other please specify

12. Do you ever wean ventilation 'outside of the protocol'?Optionsa. Yesb. Noc. Very occasionallyd. Yes but only the oxygene. Other please specify

13. What factors prevent you from undertaking extubations? Please rank.a. The doctors/ANPs often just do itb. I am concerned that something may go wrongc. I do not feel that I have adequate skills and knowledged. The doctors/ANPs do not support me to do ite. It often goes past the end of my shiftf. The presence from parents at the bedside inhibits me from doing itg. Other please specify

14. Have you ever had a serious adverse clinical event (emergency reintubation etc) occur following anextubation you've done?a. Yesb. No

15. If yes, to previous question please give a brief description of the event16. Has an incident affected your confidence in extubating?

a. Yesb. Noc. Don’t knowd. Other please specify

17. What things would help you undertake more protocol ventilation weaning and extubations?18. We thank you for taking the time to complete this survey. Have you got any other comments you would

like to make about protocol-directed ventilation weaning and extubation on PICU?

Figure 2 continued

surveys were developed by A. S. and L. T. (Figures2 and 3). Survey development was undertaken withextensive feedback from the senior PICU team (doctorsand nurses) and the surveys were piloted on four staff(two nurses and two doctors) to ensure face validityof the survey and to identify any other issues thatthey felt we should ask about. The nurse survey wasadministered first because we wanted to explore themedical/ANP staffs’ views of the nursing responses.The data were analysed descriptively and inferentiallywhere possible to examine differences within thegroups. Likert scale responses are presented as amean and median rating score. Differences within thesurvey groups were examined using non-parametrictests (Kruskal-Wallis). The significance level was setat <0·05. Free text responses were analysed usingsimple thematic analysis so as to generate commonthemes. In line with the iterative approach suggestedby Attride-Stirling (2001), initial coding of the nurseand medical surveys were kept separate. Free textresponses for each question were collated and theneach individual response was coded. Following thisany redundant codes were collapsed and codes andcode labels revised as needed. The code labels from themedical and nurse surveys were compared and, where

appropriate, further revised. Once the researchers weresatisfied with the coding, the codes were collapsed intothree main themes that reflected the key issues fromboth the nurse and medical survey.

In the UK, research involving NHS staff is nolonger reviewed by NHS Ethics committees unlessit raises significant ethical issues (HRA, 2012); thus thissmall practice development study was registered asservice evaluation with the NHS Trust. Data protectionguidance and sound ethical practices were adheredto and consent was implied by the return of theanonymous survey.

RESULTSThe nurse survey response rate was 90% (36/40)and all were PICU-trained nurses; the medicalsurvey response rate was 54% (20/37) and includedconsultants, registrars and ANPs (Table 1).

Nurse survey resultsThe two main reasons cited for undertaking this rolewere to improve the timely weaning and ventilationof their patient (49%) and to extend their professionalrole (40%) and this did not differ significantly per nurse

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Medical and ANP survey questions1. What is your job title?

a. ANP/nurse consultantb. Paediatric registrarc. PICU Grid Traineed. Anaesthetic registrare. Consultantf. Other please specify

2. Approximately how long have you worked on Alder Hey PICU?3. Have you worked on another ICU where nurses weaned and extubated patients?

a. Yesb. Noc. Other please specify

4. Were you aware that some nurses on the unit could wean ventilation (via a protocol)?a. Yesb. Noc. Other please specify

5. At your induction (if you had one) were you made aware that some nurses on PICU can wean ventilation(via a protocol) if you complete the weaning orders paperwork?a. Yesb. Noc. Not had an inductiond. Other please specify

6. Do you know what the requirements are for this role and what training and assessment the nurses that dothis role have had?a. Yesb. Noc. Not sured. Other please specify

7. Do you think that experienced PICU nurses should be allowed to wean mechanical ventilation andextubate standard risk (grade 1 intubations only) patients on PICU? a. Yesb. Noc. Don’t knowd. Other please specify

8. Does the information above (about nurse training for this role) change your view on whether nursesshould be able to wean and extubate?a. Yesb. Noc. Not sured. Other please specify

9. For the nurses to wean ventilation the doctor or ANP needs to prescribeparameters for weaning on theweaning form, so that the nurses can wean ventilation and keep blood gases in a range that you set. Haveyou ever written any 'weaning parameters' for nurses to wean? a. Yesb. Noc. Other please specify

10. Please rate, on a scale of 1 – 6 how comfortable you feel (or would feel) in writing out weaning parametersfor the nurses

11. Please rate, on a scale from 1-6 how actively you encourage the nurses (who can) to wean ventilation andextubate children on PICU

12. Have you got any comments about the doctor or ANPs role in encouragement of the nurses to wean?13. Please rate on a 1 -6 scale how much impact (if any) you think it would make to reducing ventilation time

on PICU if all nurses who could wean and extubate (n = 40) actually did it all the time? 14. Nurse ventilation weaners sometimes report that doctors and ANPs don't support them in their role as a

ventilation weaner. Why do you think they might say this?15. At any point in the ward round is it made clear to you whether any nurses on the shift or with particular

patients are ventilation weaners? a. Yesb. Noc. Other please specify

16. From a medical or ANP perspective how do you think we could maximise the amount of nurse ventilationweaning and extubation being undertaken on PICU?

17. What do you expect from a nurse who is weaning ventilation by protocol on your patient?18. We thank you for taking the time to complete this survey. Is there anything else you would like to say

about nurse-led ventilation weaning and extubation on PICU?

Figure 3 Medical survey instrument on ventilation weaning.

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Table 1 Survey respondents

Respondents

Nursing (n= 36)Staff nurse (band 5) 25% (9/36)Junior charge nurse (band 6) 66·7% (24/36)Senior charge nurse (band 7) 8·3% (3/36)

Medical/ANP (n= 20)ANP 20% (4/20)Training paediatric doctor 25% (5/20)Training PICU doctor 20% (4/20)Training anaesthetic doctor 10% (2/20)PICU consultant 25% (5/20)

grade/band. However, only 58% (21/36) nurses hadcompleted their weaning and extubation competenciesand of these, 62% (13/21) had completed these within3–6 months. Nurses working less than 30 h per weektook longer to achieve their competencies, with band 6nurses (junior charge nurses) taking longer than staffnurses (band 5) or senior sisters/shift coordinators(band 7). This however may reflect the demographicsof this nurse group in our PICU, many of whom havesmall children and work part time.

Nurses were asked, using a Likert scale question(1–5 with 5 being the most significant factor), the mostsignificant factors/barriers that prevented them fromNLVW. The top four reasons nurses cited as the mainfactors delaying achievement of their competencies(Figure 1, Question 8) were not being allocated toa ‘weanable’ patient (mean rating 4·1, median 4·0);always being in a team leader or a runner role (meaningthey did not look after a specific patient) (meanrating 3·1, median 3·0); high clinical workload (meanrating 3·0, median 3·0); and the medical staff/ANPsnot supporting them (mean rating 2·9, median 2·0).The only significant difference between the nursingroles/grades was for being in an in-charge or teamleader role (p = 0·021).

When asked whether the factors that delayed themachieving their competencies differed with regard toextubation of the patient (Figure 1, Question 10),similar responses emerged. The Likert scale in thisquestion ranked 1 as the most important factor to 5as the least important factor. The top four reasonscited were the restrictive nature of the protocol (meanrating 2·44; median 2·0), a high clinical workload(mean rating 2·55; median 2), not being allocateda ‘weanable’ patient (mean rating 2·7; median 3)and being in charge of the unit (mean rating 2·7;median 3). A significant difference between nursegrades was found only with regard to perceptionof high clinical workload (p = 0·041) with band 5

(more junior nurses) perceiving a higher clinicalworkload.

The two main barriers rated by nurses for notweaning by protocol were the protocol was toorestrictive (mean rating 1·97, median 2·0) and the longertime taken to wean by protocol (mean rating 2·51,median 2·0) and there were no significant differencebetween nursing grades. This ‘restrictiveness’ ofthe protocol had led some (the more experiencedsenior sisters) nurses to wean outside the protocoloccasionally. The main barriers for the nurses notundertaking extubation (Figure 1, Question 13) werenursing shift patterns and patient readiness (meanrating 2·51; median 2) and the doctors/ANPs justdoing the extubation (mean rating 2·74; median 3). Asignificant difference was found between the nursinggrades only with regard to concern that somethingmight go wrong (p = 0·016), with band 5 (more juniornurses) having greater concern. Nurses in general didnot report particular concern about something goingwrong at extubation; however, it is clear that this wasmore of a concern for more junior nurses. Only 14%(5/36) of nurse weaners had encountered an adverseevent where the child needed re-intubation, and formost (93%) of these nurses, this event had not affectedtheir confidence in extubation.

Medical survey resultsThe majority (70%) of medical staff had not previouslyworked on an ICU where nurses weaned ventilation,but all were aware that some nurses on this PICUcould wean ventilation. Fewer than half (40%) knewwhat the requirements and training were for nursesto undertake this role. Overwhelmingly though, 90%(18/20) believed that PICU-trained and experiencednurses should be allowed to wean ventilation. In termsof encouragement, medical staff were asked on a Likertscale how much they encouraged nurses to wean from1 to 6 (extreme encouragement): the mean score of 4·7(median 5) demonstrated most medical staff/ANPs feltthey gave the nurses significant encouragement andsupport to wean ventilation. There were no significantdifferences between ANPs and doctors (p = 0·25). Bothmedical staff and ANPs all felt very comfortable inwriting weaning parameters for the NLVW (meanscore 5·3; median 6) with no difference between thegroups (p = 0·35). The majority of medical/ANP staff(mean score 4·1; median 4) felt it would make amoderate impact on reducing ventilation times onthe PICU if all PICU nurses could wean ventilation,and there were no differences between ANPs ordoctors (p = 0·38). However, the communication ofwho could wean was not always clear to the medicalstaff and 94% reported at no time on the morning

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ward round was it made clear to them which nurseswere ventilation weaners. Medical staff were askedwhat their expectations of nurse weaners were and thepredominant theme of ‘working together’ emerged,along with the nurse being aware their limitations andputting themselves forward for this role.

Analysis of free text responsesThe majority of respondents provided answers to open-ended free-text questions and many were quite detailedin response to the barriers and facilitators to nurseventilation weaning on PICU. These responses fell intothree main themes: the restrictive nature of the currentprotocol; nurses needing the right patient and being inthe right role (bedside nurse) to wean; and a perceivedlack of support in undertaking this role.

The restrictive nature of the current protocolOverall the comments provided by the nursesidentified that they felt the current protocol to be ‘toorestrictive’ and ‘too rigid at times’ and that the protocoldid not allow for ‘thinking outside the box’. Greaterflexibility in the protocol was felt likely to result in‘much more successful’ nurse-led weaning.

There were also concerns about ‘the amount of bloodgases we have to take, especially in smaller neonates’.Another nurse explained, ‘more leeway in the protocolcould mean we could go off end tidal CO2 rather than havingto stab patients, as this puts me off if they don’t have a lineto take gases from’.

The restrictive nature of the protocol also raisedconcerns about the length of time taken to wean achild. One nurse commented that ‘some patients canbe weaned more quickly by medical staff ’, with anotheremphasizing ‘protocol weaning often takes a long time andmany children are ready for extubation prior to reaching thecorrect point on the protocol’. A further comment relatedto the medical team’s apparent frustration with theprotocol, with a nurse stating ‘the doctors often take over(weaning) as the weaning protocol takes a long time’.

The rigidity of the protocol was not felt toaccommodate the diversity of children’s needs, as onenurse explained ‘the protocol needs to be more flexible toallow for fast track weaning of post op patients and slowerweaning of longer term ventilated patients or for those whowe can anticipate a deviation from the normal respiratoryparameters which would be expected’.

It was evident that nurses are constrained by therigidity of the protocol which results in them beingunwilling to wean using the protocol. Yet, despite theapparent restrictions, some nurses did not experiencebarriers and appeared confident and proactive ‘if mypatient is ready to wean, I ask a doctor to sign the protocolform and I wean my patient’.

Needing the right patient and right role to beable to weanThe participants provided clear explanations abouthow their role on PICU could conflict with their abilityto undertake weaning. The nurses, eligible and trainedto wean ventilation, were experienced, PICU-certifiednurses, which meant they were often acting in ateam leader role. This role created specific demandswhich produced difficulties as they were often ‘toobusy running the ward’ and ‘unable to return (to thechild) and thoroughly wean’. One nurse explained thedifficulties of being in-charge meaning ‘not being ableto constantly monitor the patient I was weaning’, althoughthis may be (she acknowledged) her own issue withtrust in other nurses. Aside from the obvious conflictarising from managing the complex process of weaningwhilst being a team leader, the nurses also related thatthey were rarely allocated a patient ready for weaning.One nurse explained ‘I am often allocated to the ECMO orCVVH patients, and am unable to be allocated a weanablepatient because of the skill mix on that shift’.

A perceived lack of support from medicalstaff/ANPsHaving ‘more support’ and ‘more encouragement fromthe medical staff/ANPs and team leaders’ were seenas ways of facilitating nurses to undertake the weaningrole. So although nurses expressed the need for moresupport, there was also a sense that nurses should beleading the way with this role themselves. One nurseexplained ‘if more nurses could do it, it would encourageothers’. Another nurse observed ‘it would be helpful if themedical staff would allow us more scope to do this role too. Iusually try and ‘‘sell it to them’’ as one less thing they haveto worry about’.

The medical respondents also commented on factorswhich facilitate nurse-led weaning, the perceived lackof medical support and medical staff’s expectations ofnurse weaners. These comments were overwhelminglypositive towards nurse ventilation weaning. Typicallyrespondents mentioned the importance of nurse-ledweaning especially ‘when the unit is busy’ with onedoctor stating ‘the bedside nurse has a better feel for howthe patient is coping with weaning’. Another respondentdiscussed the need for continuity of weaning ‘I thinkthat the nurse and doctor/ANP looking after a patient bothbeing able to wean is a great idea and should ensure thepatient continues to be weaned even when the Doctor/ANPis busy’.

Other themes that emerged from the medicalresponses included weaning as a collaborative process;and the importance of ‘knowing the nurse’ and beingsupportive.

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Weaning as a collaborative processWeaning was identified as a collaborative processwith the medical staff identifying their support ofthe nursing staff, whilst placing this in the context ofthe nurses needing to discuss issues and keep theminformed. One respondent explained the need for thenurses to be reflexive and prepared, said: ‘I alwayssupport nurses to develop their roles but I expect them toapproach me prepared. I prefer them to think about and writewhich weaning parameters they think are appropriate’.

Whilst respondents felt the nurses should ‘go aheadwith weaning according to the protocol’ there wasalso an expectation of them being ‘proactive’ and theweaning not just being a case of ‘me (the doctor)setting parameters for them to follow’. Needing towork in a ‘harmonized’ way and to ‘jointly agree theacceptable parameters to progress with weaning’ wereall identified as core to successful collaboration.

The most concern was raised about extubationwith one respondent describing themselves as being‘anxious’ due to the potential problems associatedwith laryngospasm post extubation. A less experienceddoctor identified the need for checking as ‘Regardingextubation – I am not sure whether nurse weaners shouldneed to check that the doctor/ANP is happy for themto extubate. My instinct is they should but then I aminexperienced in PICU so I would always run it by aconsultant before extubation. What I feel more sure aboutis that, if not to check re the decision, the doctor shouldbe informed so as to check re the timing – in order toensure a doctor/ANP is available in case re-intubation/otherintervention is required’.

The importance of ‘knowing the nurse’ andbeing supportiveKnowing the nurse was core to how much confidencethe medical staff had in terms of trusting the protocolor the nurse to wean. One respondent explained that‘Doctors who do not know nurses well may have concernsabout their ability to wean’ whereas others who hadworked on the unit longer got ‘to know all the nurses andtheir skills’.

In somewhat of a contradiction to the commentsabout being supportive, a note of caution was raisedwhen one respondent explained that the ‘level ofencouragement I give depends on how well I know thenurse involved and his/her apparent comfort with the role’.

When asked about why the nurses might perceive alack of support from the medical staff/ANPs, a numberof explanations were suggested. Some doctors relatedtheir own (or others) apprehension about extubationmay have affected the support they gave to the nursesfor example ‘some of the junior doctors themselves arenot that confident in weaning themselves’.

Others stated they did not know nurses could weanand who they were and that the role was a medicalone, for example ‘some people have fairly fixed views onwhich roles should be medical versus nursing – it may bejust a lack of seeing this be successful that leads to doubtsand therefore lack of encouragement’.

A number of medical staff believed that nursesneeded to be more assertive and proactive in this role,for example ‘the nurses need to indicate that they aretrained and happy and actively seek out the opportuni-ties’. Some medical staff indicated they were surprisedthe nurses felt this way (perceived a lack of support).

DISCUSSIONThe aim of this study was to explore nurses’ anddoctors’ perceptions of NLVW in a PICU and todescribe barriers to undertaking NLVW by thesetrained nurses, with a view to improving the numberof patients being weaned by nurses on the PICU. Ourmajor finding for nurses not weaning ventilation wasthe restrictive and inflexible nature of our protocol.Clearly, if there is a perception that the protocol willtake longer than standard clinical weaning practice,then this will inhibit compliance with the protocoland means that the protocol is not achieving itsintended goal, to facilitate more timely ventilationweaning. Two papers have published their paediatricweaning protocols (Keogh et al., 2003; LecLerc et al.,2010) and both have differences to that of ours. TheKeogh et al. paper (2003) used only SIMV mode towean, which impacts upon the way the ventilator isweaned, using only breath rate in their protocol. Incontrast, we use BIPAP (a pressure cycled mode onthe Evita 4 ventilator), which enables us to wean bothby pressure or breath rate. The LecLerc et al. paper(2010) is less prescriptive and emphasizes the dailytesting of ‘readiness for extubation’ including adequatesedation level (and an FiO2 ≤ 50% and PEEP ≤ 5 cm),then progresses to a spontaneous breathing trial (SBT)with little guidance as to how to get to this point.

Despite some evidence on the efficacy of NLVW(Blackwood et al., 2011), there were no studies foundwhich examined paediatric nurses’ perceptions of theventilation weaner role and barriers to undertakingthe role. However, a qualitative study in adult inten-sive care in Norway examined nurse’s perceptions ofprotocol-led weaning (Hansen and Severinsson, 2007).This work found that nurses liked the protocol and feltit allowed them to act within boundaries without refer-ence to a physician. The only barriers they noted werea lack of physician instructions for weaning, and diffi-culty in getting weaning parameters prescribed due to aperceived lack of interest, continuity and collaboration.

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Our findings also identified multidisciplinary com-munication was not always sufficient, with 94% ofmedical respondents not being aware of which nursescould wean ventilation. The nurses apparently per-ceived this as a lack of medical support, resulting indifficulty in getting the weaning prescriptions com-pleted. However, the nurse has a key role as patientadvocate and when taking on ‘extended roles’ likeventilation weaning, needs to be proactive in his/herapproach to this role. Effective decision-making in ven-tilation weaning stems from good multidisciplinarycommunication (Henneman et al., 2002), and a lack ofcooperation and collaboration between disciplines hasbeen cited as a barrier to the weaning process (Henne-man, 2001; Eckerblad et al., 2009), resulting in delayedweaning and prolonged ventilator time (Rose et al.,2011). A perceived high nursing workload, inappro-priate (not a weanable) patient allocation and havingan in-charge role were also barriers that were high-lighted in our study. For us, being in an ‘in-charge’ roleand the perception of a high clinical workload werethe only two significant factors that affected perceivedability to undertake NLVW. Being ‘in-charge’ meansthat the nurse does not have specific patient respon-sibility, but rather responsibility for all the patientsunder his/her remit (which is our unit is either 8 or 15depending on the area of the unit the nurse is in-chargeof. Not being with just one patient may affect the nursesability to ‘know the patient’ which has previously beenidentified as an important nursing issue in relation toventilation weaning (Crocker and Scholes, 2009).It wasinteresting to note the more junior nurses (staff nurses)on our PICU perceived their clinical workload to besignificantly higher than the more senior nurses andthis impacted on their ability to undertake NLVW. Itmay be that with increasing PICU nurse experiencethe ability to prioritize and manage ones workloadbecomes easier and thus a similar workload may beperceived less high by more experienced nurses.

Hansen and Severinsson (2007) also found thatventilation weaning assumed a lower priority attimes, amongst other things that the nurse had todo; however, nursing role was not found to bea barrier. Hansen et al. (2008) noted a significantdiscrepancy between the time available and time usedfor nurse-led weaning and found that even whenweaning prescriptions were issued, the nurses didnot always follow them. Even when nurses had theopportunity to initiate weaning protocols they oftendelegated or deferred the responsibility to the medicalstaff (Gelsthorpe and Crocker, 2004).

Our finding of the dissonance between nurses’perceptions of a lack of medical support and theposition stated by medical staff of their support of

nurses and of NLVW is interesting, and may, inpart, be explained by the importance of ‘knowing thenurse’. Medical staff may be more overtly supportiveof nursing staff they know and in whom they haveconfidence. This finding is consistent with the findingsof others who found that the medical staff weremore likely to have a positive influence on weaningwhen they were familiar with the nurse and theirlevel of competence (Hansen and Severinsson, 2009).Blackwood et al. (2004) also found medical staff weresupportive in theory, but raised various concernsincluding protocol rigidity and variability in nurseexperience. Our findings show that our protocol washighlighted as the major barrier: deemed as beinghighly restrictive, with too many steps and insufficientflexibility. We have now altered the protocol and allowthe nurse to use end tidal CO2 measurements combinedwith the child’s clinical effort: respiratory rate, workof breathing and general appearance instead of arterialblood gases being taken after every ventilation change.

The use of weaning protocols attracts contradictoryviews, with some considering them a methodof standardizing practice and increasing nursingautonomy (Martensson and Fridlund, 2002) and othersviewing them as inhibitors of analytical and criticalthinking (Kingston et al., 2000). Irrespective of this,there is increasing evidence in adult critical care thatprotocol-directed weaning can reduce ventilation times(Blackwood et al., 2011) and nurses (particularly thoseworking at the patient’s bedside) are well placedto monitor both patient readiness for extubationand their progress through the weaning process.Organizational factors also influence the effectivenessof weaning protocols, with protocols being favouredin settings where nurses have less autonomy over MVweaning decisions (Keogh et al., 2003; Rose and Nelson,2006).

Future research needs to explore more broadlythe views of nursing and medical staff within PICUtowards nurse-led, protocol-driven ventilation acrossthe UK and Europe. This should be more in-depth,qualitative research that includes all nursing staff, notjust those who wean ventilation.

Our study is limited by a number of factors:the small number of participants, the non-validatednature of our survey and it being undertaken in onePICU. In addition, a change in the Likert scale orderwithin the nursing survey may have impacted on theresults; however, respondents were consistent in theirresponses, which implies this was not a problem. Theresponse rate for the medical staff was lower than ideal(54%). However, the study has provided some possiblebarriers for NLVW weaning in our PICU, to enable usto address these issues. We only surveyed the nurses

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who weaned ventilation and it may have been usefulto also survey the nurses who do not wean ventilationfor their views of the process.

CONCLUSIONSIt is clear that nurse-led, protocol-directed ventilationweaning is a complex process, that not only relates tothe protocol, but also to organizational processes andstructural factors in a PICU (staffing, patient allocationand effective interdisciplinary collaboration). Therestrictive nature of our weaning protocol was a majorfactor for reduced weaning activity and in light ofthe findings we have revised our protocol and areexamining ways to address the other more complex

human and team factors that impact upon nursesundertaking this role.

ACKNOWLEDGEMENTSWe gratefully acknowledge the Alder Hey PICUPICANET team who manage the unit’s PICANETdatabase: Dr Paul Baines, Mrs June Wilding andMrs Tina McLelland for providing the comparisondata of ventilation times. Ms Rebecca Hill developedthe original weaning protocol and the one daytraining program in 2004 following a systematic reviewundertaken as part of herMSc in Clinical Nursing. MsElaine Scott translated the weaning protocol publishedin the LecLerc paper from French into English.

WHAT IS KNOWN ABOUT THIS TOPIC?

• Protocolized MV weaning is used commonly in adult critical care in the UK, but less commonly in paediatric intensive care• Nurse-led, protocol-directed ventilation weaning is a complex process, that is impacted upon by organizational processes and structural

factors in an ICU

WHAT THIS PAPER ADDS?

• An insight into paediatric intensive care nurses’ and doctors’ perceptions on nurse-led (protocol-directed) ventilation weaning on a UKPICU

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