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Difficult to wean patients: cultural factors and their impact on weaning decision-making

Authors

  • Kalliopi Kydonaki MSc, PhD, RN,

    Research Fellow, Corresponding author
    1. Critical Care Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
    • Correspondence: Kalliopi Kydonaki, Research Fellow, Critical Care Research Group, Royal Infirmary of Edinburgh, Chancellor's Building, GU 309, 49 Little France Crescent, Edinburgh EH16 4SB, UK. Telephone: +44 (0)131 2429453.

      E-mail: claire.kydonaki@ed.ac.uk

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  • Guro Huby PhD,

    Honorary Fellow
    1. School of Health in Social Science, University of Edinburgh, Edinburgh, UK
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  • Jennifer Tocher MSc, PhD, RN

    Lecturer, Nursing Studies
    1. School of Health in Social Science, University of Edinburgh, Edinburgh, UK
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Abstract

Aims and objectives

To examine the elements of the intensive care environment and consider the impact on nurses' involvement in decision-making when weaning from mechanical ventilation.

Background

Optimal management of difficult to wean patients requires the dynamic collaboration of all clinicians and the contribution of their knowledge and skills. The introduction of weaning protocols has increased nurses' input in decision-making, but there are various elements of the decision environment that impact on their involvement, which have been given little consideration.

Design

Ethnography was used as the research design for this study.

Methods

Fieldwork took place in two tertiary hospitals in Greece and Scotland for five months each to unveil clinicians' behaviour and interactions during the weaning practice. Observation was based on the weaning process of 10 Scottish and 9 Greek long-term ventilated patients. Semi-structured interviews followed with nurses (= 33) and doctors (= 9) in both settings to understand nurses' perceived involvement in weaning decision-making. Thematic analysis of interviews and field notes followed using the Qualitative Data Analysis software NVivo. Clinicians' participation was voluntary.

Results

The main themes identified were the (1) organisation of the units (time and structure of the ward rounds, staff levels and staff allocation system), (2) the inter- professional relationships, (3) the ownership and accountability in weaning decision-making and (4) the role of the weaning protocols. These elements described the culture of the ICUs and defined nurses' role in weaning decision-making.

Conclusions

Clinical decision-making is a multi-dynamic process specifically in complex clinical situations such as weaning from mechanical ventilation. This paper suggests that weaning practice should be considered in relation to the elements of the clinical environment to provide an individualised and patient-centred weaning approach.

Relevance to clinical practice

Methods to enhance nurses' role in teamwork and collaborative decision-making are suggested.

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