Understanding nurses’ decision-making when managing weaning from mechanical ventilation: a study of novice and experienced critical care nurses in Scotland and Greece.

Aim and objectives To examine how nurses collect and use cues from respiratory assessment to inform their decisions as they wean patients from ventilatory support. Background Prompt and accurate identification of the patient's ability to sustain reduction of ventilatory support has the potential to increase the likelihood of successful weaning. Nurses' information processing during the weaning from mechanical ventilation has not been well-described. Design A descriptive ethnographic study exploring critical care nurses' decision-making processes when weaning mechanically ventilated patients from ventilatory support in the real setting. Methods Novice and expert Scottish and Greek nurses from two tertiary intensive care units were observed in real practice of weaning mechanical ventilation and were invited to participate in reflective interviews near the end of their shift. Data were analysed thematically using concept maps based on information processing theory. Ethics approval and informed consent were obtained. Results Scottish and Greek critical care nurses acquired patient-centred objective physiological and subjective information from respiratory assessment and previous knowledge of the patient, which they clustered around seven concepts descriptive of the patient's ability to wean. Less experienced nurses required more encounters of cues to attain the concepts with certainty. Subjective criteria were intuitively derived from previous knowledge of patients' responses to changes of ventilatory support. All nurses used focusing decision-making strategies to select and group cues in order to categorise information with certainty and reduce the mental strain of the decision task. Conclusions Nurses used patient-centred information to make a judgment about the patients' ability to wean. Decision-making strategies that involve categorisation of patient-centred information can be taught in bespoke educational programmes for mechanical ventilation and weaning. Relevance to clinical practice Advanced clinical reasoning skills and accurate detection of cues in respiratory assessment by critical care nurses will ensure optimum patient management in weaning mechanical ventilation

COSMOS - Congestion management strategies and methods in urban sites.

The paper describes the strategies for Congestion and Incident Management (CIM) on the basis of Automatic Congestion and Incident Detection (ACID) that COSMOS will develop, implement in SCOOT, UTOPIA and MOTION, and validate and demonstrate in London, Piraeus and Torino. Four levels of operation were defined for CIM: strategies, tactics, tools and realisation. The strategies for CIM form the top level of this hierarchy. They have to reflect the strategic requirements of the system operators. The tactics are the means that can be employed by the strategies to achieve particular goals in particular situations. The tools that are used by the tactics relate to the elements of the signal plan and the ways in which they can be modified. Strategies, tactics and tools are generally common to all three systems, while the realisation of individual strategies and tactical decisions, through the use of particular common sets of tools, will generally be system specific. For the covering abstract, see IRRD 490001.