The impact of nurse-directed protocolised-weaning from mechanical ventilation on nursing practice: A quasi-experimental study

Background:
Internationally, nurse-directed protocolised-weaning has been evaluated by measuring its impact on patient outcomes. The impact on nurses’ views and perceptions has been largely ignored.

Aim:
To determine the change in intensive care nurses’ perceptions, satisfaction, knowledge and attitudes following the introduction of nurse-directed weaning. Additionally, views were obtained on how useful protocolised-weaning was to practice.

Methods:
The sample comprised nurses working in general intensive care units in three university-affiliated hospitals. Nurse-directed protocolised-weaning was implemented in one unit (intervention group); two ICUs continued with usual doctor-led practice (control group). Nurses’ perceptions, satisfaction, knowledge and attitudes were measured by self-completed questionnaires before (Phase I) and after the implementation of nurse-directed weaning (Phase II) in all units.

Results:
Response rates were 79% (n=140n=140) for Phase 1 and 62% (n=132n=132) for Phase II. Regression-based analyses showed that changes from Phase I to Phase II were not significantly different between the intervention and control groups. Sixty-nine nurses responded to both Phase I and II questionnaires. In the intervention group, these nurses scored their mean perceived level of knowledge higher in Phase II (6.39 vs 7.17, p=0.01p=0.01). In the control group, role perception (4.41 vs 4.22, p=0.01p=0.01) was lower and, perceived knowledge (6.03 vs 6.63, p=0.04p=0.04), awareness of weaning plans (6.09 vs 7.06, p=0.01p=0.01) and satisfaction with communication (5.28 vs 6.19, p=0.01p=0.01) were higher in Phase II. The intervention group found protocolised weaning useful in their practice (75%): this was scored significantly higher by junior and senior nurses than middle grade nurses (p=0.02p=0.02).

Conclusion

We conclude that nurse-directed protocolised-weaning had no effect on nurses’ views and perceptions due to the high level of satisfaction which encouraged nurses’ participation in weaning throughout. Control group changes are attributed to a ‘reactive effect’ from being study participants. Weaning protocols provide a uniform method of weaning practice and are particularly beneficial in providing safe guidance for junior staff.

Do pigs form preferential associations?

This investigation examined whether pigs form long-term preferential associations or ‘friendships’ and factors that may influence the formation of these relationships. Thirty-three pigs from 16 litters were housed together from 4 weeks of age. At 10 weeks they were split into two groups of 16 and 17 pigs and each introduced into 3.05 m × 3.66 m observation pens (1st pen). At 17 weeks the two groups swapped pens (2nd pen). The lying patterns of each group were recorded over 3 weeks in both the 1st and 2nd pens. To identify dyads with preferential associations, association indices were calculated for each pair based on their lying patterns and analysed using SOCPROG1.3 and the permutation method [Whitehead, H., 1999. Programs for analysing social structure. SOCPROG 1.2, http://is.dal.cal/~whitelab/index.htm]. Dyads with high association indices for at least 2 out of 3 weeks in either pen, i.e. =0.10 (twice the mean), were classed as having preferential associations. Mantel tests were used to examine the relationship between the relative sex, weight, familiarity and relatedness of a dyad and their level of association and to examine consistency of associations between pens. The existence of preferential associations was identified in both groups, since the standard deviations for the observed half-weight association index means were significantly higher than for the randomly permuted half-weight association index means (P < 0.001). Of the 33 pigs observed, 32 formed preferential associations with one or more pigs in their group, resulting in 50 dyads. Only six dyads (12 pigs) formed preferential associations in both pens, suggesting that the remaining dyads either formed short-term associations only or were simply displaying a shared preference for the same lying location. Levels of association between pens showed no significant correlation. The relative sex, weight, familiarity and relatedness of dyad members also showed no significant correlation with their level of association. These findings suggest that unrelated pigs are capable of forming preferential associations. However, it is unclear whether such associations are widespread or important to pigs, since most dyads’ preferential associations were not consistent between pens.

An evaluation of protocolised weaning on the duration of mechanical ventilation

Using a before and after study design, we compared protocolised weaning from mechanical ventilation with usual non-protocolised practice in intensive care. Outcomes (duration of mechanical ventilation, duration of intubation, intensive care stay) and complications (re-intubations, tracheostomy, mortality) were compared between baseline (Phase I) and following implementation of protocolised weaning (Phase II). Over the same period, we collected data in a second (reference) unit to monitor practice changes over time. In the intervention unit, outcomes were longer in Phase II compared with Phase I (all p < 0.005). When adjusted for admission APACHE II score and diagnostic category, only intensive care stay remained significantly longer (p = 0.002). There were significantly more tracheostomies in Phase II (p = 0.004). The reference unit demonstrated no statistically significant differences in study outcomes or complications between Phases. Protocolised weaning did not reduce the duration of mechanical ventilation and was not associated with an increased rate of re-intubation or intensive care unit mortality.