American Journal of Critical Care. 2007;16: 445-446
Copyright © 2007 by the American Association of Critical-Care Nurses.
Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attendees review and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General and specific questions such as those outlined in the "Discussion Points" box aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 434–443, consider the questions and discussion points outlined in the "Discussion Points" box. Visit www.ajcconline.org to discuss the article online.
Evidence-Based Review and Discussion Points
By
Ruth Kleinpell, RN, PhD.
Ruth Kleinpell is contributing editor of the Evidence-Based Review section. She is a professor in the Rush University College of Nursing, a teacher-practitioner at the Rush University Medical Center, and a nurse practitioner with Our Lady of the Resurrection Medical Center, Chicago, Ill.
This study, "Decisions Made by Critical Care Nurses During Mechanical Ventilation and Weaning in an Australian Intensive Care Unit," by Rose and colleagues, reports on a 3-month prospective cohort study of 474 patients admitted to a medical-surgical intensive care unit (ICU) in Australia. The study assessed the role of Australian critical care nurses in decision making regarding mechanical ventilation and weaning. Sixty-seven percent of the patients (n=319) received mechanical ventilation during the 81-day study period. A total of 3986 ventilation and weaning decisions were made including ventilator setting changes as well as adjustments to rate or pressure support, tidal volume, positive-end expiratory pressure, and fraction of inspired oxygen. Nurses made 64% of decisions, physicians made 17%, and 19% were made collaboratively.
The results of the study demonstrated high levels of responsibility and autonomy of critical care nurses in decision making regarding mechanical ventilation and weaning.
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Information From the Authors
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Louise Rose, MN, Adult Ed Cert, BN, ICU Cert, lead author of this EBR article, reports that the study was conducted to provide information on Australian nurses’ roles in managing patients on mechanical ventilation, something that is lacking in the literature. "There are no specific guidelines or practice outlines in existence regarding mechanical ventilation," she says. "The ICU admits a heterogeneous group of patients from medical to surgical to trauma, which means that generic practice guidelines may be difficult to apply."
Rose also explains that "nurses receive substantial education on ventilation and weaning, both as part of a formal 12-month tertiary qualification (held or being obtained by the majority of staff) and less formal clinical and bedside education, which is provided by senior staff members and staffed by 4 full-time nurse clinical educators." Decision making by the nurses and physicians varied by diagnosis. "There was a difference in the profile of decision making," Rose says. "Patients with primary respiratory disease had more collaborative decision making and patients with increased severity of illness experienced more medical decision making."
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Implications for Practice
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Although there are differences between Australian and American ICUs, the results have implications for all clinicians. "Mechanical ventilation is associated with increased complications if applied inappropriately. Identification of ways to introduce more efficient weaning methods is an international research priority. Studies of weaning protocols conducted in North America have disparate results; the most recent study by Krishnan et al1 found no significant reduction in the duration of weaning and attributed this to the organizational structure of their ICU.
"This ICU operated with a closed medical model and high levels of physician staffing," Rose continues. "The ventilation and weaning methods described in the study were conducted in an ICU with a similar closed medical model and significant collaboration and input from ICU nurses into the ventilatory processes. Staff from North American ICUs may be interested in the description of this ICU model and the ventilatory practices as an alternative to existing models of practice."
These Australian ICU nurses had both high levels of responsibility for managing patients on mechanical ventilation and autonomy in decision making regarding ventilator management and weaning. "When adequately educated and experienced, nurses can play an essential role in the management of ventilation and weaning," Rose asserts.
Another difference between US and Australian ICU care is that the nurse to patient ratio is often 1 to 1 in Australia. "I think a 1 to 1 nurse to patient ratio may increase the frequency of decision making. However, this ratio has to be placed in the context of the ICU organizational system. Although a 1 to 1 nurse to patient ratio is maintained, there are very few other allied health professionals employed in the unit; in particular, there are no respiratory therapists, as this professional group does not exist in Australia."
This research may lead to additional related studies. "We did not directly examine the factors of work experience characteristics because these are issues for further study," Rose notes. "However, in this ICU at this time, 75% of the nurses held a tertiary level postgraduate qualification in the intensive care specialty." Readers of the American Journal of Critical Care can use the information from the study to inform nursing practice. "This information may inform future debates on nursing scope of practice and ICU organizational structure," she concludes.
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Investigator Spotlight
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Louise Rose
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This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.
What role do nurses play in ventilator management and weaning practices? Louise Rose, this study’s lead investigator, notes that her research team identified a gap in the literature, and thus decided to conduct the study to provide information on nurses’ role in ventilator management and weaning.
"The study was set up because we had the impression that practice in this ICU differed from international descriptions of ventilation practices," she notes. "Little existed in the scientific literature on Australian ventilatory practices and even less on the role of critical care nurses in ventilation and weaning in the absence of protocols."
Several challenges emerged for the research team, including the difficulty of collecting data over a 24-hour period. "Collection of data over a 24-hour period in a 24-bed ICU was especially difficult. As the study’s primary investigator, I visited the unit every morning and afternoon 7 days a week to try to monitor and improve compliance with bedside data collection. Changes in ventilator settings could be identified from the bedside chart to determine compliance with data collection. However, the indication or decision responsibility could not be determined if it was not documented correctly by the bedside nurse, so I worked to ensure proper documentation."
Despite these and similar challenges, the team was able to collect the required data on all ventilated patients during the study period. To those nurses seeking to conduct research in their hospitals, Rose offers the following piece of advice: "Ongoing communication, enthusiasm, and encouragement are needed for any clinical study. Remember that the research project may not be perceived to be as important to the bedside clinician as it is to the investigators, but I would advise prospective researchers not to be offended by that!"
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Discussion Points
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- Description of the Study
What was the purpose of the study?
- How were patient ventilation and weaning decision episodes identified?
- Literature Evaluation
- What previous research has been conducted examining nurse decision making on ventilator management or weaning issues?
- Sample
- How were patients identified for inclusion in the study?
- Methods and Design
- How were the clinical decisions made by the nurses regarding ventilator management and weaning identified and classified?
- How were decisions categorized as exclusively nursing, exclusively medical, or collaborative?
- Results
- What were the findings of the research?
- What were the categories that had the highest number of decisions made exclusively by nurses for ventilator management and weaning decisions?
- Clinical Significance
- What are the implications of this study for clinical practice?
eLetters
Now that you’ve read the EBR article and accompanying features, discuss them with colleagues. To begin an online discussion using eLetters, just visit www.ajcconline.org, select the article in its full-text or .pdf form from the table of contents, and click "Respond to This Article" from the list on the right side of the screen. All eLetters must be approved by the journal’s coeditors prior to publication.
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REFERENCE
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- Krishnan JA, Moore D, Robeson C, Rand CS, Fessler HE. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med. 2004;169(6):673–678.[Abstract/Free Full Text]
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Information From the Authors
Implications for Practice
