A STUDY TO ASSESS THE KNOWLEDGE REGARDING WEANING

THE CRITICALLY ILL PATIENT FROM MECHANICAL

VENTILATION AMONG ICU NURSES AT SELECTED HOSPITAL IN

BANGALORE

M.Sc.Nursing Dissertation Protocol Submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Banglore

By

Miss. Mamta Thapa

M.Sc.Nursing 1st year

2011-2013

Under the Guidance of

HOD, Department of Medical-surgical Nursing

Nightingale College of Nursing

Guruvanna Devara Mutt, Near Binnystone Garden

Banglore - 560023

0

RAJIV GHANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA

CURRICULUM DEVELOPMENT CELL

ANNEXURE-2

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERATION

1. NAME OF THE CANDIDATE AND

ADDRESS

MS MAMTA THAPA

1 YEAR MSC.NURSING NIGHTINGALE

COLLEGE OF NURSING GURUVANNA

DEVARA MUTT, NEAR BINNYSTON

GARDEN MAGADI ROAD

BANGALORE-23

2. NAME OF THE INSTITUTION NIGHTINGALE COLLEGE OF NURSING

GURAVANNA DEVARA MUTT,

MAGADI ROAD BANGALORE.

3. COURSE OF STUDY AND SUBJECT MSC NURSING IN MEDICAL SURGICAL

NURSING

4. DATE OF ADMISSION TO THE

COURSE

04/05/2011

5. TITLE OF THE TOPIC

A STUDY TO ASSESS THE KNOWLEDGE REGARDING WEANING THE

CRITICALLY ILL PATIENT FROM MECHANICAL VENTILATION AMONG ICU

NURSES AT SELECTED HOSPITAL IN BANGLORE

1

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

The trouble with always trying to preserve the health of the body is that it is so difficult

to do without destroying the health of the mind. -G.K. Chesterton

Advanced technology is a major part of the ICU and mechanical ventilation (MV) is

one of the most commonly used treatment modalities in the care of the critically ill

patient.1 Up to 90% of patients globally require mechanical ventilation (MV) during

some or most part of their stay in the ICU.2 Mechanical ventilation (MV) is a key

component in the care of critically ill and injured patients. Delays in weaning the

patient from MV increase the number of complications and may lead to increased

expenditure. Consequently, weaning constitutes a major challenge for the intensive care

staff. It is important to wean the patient from MV as expeditiously as possible. Several

studies indicate that the implementation of nurse-led, protocol-directed weaning reduces

the amount of time spent on MV, the length of ICU stay, and associated costs.3

Mechanical ventilation is often life-saving procedures, but constitutes an expensive

treatment modality which is associated with iatrogenic complications such as ventilator-

associated pneumonia (VAP) and ventilator-induced lung injury, which can lead to the

development of the Acute Respiratory Distress Syndrome (ARDS) and increased

mortality and morbidity.4 The reasons for initiating MV are diverse. The most common

reasons for initiation of MV are described as follows: pneumonia/acute lung injury

(33.2%), chronic obstructive pulmonary disease (9.7%), cardiogenic pulmonary oedema

(5.2%), neurological emergencies (16.9%), post-operative complications (24%) and

cardiopulmonary arrest (11%).5

The time used versus time available for weaning ratio represents a new way of reporting

the weaning status and process at an organizational level. Although various patient and

systemic factors were linked to weaning activity, the most important factor was whether

the intensive care unit nurse’s made use of time available. It showed that weaning

frequently was given low priority despite being an essential part of care of the

2

mechanically ventilated patients.6 It is vital for intensive care nurses to deliver high

quality care to the critically ill patient using relevant technologies but also incorporating

psychosocial care measures. This balance is often one of the largest challenges facing

by nurses in the intensive care environment. For this reason, intensive care nurses need

to determine the unique interventions that will positively impact on the mechanically

ventilated patient and assist in the patient’s progression toward desired outcomes.7

Our geographical isolation often results in difficulty recruiting experiences critical care

nurses. This combined with global nursing shortage, results in hiring and educating new

graduates or nurses with no critical care experience. Even experienced critical care

nurses have belief that there is an increased risk of error if a standardized approach is

not followed.8

Critical care nurses’ skill level is dependent upon their knowledge, experience of, and

exposure to, critically ill patients.9 Nurses can improve patient recovery by skilled and

timely reduction of sedation as well as weaning from ventilation. The skilled critical

care nursing will reduce the risk of complications, the number of critical care bed days

and improve patient outcomes. Nurses’ is key provider of information to patients,

relatives and other members of the interdisciplinary team.R O Y A L C O L LE O F N U R S I N G

NEED FOR STUDY

Mechanical Ventilation (MV) is one of the core components of supportive therapy for

critically ill patients and is often lifesaving. But its application may lead to numerous

types of lung injury, known as ventilator-induced lung injury (VILI).10 Caring for a

patient who needs MV requires sound knowledge of MV and pulmonary physiology.

Understanding the basics of MV can make all the difference for your patient. Critical

care nurses assume an increasingly important role in the early identification of

complications. Critical care nurses can identify subtle changes in a patient’s clinical

3

6.1. status and initiate appropriate nursing interventions rapidly and effectively.

Translating research into practice is essential in providing care that promotes both cost-

efficient and effective health care delivery. Nurses practicing in the intensive care unit

are in need of education that can build research self-efficacy and promote understanding

and the ability to apply research findings. The critical reading of research publications

plus course with intensive care unit nurses showed that using a course along with

mentors may increase the research self-efficacy of practicing nurses.11

Responsibilities of critical care nurses for management of mechanical ventilation may

differ among countries. Organizational interventions, including weaning protocols, may

have a variable impact in settings that differ in nursing autonomy and interdisciplinary

collaboration. Critical care nurses have high levels of responsibility for, and autonomy

in, the management of mechanical ventilation and weaning. Revalidation of protocols

for ventilation practices in other clinical contexts may be needed.12 Critical care nurses

are responsible for the majority of the decision episodes that resulted in a change to

ventilator settings, ranging in complexity from the simple titration of FIO2 to a decision

to commence weaning.

Mechanical ventilator weaning is a process of continuous communication between

nurses and physicians, constituting a process of experimentation where actions are not

always preceded by articulated goals. The process of weaning is dependent upon mutual

adjustment among decision makers but this process is hampered by the lack of common

understanding of implicit norms for action.13 Nurses lack formal competencies in

relation to mechanical ventilation, and the formal competencies do not increase as the

qualifications increase, but there is an acceptance that nurses' informal competencies

increase with experience. Critical care education for nurses is not mandatory, and the

education is viewed by many as a reward rather than a prerequisite for work in critical

4

care.

Competence is currently assumed on successful completion of a nursing qualification. It

is recognized that not all nurses function at the same level of expertise and knowledge,

and therefore there is always a risk of nurses acting in ignorance. If nurses do not have

adequate knowledge on which to base decision-making, patients in ICU may be

exposed to unsafe practices leading to complications, increased length of ICU stay,

increased morbidity and mortality and the possibility of litigation, as nurses are

accountable for all their actions.

There appeared to be lack of knowledge of nurses working in ICU/CCU with regard to

weaning from mechanical ventilation. Nurses’ knowledge regarding weaning a patient

from mechanical ventilation needs to be up to date in order to facilitate the process. As

mechanical ventilation is a cornerstone of managing the critically ill patient and in view

of the fact that it has numerous complications as discussed earlier, it is imperative that

nurses caring for these patients are in possession of an adequate level of knowledge

regarding MV and weaning modalities to ensure patient safety and optimum treatment.

Prompt weaning from mechanical ventilation will also contribute to decreased length of

stay in the ICU. If these casual observations are taken into account, it is obvious that the

area of weaning the critically ill patient from mechanical ventilation needs further

exploration.

REVIEW OF LITERATURE

INTRODUCTION

Review of literature is a key step in the research process. Literature review is an

extensive, exhaustive and systematic examination of publications, relevant to the

research project. It is an important source for development of research problem and

provides information of what has been done previously. It helps the researcher to be

familiar with the existing studies and also provides basis for research. The major goals

of review of literature are to develop a strong knowledge base to carry out research and

non-research activity. The review of literature for the present study will be done on care

of mechanically ventilated patients among nurses from published articles, textbooks,

5

6.2. reports, newspapers, pub-med and internet search. The reviewed publications have been

organized and presented as follows.

The cost of providing care to critically ill patients in the United States consumes

roughly 15% of all health care dollars. Contributing to this economic burden are

patients admitted to the intensive care unit (ICU) who require mechanical ventilation

and patients with complications from their dependence on this technology. In fact, 50%

of ICU patients receive mechanical ventilation.14

SECTION A: NURSES KNOWLEDGE REGARDING WEANING

Successful mechanical ventilation requires a basic understanding of respiratory

physiology and ventilator mechanics in addition to intensive nursing care. The type of

breath delivered by a ventilator is determined by the combination of variables set by the

operator. This combination of settings is known as a mode. The choice of appropriate

ventilator settings is largely influenced by underlying disease process and usually

requires some trial and error for each patient. Nurses should have knowledge regarding

ventilator terminology and settings, patient setup, monitoring, and some of the common

complications associated with mechanical ventilation.15

Critical care nurses have a high level of responsibility and autonomy for mechanical

ventilation and weaning practices and therefore require in-depth knowledge of

ventilator technology, its clinical application and the current evidence for effective

ventilation strategies. Lung protective ventilatory strategies are not consistently applied

and weaning and extubation continue to be delayed. Critical care nurses play a vital role

in the recognition of patients capable of spontaneous breathing and ready for

extubation. Critical care nurses need to establish a strong knowledge base to promote

effective and appropriate management of patients requiring mechanical ventilation.16

The professional nurses lack knowledge regarding weaning the critically ill patient from

mechanical ventilation. The professional nurses do not have adequate knowledge

6

related to the underlying indications that need to be resolved prior to commencing

weaning in the critically ill patient. Issues pertaining to withdrawal of ventilator

support, when weaning should be considered successful, the role of NIPPV in weaning

as well as the endpoints of the final stages of weaning revealed a lack of knowledge.17

Knowledge of nurses, both ICU trained and non-ICU trained, working in the ICUs of

three public and two private hospitals was found to be lacking in the three care areas

tested in this study, namely pain management, glycaemic control and weaning from

mechanical ventilation. The difference in knowledge between ICU trained and non-ICU

trained nurses was statistically significant but relatively small. A weak correlation was

found between level of knowledge and years of ICU experience. 18

Internationally, nurse-directed protocolised-weaning has been evaluated by measuring

its impact on patient outcomes. 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. Weaning protocols provide a uniform

method of weaning practice and are particularly beneficial in providing safe guidance

for junior staff.19

A study was conducted on “evidenced-based practice: use of the ventilator bundle to

prevent ventilator associated pneumonia” among critical care nurses regarding

knowledge about the use of the ventilator bundle to prevent ventilator associated

pneumonia. The study concluded that, education sessions designed to inform nurses,

about the ventilator bundle and its use to prevent ventilator-associated pneumonia, have

a significant effect on participants, knowledge and subsequent clinical practice.20

An overall total of 3986 decisions on mechanical ventilation and weaning were

identified, a median of 6 decisions per patient per day of mechanical ventilation.

Among the recorded decisions, 2538 (64%) were made exclusively by nurses, 693

(17%) were made exclusively by medical staff, and 755 (19%) were made by

collaboration. In the collaborative decisions, the patient’s bedside nurse discussed the

situation with a medical colleague and nursing input was considered and used in the

7

decision making process.21

SECTION B: MECHANICAL VENTILATION ASSOCIATED

COMPLICATIONS

Ventilator-associated pneumonia (VAP) is considered to be an important cause of

infection related death and morbidity in intensive care units. The educational program

involving respiratory therapists and nurses and a self-study module with pre-

intervention and post-intervention assessments, lectures, fact sheets, and posters was

conducted. A focused education intervention resulted in sustained reductions in the

incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and cost of

hospitalization.22

Previous experimental studies have shown that injurious mechanical ventilation has a

direct effect on pulmonary and systemic immune responses. Evidence from

experimental studies suggests that lung over distension during mechanical ventilation

causes or exacerbates lung injury referred as ventilator-induced lung injury (VILI). The

current study supports pathway for the overexpression and release of pro-inflammatory

cytokines during ventilator-induced lung injury. The study also suggests that injurious

mechanical ventilation may elicit an immune response that is similar to that observed

during infections.23

Dyssynchrony may result because mechanical ventilators lack the simultaneous

responsiveness needed for interaction with the dynamic conditions of patients. Patient

ventilator dyssynchrony (PVD) can prolong mechanical ventilation and hospital stay,

and is common yet underappreciated in critically ill patients. Sedation is a common

solution for managing dyssynchrony, but it may not always be the best answer for all

types of dyssynchrony. We can describe the biochemical markers of PVD, through

direct observations and continuous data recordings of heart rate, respiratory rate, end

8

tidal carbon dioxide, and oxygen saturation. Collaborative teamwork will resolve the

identification and treatment of PVD.24

Nosocomial pneumonia (NP), also known as hospital-acquired pneumonia, is a lower

respiratory tract infection that was not present or incubating on admission to hospital. In

critical care units (CCUs) NP is the most common nosocomial infection, with

prevalence rates ranging from 10% to 70%. Ventilator support is a well-known risk

factor for NP; the incidence of NP is 6 to 20 times higher in patients treated with

continuous ventilatory support. Several important deficits in nosocomial pneumonia

knowledge were identified indicating a need for critical care nurses to have greater

exposure to nosocomial pneumonia prevention education, guidelines, and research.25

STATEMENT OF PROBLEM

A study to assess the knowledge regarding weaning the critically ill patient from

mechanical ventilation among ICU nurses at selected hospital in Bangalore.

OBJECTIVES

-To assess the knowledge regarding weaning the critically ill patient from

mechanical ventilation among ICU nurses.

-To develop structured teaching program along with protocol regarding weaning

the critically ill patient from mechanical ventilation among ICU nurses.

-To compare the pre-post knowledge score of weaning the critically ill patient

from mechanical ventilation among ICU nurses.

-To associate demographic variables with pre-post knowledge score of ICU

nurses with selected demographic variables.

HYPOTHESIS

H1:- There will be significant difference in pre-test and post-test knowledge score of

ICU nurses on weaning the critically ill patient from mechanical ventilation.

9

6.3.

6.4.

6.5.

6.6.

H2:-There will be significant association between pre-post knowledge score among

ICU nurses with selected demographic variables (such as; age, qualifications, years of

work experience, trainings).

OPERATIONAL DEFINITIONS

ASSESS

Assess refers to the process of detecting knowledge of ICU nurses regarding weaning

the critically ill patient from mechanical ventilation.

KNOWLEDGE

It refers to correct responses of ICU nurses to the knowledge part of self - administered

questionnaire and express as knowledge score.

NURSES

The word refers to the nursing staff working in ICU ward and acquires knowledge on

the given topics.

MECHANICAL VENTILATOR

Mechanical ventilators are devices that provide ventilation (respirations) for the patient

who are unable to breathe effectively on their own.

ASSUMPTIONS

-Structured teaching program on weaning the critically ill patient from

mechanical ventilation among nurses will improve the quality and safety of

client care.

-ICU nurses should be able to co-relate nursing care of mechanically ventilated

patients with complications.

DE-LIMITATIONS

10

6.7.

6.8.

6.9.

The study is delimited to:

-Nurses working in ICU ward in selected hospital in Bangalore.

-Nurses who are willing to participate.

-The duration of study is one month.

PROJECTED OUTCOME

The pre-set study will help nurses to understand about the ventilator settings and

nursing management regarding weaning mechanically ventilated patient.

MATERIALS AND METHODS

SOURCE OF DATA

The primary data will be collected from nurses working ICU ward in selected hospital.

7.1.1. RESEARCH DESIGN

The research design adopted for this quasi- experimental study is one group pre-test and

post-test design.

RESEARCH APPROACH

The research approach is evaluative approach.

7.1.2. SETTING

The study will be conducted in selected hospital at Bangalore

7.1.3. POPULATION

The population selected in this study include ICU nurses working in selected hospital in

Bangalore.

METHOD OF COLLECTION OF DATA

7.2.1. SAMPLING PROCEDURE

The sampling technique adopted for this study is purposive.

11

7.

7.1.

7.2.

7.2.2. SAMPLE SIZE

The sample size is 60.

7.2.3. INCLUSION CRITERIA

The criteria for sample selection are nurses:

-Who are present at the time of data collection

-Who are willing to participate in the study

-Who are working in ICU ward

7.2.4. EXCLUSION CRITERIA

The criteria for excluding sample are nurses:

-Who are not willing to participate in the study

-Who are on leave at time of data collection

-Who are not working in ICU ward

7.2.5. INSTRUMENT INTENDED TO BE USED

SELECTION OF TOOL

This consists of three parts:

Part-1:- Consist of demographic variables such as age, qualifications, socio-economic

status, years of work experience, training etc.

Part-2:- Self-administered questionnaire will be used to assess the knowledge.

The content of Self-administered questionnaire will be:

-Basic knowledge regarding weaning critically ill patient from mechanical

ventilation.

-Advanced knowledge regarding weaning critically ill patient from mechanical

ventilation.

-Applied knowledge regarding weaning critically ill patient from mechanical

ventilation.

12

Part-3:- Structured teaching program regarding ventilator settings and nursing

management regarding weaning mechanically ventilated patient.

SCORING PROCEDURE

For Knowledge Assessment

For Answers

If answer is yes 1

If answer is no 0

SCORING INTERPRETATION

LEVEL OF KNOWLEDGE RANGE

Adequate knowledge 75-100%

Moderate knowledge 51-74%

In adequate knowledge 50% and below

7.2.6. DATA COLLECTION METHOD

Prior permission will be obtained from the superintendent of the hospital before

conducting the study. Questionnaire will be distributed to the nurses between 10 am-

3pm. Data will be collected 15 samples per day. The duration will be 4 weeks.

Phase-1:- With prior informed consent pre-test will be conducted among nurses

regarding care for mechanically ventilated patients.

13

Phase-2:- The researcher will conduct structured teaching program among nurses

regarding care for mechanically ventilated patients.

Phase-3:- After 3-5 days of conducting structured teaching program among nurses

working in intensive care unit, post-test on knowledge will be conducted among nurses

regarding care for mechanically ventilated patients.

2.7.7. PILOT STUDY

6 Samples will be selected and study will be conducted to find out feasibility.

2.7.8. DATA ANALYSIS PLAN

The data obtained will be analysed in view of the objective of the study using analytic

and inferential statistics.

The plan for data analysis is as follows:

-Means, median and modes, standard derivation is used for assessing the

knowledge score.

-Chi-square test to find out the association between knowledge with selected

demographic variables.

-Frequencies and percentage of distribution will be presented in tables, figures

and graph.

DOES THE STUDY REQUIRED ANY INVESTIGATION OR INTERVENTION

TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?

NO

WAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes, ethical clearance will be been obtained from the research committee of nightingale

college of nursing.

Consent will be taken from the medical superintendent and permission will be taken

14

7.3.

7.4.

from the study subjects before the collection of data.

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14. Marine LP. The ICU Book. 3rd edition. Lippincott’s William & Wilkins: Wolters

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9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1. GUIDE

11.2. SIGNATURE

11.3. CO-GUIDE

11.4. SIGNATURE

11.5. HEAD OF DEPARTMENT

11.6. SIGNATURE

12. 12.1. REMARKS OF THE PRINCIPAL

12.2. SIGNATURE

19