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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
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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
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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
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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
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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,
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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
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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
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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
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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.
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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
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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.
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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.
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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.
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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
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7.3.
7.4.
from the study subjects before the collection of data.
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