Abstract:

Background:

Prolonged mechanical ventilation is harmful for patients requiring prompt weaning approaches from an interprofessional team with different and overlapping scopes of practice. Nurses play a key role in interprofessional teams, and optimization of their role can reduce the duration of mechanical ventilation.

Purpose: To understand the role of nurses in critical care in healthcare teams when weaning patients from mechanical ventilation.

Methods: Multiple-case study with concurrent mixed methods data collection was conducted in two critical care units following a pilot study in Québec, Canada. A validated and adapted questionnaire, “Survey of Mechanical Ventilation and Weaning Role Responsibilities” was completed by nurses, respiratory therapists, and physicians (n = 102). Interviews (n=49) were conducted with content analysis completed. Descriptive statistics were generated for quantitative data. Rodgers et al. (2016) reporting standards for case studies were used.

Results: Questionnaires showed that nurses had little involvement, autonomy, and influence over decisions related to weaning. However, in interviews, participants described several strategies used by nurses to support patients’ weaning from mechanical ventilation.

Discussion: In the context of this research, the role of nurses in critical care is suboptimal when weaning patients from ventilators, however, in-depth knowledge of patient status, protocols, and education can support optimizing the nurse’s role in the weaning process.

Conclusion: Strategies are needed to optimize the role of nurses in critical care when weaning patients from mechanical ventilation.

Implication for nurses

• A role clarification of nurses in critical care in weaning from mechanical ventilation (WMV), which includes: 1) monitoring patient readiness; 2) promoting WMV; 3) managing the level of wakefulness and comfort levels; and 4) integrating into the WMV process an in-depth knowledge of the patient.
• Nurses in critical care play an articulation role within the healthcare team, including activities to align team members, maintaining continuity of care, and ensuring that, collectively, key activities are in place for the patient’s WMV.
• In-depth knowledge of the patient fosters nurses’ commitment to the optimal execution of their role in critical care and has had a major positive influence on nurses’ roles during WMV.

Keywords: case study, critical care, nurse, nursing scope of practice, weaning from mechanical ventilation, role enactment

Background and purpose

Mechanical ventilation and weaning

Prolonged mechanical ventilation (MV) is associated with complications that increase critical care unit stays, mortality rates, and costs (Zilberberg et al., 2020). Therefore, it is important to perform the required monitoring (assess respiratory parameters, synchronize with ventilator, assess patient comfort, etc.) and promptly implement interventions to facilitate weaning from mechanical ventilation (WMV) (Burns et al., 2021). WMV is a crucial period in critical care, and its success requires the concerted effort of an interprofessional team (Moraes et al., 2022). Weaning from mechanical ventilation (WMV) begins with assessing the patient’s ability to breathe independently and is considered successful if the patient remains extubated for 48 hours. This process involves multiple stages and the coordinated efforts of the healthcare team.

Nurses’ role in the healthcare team

Nurses in critical care units have a leading role in the team during WMV, given their continuous presence and patient monitoring (Paquette & Kilpatrick, 2020; Starnes et al., 2019). When nurses are involved in the weaning process, they reduce the duration of MV and the length of stay in critical care (Gunther et al., 2021; Hirzallah et al., 2019). However, for nurses to effectively assume a leading role in an interprofessional team, they must be able to operate to their full scope of practice. Nonetheless, there is a paucity of research describing the role of nurses in critical care teams during WMV, and where such research exists, the enactment of the nurses’ role in critical care is suboptimal (Burns et al., 2018; Michaud et al., 2021; Paquette & Kilpatrick, 2020).

A professional’s scope of practice encompasses the legal framework dictating the roles, functions, and activities that a professional is authorized to perform based on their training, knowledge, and skills (Almost, 2021). The legal scope can vary in its application (Feringa et al., 2018). Role enactment (RE) reflects professionals’ day-to-day work, considering various factors influencing role execution. Healthcare practitioners aim for an “optimal” scope of practice by effectively carrying out their roles while acknowledging the competencies of other team members (Almost, 2021). Conversely, practicing “below” regulatory standards or a “suboptimal” scope signifies a misalignment between role expectations and scope of practice (Déry et al., 2021).

 Nurses’ scope of practice differs from one country to another, and from one jurisdiction to another within countries (Paquette & Kilpatrick, 2020). In Québec, Canada, little information about the legislative limits of the nurse’s role during WMV is available in the regulations (Durand et al., 2016). Moreover, critical care skills and knowledge are addressed only at the university level and are not assessed during the licensure exam (Ordre des infirmières et infirmiers du Québec (OIIQ), 2022). As a result, nurses entering critical care start with different levels of education and knowledge. National certification is an option but not mandatory for nurses in critical care in Canada. In Québec, less than 2% of nurses in critical care hold their Canadian certification in critical care (M. Marques, personal communication, February 28, 2022).

These elements can alter how nurses enact their role in interprofessional teams regarding WMV. In Québec, interprofessional team members involved in WMV include nurses, respiratory therapists (RTs), and physicians (Institut canadien d’information sur la santé (ICIS), 2016). Other factors influence the enactment of roles in teams, including location (e.g., rural, urban), hospital affiliation (e.g., university or not), nurse-to-patient ratio, team composition, and education (Déry et al., 2016; Paquette & Kilpatrick, 2020; Rose, Blackwood, Burns, et al., 2011).

In countries such as Australia and several European countries, nurses in critical care often adjust the oxygen dose, adjust ventilator parameters and assess the patient’s ability to breathe spontaneously during WMV (Burns et al., 2021; Paquette & Kilpatrick, 2020). Their contribution to these activities highlights the collaborative approach and shared responsibilities between nurses and physicians in these regions (Paquette & Kilpatrick, 2020). However, an international study by Burns et al. (2021) revealed significant discrepancies in the roles of healthcare professionals involved in WMV across different countries. Also, a survey in Canadian hospitals (n = 156) indicated limited nurse involvement in the weaning process, with physicians and RTs taking primary responsibility for adjusting weaning parameters (Burns et al., 2018). In Québec, RTs are qualified to assess patients’ cardiorespiratory status, oversee ventilator management, and administer analgesia or sedation, which overlaps with roles typically assigned to nurses (Durand et al., 2016). The composition and roles within a healthcare team significantly impact nurses’ RE in the context of WMV.  In North America, nurses primarily focus on pain, agitation, and delirium management (Burns et al., 2018; Michaud et al., 2023; Paquette & Kilpatrick, 2020) but the literature also indicates that their involvement in other aspects of their role may be suboptimal, potentially affecting weaning efficiency and patient outcomes.

An integrative review by Michaud et al. (2021) explored the holistic care of ventilated patients to better understand the nurse’s role. The review included 45 primary and secondary sources and identified that managing anxiety, agitation, pain, dyspnea, hygiene, sleep, and environmental noise are key dimensions of the nurse’s role in the care of mechanically ventilated patients. These authors point out that there is little literature on this subject (Michaud et al., 2021). Several authors highlight that the nurse’s assessment is crucial and fundamental for involvement in decisions about WMV. Several authors emphasize the critical role of nurses’ assessments in decisions regarding WMV, facilitated by their continuous bedside presence (Khalafi et al., 2016; Paquette & Kilpatrick, 2020; Tingsvik et al., 2015).

The specific activities of nurses in critical care during WMV require further investigation to understand how their roles are enacted (Burns et al., 2018). Therefore, the purpose of this study was tounderstand how nurses in critical care enact their role in healthcare teams when patients are being weaned from MV.

Methods and procedures

Design

This multiple-case study employed a mixed-methods approach. Data were collected using a questionnaire (cross-sectional study) for the quantitative data and interviews were conducted to capture qualitative insights. According to Yin (2018), case studies aim to explore, describe, and explain a phenomenon of interest comprehensively. They address research problems involving complex contexts and inquire into how and why questions. A mixed-methods approach allows for the collection of data not only pertaining to participants but also the context, minimizing potential bias (Yin, 2018). Each case, as per Yin (2018), is bound by time and defined in this study as the role enactment of nurses in critical care during WMV, involving members of the interprofessional team.

Reporting standards for organizational case studies by Rodgers et al. (2016) were followed. The project obtained approval from the Multicenter Research Ethics Review Board (MP-12-2019-1737), institutional approval from participating sites, and approval from the Ethics Committee for Health Research of the Université de Montréal.

Pilot Study  

            Before the main study, a pilot study refined the data collection tools (Yin, 2018), including cross-cultural validation of the questionnaire using Vallerand’s methodology (1989). Adaptations were made from its previous use in Swiss intensive care units (Rose, Blackwood, Egerod, et al., 2011) to suit Québec’s context (e.g., modes of ventilation, respiratory therapist). Item clarity was evaluated by a panel of experts, including nurses in critical care, a nursing professor, and a respiratory therapist. Subsequently, questionnaires were completed by nurses in critical care (n = 4), RTs (n = 2), and physicians (n = 2). Interviews (n = 4) lasting between 30 and 60 minutes with representatives from each group. These interviews aimed to gauge comprehension of the tool and identify areas for improvement. Additional instructions for answering questions and abbreviations in response items were added to enhance readability and efficiency.

The conceptual framework of role enactment, boundary work, and perceptions of team effectiveness (Kilpatrick et al., 2013) was used to understand how nurses in critical care enact their role in healthcare teams during WMV. RE, changes in professional boundary lines and perceptions of team effectiveness influence one another to support optimal team functioning. Following Yin’s (2018) guidance, the conceptual framework supported all phases of the case study. The framework was refined following a comprehensive literature review and the cross-case analysis.

Sampling: Case selection

Two contrasting cases were chosen based on the different characteristics known to influence the RE of nurses in critical care during WMV (e.g., university affiliation, size, location, open or closed ICU, nurses’ level of education, nurse-patient ratio, and orientation program) (see Table 1). A critical care unit is said to be closed when care is provided by a multidisciplinary team led by a physician.

Participants included nurses, physicians, RTs and other members of the interprofessional team with a direct role during WMV (, nutritionists, physiotherapists). Interprofessional team members, other than nurses, were included to gain insight into nurses’ role enactment during WMV. Nurses’ RE is based on the interplay and interactions with several professional groups (Kilpatrick et al., 2013).

[Table1]

Sample characteristics : Case 1

The healthcare team in Case 1 – 127 nurses, 67 RTs, 13 critical care physicians, residents, and one physiotherapist. The RTs rotated between the critical care unit and other care areas, and physiotherapists are present part-time in the critical care unit. They do passive and active mobilization exercises and help nurses during chair lifts. Physicians and residents conducted daily medical rounds, starting with shorter sessions in the morning and transitioning to more comprehensive rounds later in the day.

For Case 1, 60 questionnaires were returned, with 45% in printed format and 55% completed online. The participation rate was estimated to be 27%. This participation rate was approximate because, to ensure confidentiality, the primary author did not have access to respondent emails. The sample was 87% (n= 47) female for the questionnaire (see Table 2). Nurses represented 46.7% of respondents, with physicians representing 9.3% and RTs 35.2%. The median age was 34.0 years (Q1 = 27.0, Q3 = 46.0). Respondents were licensed to practice for a median of 10.5 years (Q1 = 6.0, Q3 = 17.5) and worked in the critical care unit for a median of ten years (Q1 = 4.8, Q3 = 15.0). More respondents worked part-time (61.1%) compared to those who worked full-time (37.0%). Interview participants (n = 25) were primarily female (68%) and included nurses (n = 11), RTs (n = 5), physicians (n = 3), an interprofessional team member (n = 1), and administrators (n = 5). Regarding the socio-demographic characteristics of interview participants, the median age of 41.0 (Q1 = 32.0, Q3 = 47.0) was slightly higher, and there was a higher proportion of full-time workers (56%). Participants had held their license to practice for longer than the questionnaire respondents (median 14.0 years, Q1 = 7.0, Q3 = 25.5).

Sample characteristics: Case 2

The healthcare team in Case 2 included 69 nurses, supported by a group of 21 RTs who alternated between the critical care unit and the other units. The medical team included five physicians, complemented by a physiotherapist available 20 hours per week onsite. Since the integration of physiotherapists, patients on MV are mobilized and lifted into the chair more frequently. A nutritionist is integrated when parenteral nutrition is required.  Each morning, the assistant head nurse presents a report to respiratory therapists, physiotherapists, and physicians. There are no medical rounds. The physician in charge evaluates each of their patients alone and leaves the critical care unit afterward.

For Case 2 (see Table 2), 42 questionnaires were completed, four (10%) were completed online, with the remainder in print form. (90%). The participation rate was 41.6%, which was also approximated. Among the respondents, 73.8% (n = 31) were female. The sample comprised 66.7% nurses, 11.9% physicians, and 14.3% RTs. The median age was 36.0 years (Q1= 30.0, Q3 = 41.0). Respondents had been licensed for a median of 10.5 years (Q1= 6.0, Q3 =16.25), and the median time on the critical care team was 5.0 years (Q1 =3.0, Q3 =10.0). Most respondents worked full-time (66.7%). Interview participants (n = 24) included nurses (n = 10), RTs (n = 4), physicians (n = 3), members of the interprofessional team (n = 1), and administrators (n = 6). Overall, there were more males (37.5%), full-time employees (79.2%), and participants who had been on the team longer compared to the questionnaire respondents.

[Table 2]

Data collection

Data collection took place between April 2019 and January 2020 and included both a self-questionnaire and interviews.

Questionnaire

The original, validated version of the questionnaire “Ventilation and weaning from mechanical ventilation: tasks, skills, and responsibilities of intensive care nurses” (Rose, Blackwood, Egerod, et al., 2011), once adapted, was distributed. This self-administered instrument includes 45 questions and takes approximately 15–20 minutes to complete. This questionnaire has been used in several studies in adult critical care units in European countries and Australia. Authorization to use the French version had previously been obtained from the primary author. Questions were designed to determine which professional (nurses, RTs, physicians) was making the decisions about mechanical ventilation.

All respondents were asked two questions regarding their perception of nurses’ autonomy and their influence on decisions related to mechanical ventilation. Autonomy is the ability to make decisions about MV and to implement them without direct supervision from a physician (Rose, Blackwood, Egerod, et al., 2011). The perceptions of nurses’ autonomy and their contribution to MV decision-making were measured on separate visual analog scales ranging from 0 (no autonomy or influence) to 10 (full autonomy or influence). A value of seven was considered moderate for autonomy (Rose, Blackwood, Egerod, et al., 2011). A convenience sample of nurses in critical care, RTs, and physicians was constituted in two selected critical care units. The questionnaire was available online or in print. Several strategies were employed to recruit respondents, such as consistent presence on the units during data collection, hand-delivering printed copies or inviting team members to complete online questionnaires, utilizing formats that minimized response burden, and regularly sending reminders (Dillman et al., 2014).

Interviews

Participants were recruited using maximum variation sampling (Yin, 2018). This type of recruitment aims to intentionally select participants to obtain a variety of perspectives. Management teams, comprised of unit manager, medical director, RT manager and clinical consultant  were invited to participate. . Nurses, RTs, physicians, and other members of the interprofessional team were purposively sampled for diversity (Yin, 2018). The inclusion criteria were to hold a permanent position in the hospital and speak French. The exclusion criteria were to hold a temporary position, casuals or work for a private healthcare staffing agency.

Individual interviews were conducted to explore nurses’ RE during WMV. The interview guide was based on the conceptual framework and tested in previous research (Kilpatrick et al., 2016). Questions centered on nurses’ perceptions of their role, their day-to-day practice, and distinctions between their role and those of other professionals engaged in WMV. Similar inquiries were directed towards other healthcare professionals to grasp their perspectives on their role within the team and their views regarding the role of nurses. In both cases, the interviews lasted between 23 and 90 minutes with an average of 45 minutes. The audio recordings were transcribed verbatim. A socio-demographic questionnaire was completed by participants (Kilpatrick et al., 2016).

Data analysis

Data analysis was carried out according to the recommendations of Yin (2018). The first phase consisted of the analysis of the pilot study, followed by the intra-case and cross-case analysis. For each case (intra-case), the quantitative and qualitative data were analyzed separately and integrated at the end of the analysis. For the questionnaire data, descriptive analyses (median, mean, interquartile) were performed for continuous variables and frequencies with percentages for categorical variables (Tabachnick & Fidell, 2019) with SPSS (version 25, 2019). Due to non-normal data distribution, median, and interquartile range were used for interpreting the quantitative results (Tabachnick & Fidell, 2019). Additionally, some sections and questions in the returned questionnaires remained unanswered. However, they were still included in the analysis as they contributed sufficient data to meet the study’s objectives.

Content analysis of the interviews was performed following the method outlined by  Miles et al. (2013). Data from various sources were mapped to describe the cases, enable cross-case comparisons, and identify patterns (Yin, 2018). Each case was comprehensively described to facilitate cross-case analysis (Yin, 2018). A cross-case analysis was carried out using a joint display board, which made it possible to compare the results to find convergences and divergences, understand what may have made the difference in the patterns, and achieve a comprehensive understanding of the phenomenon of interest (Miles et al., 2013). All analyses were performed by the principal investigator (LP) and reviewed by her thesis advisor (KK). A research associate contributed to the statistical analyses.

Rigor

 Yin (2018) recommends four criteria of rigor to examine specific to carrying out case study research. For construct validity, clear conceptual definitions were derived from empirical literature and integrated into the conceptual framework, enhancing the accuracy of coding. The pilot study, diverse data sources, and a chain of evidence bolstered the robustness of the study (Yin, 2018). Internal validity was ensured via data triangulation with a joint display board (Miles et al., 2013), and regular validation of coding, results, and analysis interpretation by the thesis supervisor (Francis et al., 2010). Recruitment continued until data saturation per Francis et al.’s method (2010). Coding fidelity was maintained through investigator-supervisor collaboration, verifying over 10% of textual coding, as recommended by Francis et al. (2010). External validity, specifically analytic generalization (Yin, 2018), was achieved through two cases, supporting phenomena and theory replication, and comparison with existing literature (Miles et al., 2013; Yin, 2018). Reliability was ensured by a priori protocol development, comprehensive documentation, and creation of separate databases for each case  (Yin, 2018).

Findings

Based on the analyses conducted, the RE of nurses during WMV is described as follows: 1) monitoring readiness for WMV; 2) promoting WMV; 3) managing the level of wakefulness and comfort; and 4) integrating in-depth knowledge of the patient. The findings from the cross-case analysis of the two cases are presented with the data sources and illustrative citations from which they emerged.

Nurses’ Role Enactment

As described above, four themes emerged from the cross-case analysis to describe nurses’ RE during WMV. In the presentation of the results, certain terms will be used to illustrate the frequency of a response or an interaction. In the interview results, “majority” refers to 50%-75% of participants, “most” to over 75%, and “few” to a small number (n ≤ 5).

Monitoring readiness for weaning from mechanical ventilation

According to the results of the questionnaire (see Table 3), in both cases, the contribution of nurses in assessment activities, namely the assessment of the patient’s eligibility for WMV, their response to WMV, and whether the patient was ready for extubation, had low recognition among all team members. It was identified that it was the RTs and/or the physicians who carried out these activities. In Case 1, nurses were less involved (46.7%) in assessing the patient’s response to the WMV compared to Case 2 (73.3%), where members of the interprofessional team perceived nurses as primarily responsible for this task. Conversely, in Case 1, RTs were primarily tasked with evaluating the patient’s response to the WMV. More respondents believed that nurses had a role in recognizing that the patient was ready for weaning (Case 1 = 41.7%, Case 2 = 23.8%), ready for extubation (Case 1 = 30%, Case 2 = 11.9%), or had failed to wean (Case 1 = 43.3%, Case 2 = 33.3%) compared to Case 2.   

Interviews with the nurses clarified the results of the questionnaires. It was emphasized that their evaluations during weaning or parameter adjustments were specifically focused on the patient’s response, while RTs primarily reviewed the ventilator data.

[Table 3]

According to almost all questionnaire respondents, nurses did not manage ventilator settings in the context of WMV except to adjust the fraction of inspired oxygen (FiO2). More specifically, the activity in which they demonstrated the most autonomy was the administration of a bolus of FiO2 (see Table 4). During the interviews, in Case 2, nurses reported that they perceived weaning from FiO2 to be part of their contribution to WMV, but not in Case 1.  There were also more RTs in critical care in Case 1 compared to Case 2, and this ensured more availability to modify parameters or reduce the FiO2.

In the interviews, many nurses associated WMV with the manipulation of ventilator parameters. In this regard, WMV was seen as a part of the role of RTs. As a result, when nurses were asked about their role in WMV, they repeatedly hesitated. This was consistent with the results of the questionnaire showing low levels for nurses manipulating ventilator parameters.

[Table 4]

In both cases, the questionnaire responses indicated that nurses perceived that they had low autonomy and little influence on decisions about WMV (Table 5). However, they still perceived a higher level of autonomy than what was perceived by the physicians and RTs. On the other hand, the interviews revealed the opposite, namely that the influence of nurses on the decision to WMV was fundamental to successful weaning. Nurses primarily perceived their autonomy to be related to activities clearly within their scope of practice (e.g., mouth care, respiratory tract suctioning).   

[Table 5]

Interviews provided examples of nurses’ influence on decisions related to WMV by sharing information about the patient with other team members. In Case 1, the nurses were less consulted than in Case 2. Therefore, they had fewer opportunities to voice their opinions or provide information. By contrast, in Case 2, physicians reported that they considered the nurses’ perspective on patient eligibility for WMV and acknowledgment of WMV failure. However, physicians also noted that nurses lacked knowledge of MV, leading them to discuss ventilatory parameters with RTs instead.

For the interviews, the nurses explained that they assessed the patient during WMV by collecting objective parameters, including a complete respiratory assessment, arterial blood gas results, signs of dyspnea, hemodynamic status, fluid balance, etc. Nurses also reported the patient’s assessment such as emotional well-being, comfort levels, dyspnea, etc. Additionally, the nurse’s presence and assessment were also identified as important. A physician shared this component of the nurse’s role: “The repercussions of what we choose to do or not to do, she [nurse] sees in real time” (Phy 1_Case 1).  

Promoting weaning from mechanical ventilation

Nurses interviewed stated that they undertook various activities to promote WMV, such as elevating the head of the bed, mobilizing, positioning to promote lung expansion, rest, optimizing nutritional status, and fluid balance. A difference was noted with ventilator-acquired pneumonia (VAP) prevention activities (e.g., oral care, elevated head of the bed, early mobilization). The nurses interviewed from Case 1 did not associate these activities with VAP. In Case 2, a mnemonic poster for the prevention of VAP was present at the bedside of patients. Nurses also received training on early mobilization and VAP prevention from critical care nursing colleagues. Similarly, the addition of physiotherapists favored more openness to mobilize ventilated patients compared to Case 1. Overall, some activities were identified as part of a routine of care but were not necessarily presented as being related to WMV. One physician described this aspect of the nurse’s role: “So, I think it’s the nurse’s role to stop the weaning process or to try to start it, or to precipitate it” (Phy 2_Case 2). Most participants reported that the management of analgesia, sedation, delirium, and patient comfort is a fundamental aspect of the WMV process.

 Managing the level of wakefulness and comfort

Responses to the questionnaire indicated that management of sedation and analgesia was attributed to nurses in critical care by almost all respondents (Case 1 = 83.3%, Case 2 = 88.1%). This was supported by the interviews in both cases. Managing the level of wakefulness and comfort (assessment, adjustment of medication, management of delirium) was strongly attributed to nurses, but this was also shared with physicians.

In both cases, the interviews revealed that nurses typically awaited instructions from the physicians before reducing analgesia and sedation infusions, despite having target values to achieve on the sedation scale (e.g., Richmond Agitation and Sedation Scale [RASS]). Nurses mentioned the dependence of some colleagues on physicians or RTs to make their decisions. That is, they relied on them instead of being proactive and taking the initiative. Some nurses found that their colleagues were waiting, maintaining the status quo when no initiative for WMV was undertaken: “[…] there is no supervision around WMV; it’s a free-for-all for the respiratory therapist and for the nurse; sometimes, I think that leads to failures” (Adm 3_Case1).

Most interviewparticipants, including nurses, described the critical thinking required to balance the patient’s level of wakefulness with comfort so the patient could breathe independently. Most nurses reported using the RASS scale to assess the patient’s state of wakefulness and sedation, while simultaneously determining the level required of analgesia and sedation. Nurses’ management of delirium was discussed in both cases, but there was no mention of the use of a validated scale (e.g., The Confusion Assessment Method for the Intensive Care Unit [CAM-ICU]). Nurses identified preventive activities to reduce the risk and duration of delirium, including reassurance, reorientation, facilitation of sleep periods, and family inclusion.

Several interview participants, including nurses, RTs, and physicians, also described nurses supporting patients during WMV, providing encouragement, assisting with breathing control, and alleviating anxiety. Through their presence and the development of a bond of trust, nurses supported patients (e.g., maintaining alertness, and encouraging breathing) and aimed to avoid the excessive use of deep analgesia-sedation. Some nurses cited the inclusion of the family to reduce anxiety. The following excerpt presents one nurse’s perception of this aspect of her role: “[…] if you really want to push on spontaneous ventilation, you think about giving perhaps the minimum of analgesia, not to minimize the effect of sedation and having put him [patient] too far to sleep and he’s no longer breathing” (Nur 9_Case1).

Integrating in-depth knowledge of the patient

In both cases, the significance of acquiring a profound understanding of the patient was underscored by all professionals who participated in the interviews. This activity entails building a comprehensive picture of the patient as an individual and knowledge about the family or significant others. Interview participants from the other professional groups agreed that nurses knew the patient best and thus have a pivotal role as well as being a reference for all team members. Nurses integrate this in-depth knowledge to personalize the WMV process. According to many nurses, the patient-centered approach serves as a driving force, fostering their commitment to their role. This perspective enables them to actively participate in decision-making and discussions, particularly in setting care objectives. Many nurses described “being there” for the patient and representing their interests within the team to promote WMV, as described in the following excerpt: “We have a global vision and not just a respiratory one […]. We have a different vision because we touch on all the patient’s systems […] the family too […]” (Nur 3_Case 2).

Discussion 

In this multiple-case study, nurses performed a range of activities to assess readiness for weaning from mechanical ventilation, including monitoring objective parameters and patient data. They conducted activities to promote weaning from mechanical ventilation (e.g., early mobilization, prevention of VAP). Nurses completed activities related to the assessment and management of pain, sedation, delirium, and WMV. The importance of knowing the patient was emphasized. This activity consisted of developing a body of knowledge about the patient, understanding the patient’s condition and treatment response, and knowing the patient as a “person” (Tingsvik et al., 2015).

Our findings suggest that nurses enact their role sub optimally when weaning patients from mechanical ventilation, especially compared to reports in international literature (Michaud et al., 2021; Paquette & Kilpatrick, 2020). Minimal nurse participation across various aspects of their role in WMV, including identifying eligibility, conducting spontaneous awakening trials, and adjusting ventilator settings were identified (Alkhathami et al., 2023; Burns et al., 2021).

Nurses are not adequately recognized in this area of practice, thus limiting the contribution they could offer. This could be explained by a lack of role clarity and limited knowledge of the comprehensive scope of nursing roles, training, and skills required for practice in critical care (Déry et al., 2021; Feringa et al., 2018). Internationally, researchers have found that nurses face limited role enactment, a lack of role clarity, and inadequate interpretation of nurses’ scope of practice (Déry et al., 2021; Feringa et al., 2018). Nurses tend to construct their role through experience rather than through a clear understanding of their scope of practice (Feringa et al., 2018). As a result, nurses may base their decisions more on their skills and knowledge rather than consciously adhering to their regulatory scope of practice (Feringa et al., 2018). Furthermore, Jansson et al. (2019) surveyed nurses in critical care (n = 85 nurses) in Finland and highlighted that role ambiguity among nurses stemmed from unclear expectations and organizational variations in weaning practices.

Nurses in our study described having limited autonomy in performing activities within their scope of practice because they depended on medical guidance. In addition, nurses were not involved in decision-making to the extent expected according to their scope of practice, the level of competency of nurses in critical care, and other members of the interprofessional team (Association des infirmières et infirmiers du Canada (AIIC), 2017; Danielis et al., 2020). These results were identified by Alkhathami et al. (2023) also using the questionnaire developed by Rose, Blackwood, Egerod, et al. (2011). These authors reported low nurse involvement in critical decisions, limited autonomy, and little confidence in their ability to manage MV (Alkhathami et al., 2023).

Most nurses in our study were not involved in WMV as they perceived it to be the responsibility of RTs, viewing these tasks as outside of their scope of practice  (Alkhathami et al., 2023). Their activities during WMV are intertwined with those of other healthcare professionals, including mobilization, spontaneous breathing trials, and medication adjustments (Balas et al., 2019; Boehm et al., 2016). Larsen et al. (2022) noted the difficulty in distinguishing the independent contributions of nurses from medical treatment. Consequently, nurses often define their role in WMV based on the responsibilities of other professionals rather than their defined scope of practice.

Clear role delineation among team members is essential for effective teamwork and high-quality patient care (Kilpatrick et al., 2021). However, Boehm et al. (2016) highlighted misunderstandings about the nursing role during WMV among other professionals and a lack of nurses’ understanding of other team members’ roles. This mutual understanding is vital due to the interdependent nature of tasks involved in WMV (Boehm et al., 2016).

The study highlighted the role of nurses in “articulation” work within the healthcare team, which involves aligning team members, maintaining continuity of care, and ensuring comprehensive patient coverage during WMV (Postma et al., 2015). Articulation work encompasses nurses’ deliberate efforts to connect their actions with patient needs, the responsibilities of each team member, task execution, and specific factors like unit workload and staffing. It serves to facilitate the overall WMV process by effectively coordinating various aspects of patient care. Articulation work is central to nurses’ roles, promoting a holistic and individualized approach to WMV (Cederwall et al., 2018). It leads to more holistic care and nurses’ involvement across the continuum of care during WMV (Paquette et al., 2018; Tingsvik et al., 2015). This process is important because it is grounded in an in-depth understanding of patient needs and a clear comprehension of the nurse’s role, leading to better care across the continuum during WMV (Cederwall et al., 2018; Postma et al., 2015).

Recommendations

The use of protocols or checklists to support the nurses’ RE during WMV is widespread and effective (Gunther et al., 2021; Hirzallah et al., 2019; Starnes et al., 2019). A combination of strategies is suggested, including decision support tools, reminders using posters or annotations via technological devices (e.g., intervention packages for ventilator-associated pneumonia or MV care), short informal teaching activities, and on-site champions as resource persons (Jansson et al., 2019). These supports guide nurses through various WMV-related activities and help to clarify their role (Gunther et al., 2021). Both the acquisition of knowledge related to MV and its weaning as well as experience favor a more optimal enactment of nurses’ role (Jansson et al., 2019). Educational activities concerning MV promote positive outcomes and increased adherence to best practices in WMV (Jansson et al., 2019; Kimura et al., 2023).

In the current project, unit-related characteristics influenced nurses’ role enactment during WMV. Elements beyond their control, such as environmental factors, inadequate resources, and lack of time, have been identified in several empirical studies as barriers to RE (Feringa et al., 2018; Michaud et al., 2021). Internationally, researchers (Alkhathami et al., 2023; Michaud et al., 2021) have argued that sufficient staffing and a low patient-to-nurse ratio are necessary to allow nurses to be present at the bedside and perform close monitoring of patients. These researchers describe that caring for a patient on MV is demanding and requires time and a constant presence.

Limitations

This study was limited to a specific environment, namely critical care units in the province of Québec. The choice to conduct a multiple-case study in two different settings supported a conceptual generalization (Yin, 2018). The response rate and sample size for the questionnaires were low but aligned with recent studies of healthcare professionals. Indeed, according to a systematic review of survey response rates and associated factors (Meyer et al., 2022), health professionals were found to have lower response rates than other groups of professionals. As described in the methods, the researchers in the current study undertook several activities to enhance the response rate. Interviews were a possible source of bias due to the Hawthorne effect. Steps were taken to reduce the risk; for instance, data were collected over a long period (approximately eight months), and multiple data sources were used. Considering that the primary author was known to many participants, she was seen as an insider rather than an outsider to the critical care unit and its team, which may have reduced the risk of social desirability.

Conclusion

Nurses are the professional group most present at the bedside (Paquette & Kilpatrick, 2020), so they are key to successful WMV. Nurses perform monitoring, wakefulness management, WMV activities, and develop a deep knowledge of the patient. Nevertheless, suboptimal RE persists when they are responsible for a patient during WMV. A lack of role clarity underlies this finding, and repercussions, including prolonged weaning, are to be anticipated for patients. In addition, nurses’ RE is influenced by team functioning, as WMV requires input from different professionals. Nurses can make a positive contribution to weaning from mechanical ventilation if their role is recognized. However, the more they actively engage as part of the inter-professional team in the context of MV and WMV, the greater recognition they will receive. Most research highlights nurses’ roles and responsibilities in terms of changing ventilation parameters and assessment. However, WMV success can be optimized through other activities, suggesting the importance of nurses’ involvement in the WMV process. Subsequent research should explore how team functioning influences the RE of nurses in critical care when weaning the patient from mechanical ventilation.

Author Notes

Lysane Paquette, PhD, RN, Associate Professor at the Université du Québec en Outaouais, Campus de Saint-Jérôme, Saint-Jérôme, QC

Kelley Kilpatrick, RN, Associate Professor and Holder of the Susan E French Chair in Nursing Research and Innovative Practice at the Ingram School of Nursing, McGill University, Montreal, QC.

Corresponding author:  Dr. Lysane Paquette, PhD, RN, Campus de Saint-Jérôme, Saint-Jérôme, QC, J7Z 0B7. Email :  lysane.paquette@uqo.ca.

Acknowledgements

Bourse MEES-Universités du Ministère de l’Éducation et de l’Enseignement supérieur (MEES) et de l’Ordre des infirmières et infirmiers du Québec; Bourse du Réseau de recherche en interventions en sciences infirmières du Québec (RRISIQ).

Funding and Conflicts of Interest

The authors declare no funding received and no conflicts of interest, financial, commercial, or otherwise.

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Tables

Note: Total percentage may exceed 100%, as multiple responses were possible.

Table 4 – Frequency of decisions related to weaning from mechanical ventilation

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