ORIGINAL RESEARCH

published: 12 November 2021

doi: 10.3389/fpubh.2021.726647

Design of a Clinical Practice

Guideline in Nurse-Led
Ventilator-Weaning for Nursing
Training
Sakinah Awang 1 , Norlidah Alias 1*, Dorothy DeWitt 1 , Khairul Azhar Jamaludin 2 and
Mohd Nazri Abdul Rahman 1
1
Department of Curriculum and Instructional Technology, Faculty of Education, University of Malaya, Kuala Lumpur, Malaysia,
2
Faculty of Education, Centre of Education Leadership and Policy, Universiti Kebangsaan Malaysia, Bangi, Malaysia

Cardiothoracic intensive care unit (CICU) nurses have shared the role and responsibility
for ventilator-weaning to expedite decision-making in patient care. However, the actions
taken are based on individual’s unstructured training experience as there is no clinical
practice guideline (CPG) for nurses in Malaysia. Hence, this study aims to design a CPG
Edited by:
for the process of weaning from mechanical ventilation (MV) for a structured nursing
Mainul Haque, training in a CICU at the National Heart Institute (Institut Jantung Negara, IJN) Malaysia.
National Defense University of
The Fuzzy Delphi Method (FDM) was employed to seek consensus among a panel of 30
Malaysia, Malaysia
experts in cardiac clinical practice on the guidelines. First, five experts were interviewed
Reviewed by:
Kawsar Sardar, and their responses were transcribed and analyzed to develop the items for a FDM
Bangladesh Institute of Research and questionnaire. The questionnaire, comprising of 73 items, was distributed to the panel
Rehabilitation for Diabetes Endocrine
and Metabolic Disorders
and their responses were analyzed for consensus on the design of the CPG. The findings
(BIRDEM), Bangladesh suggested that the requirements expected for the nurses include: (a) the ability to interpret
Asif Mahmud,
arterial blood gases, (b) knowledge and skills on the basics of mechanical ventilation,
Asgar Ali Hospital, Bangladesh
and (c) having a minimum 1-year working experience in the ICU. On the other hand, the
*Correspondence:
Norlidah Alias CPG should mainly focus on developing an ability to identify criteria of patient eligible for
drnorlidah@um.edu.my weaning from MV. The learning content should focus on: (a) developing the understanding
and reasoning for weaning and extubating and (b) technique/algorithm for extubating and
Specialty section:
This article was submitted to weaning. Also, the experts agreed that the log book/competency book should be used
Public Health Education and for evaluation of the program. The CPG for structured nursing training at IJN in the context
Promotion,
a section of the journal
of the study is important for developing the professionalism of CICU nurses in IJN and
Frontiers in Public Health could be used for training nurses in other CICUs, so that decision for ventilator-weaning
Received: 17 June 2021 from postcardiac surgery could be expedited.
Accepted: 06 October 2021
Published: 12 November 2021 Keywords: structured advanced nursing training, mechanical ventilation, nurse-led ventilator-weaning protocol,
clinical practice guideline, Fuzzy Delphi Method
Citation:
Awang S, Alias N, DeWitt D,
Jamaludin KA and Abdul Rahman MN
(2021) Design of a Clinical Practice
INTRODUCTION
Guideline in Nurse-Led
Ventilator-Weaning for Nursing Mechanical ventilators (MV), which are introduced as breathing aids to save lives of
Training. critically ill patients, enable gaseous exchange for acceptable oxygen concentrations, tidal
Front. Public Health 9:726647. volumes, and respiratory rates to be maintained. On recovery, patients need to be weaned-off
doi: 10.3389/fpubh.2021.726647 (withdrawal) the MV gradually and carefully (1–3). In fact, the weaning process should be

Frontiers in Public Health | www.frontiersin.org 1 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

conducted with caution and consistent to reduce the time and the focus of MV management is to ensure patients get adequate
unexpected consequences to the patients (4–6). Also, this is to support to prevent complications.
comply with the indications and prevent any complications from
postcardiac surgery. This is a routine procedure among CICU The Ventilator-Weaning Process
nurses with interprofessional collaboration between the doctor The ventilator-weaning, or the patient’s withdrawal from
(specialists in general and cardiac anesthesiology/intensivist) ventilator support and restoring spontaneous independent
and cardiothoracic intensive care unit (CICU) nurses. This breathing, has a specific protocol. The protocol depends
collaboration for sharing responsibilities has been documented on factors such as patient’s preexisting lung condition,
in Malaysian practice since 1990 (7). It is also one of the several duration of MV, and patient’s general condition (physically
factors influencing nurse-led decision-making for the weaning and psychologically). The patients on MV for short periods
process from MV. may be weaned from ventilator support using a T-piece
The complexity of this process is dependent on the condition, connected to an oxygen supply, and then, closely monitored
complication, and need for MV among the patients (4). However, for tolerance to the switch with assessments on vital signs
to maintain standards, prevent mismanagement, malpractice, and arterial blood gases (ABGs) concentration. An initial rise
unsafe treatment, any negligence, carelessness, inattentiveness, in respiratory rate, pulse, and blood pressure is expected but
and ensure patient safety, a clinical practice guideline (CPG) oxygen saturation and partial oxygen in the body should remain
is required for structured nursing training (8). As outlined by within satisfactory limits. However, patients who have been
Blackwood et al. (9), the therapists or nurses should be able to: on ventilator support for longer periods may require gradual
(a) establish clear criteria for patient readiness to begin weaning, weaning from the MV.
(b) develop an organized guideline for therapists or nurses in The criteria for weaning are found in the Malaysian Ministry
reducing the patient’s ventilatory support, and (c) establishing of Health’s Program Anaestesiologi dan Cawangan Kualiti
a clear set of criteria to help them decide the patient’s readiness Penjagaan Kesihatan BPP (2006) ICU Management Protocol
for extubation. No. 10. The protocol is valid for general ICU patients, with
The collaboration for sharing responsibilities for the weaning intraoperative care and more than 24 h on MV. However,
process and the shortage of specialist doctors have led to nurses’ in IJN, cardiac cases are normally straight forward without
assistance on the patients’ situation to expedite medical decision- intraoperative care, and patients were on MV for 4–6 h <24 h.
making (10). However, nurses risk medicolegal issues when Hence, this protocol is not relevant for IJN’s needs.
performing ventilator-weaning without any structured training
experience, guidelines, or evidence of documented practice. Nurse-Led Ventilator-Weaning for Cardiothoracic
Hence, in protecting CICU nurses from medicolegal issues, Intensive Care
a CPG for structured training to update nurses’ knowledge A CICU nurse’s responsibility is to provide critical care to
and ability for critical thinking and clinical decision-making is patients with potentially life-threatening heart conditions. The
required. The training requirement is part of the Nurses’ Code management of critically ill patients takes on many levels
of Conduct, which indicates that nurses can look forward to (12–14). First, improving patients’ outcomes with patient-
extended work rules, provided there is a structured training with centered care, proactive management, and vigilance, coping with
a particular number of hours of credit (11). unpredictable events, and providing emotional support (4, 15).
Although in other countries, the roles and responsibilities of Second, continuous observation, so as to reduce a patient’s risk
nurses extended to ventilator-weaning, this is not practiced in of deterioration, monitor their total dependence on support
Malaysia, as there is no structured training for nurses. Currently, equipment, and prevent their agitation or confusion that may
the CICU, IJN has allowed new nurses to perform ventilator- lead to harm (16). This means assimilation, interpretation, and
weaning for patients after cardiothoracic surgery under the evaluation of information, including the patient’s physical and
guidance of an anesthetist, surgeon, or senior nurse. However, psychological response to interventions, changes in condition,
professional and ethical considerations are required for CPG the significance of monitored physiological parameters, and the
for the process. Hence, this study aims to design a CPG for safe functioning of equipment. Lastly, communication, as the
nurse-led ventilator-weaning for structured nursing training to nurse is the key provider of information to patients, relatives, and
improve knowledge and skills. This guideline would enable other members of the interdisciplinary team. Hence, nurses in
nurses in Malaysia to have protocols for practice and enhance CICU are expected to be innovative, adopt new roles, multitask,
their professionalism. and have cultural awareness. They need to be able to apply
knowledge and skills to new situations to enhance the continuity,
REVIEW OF LITERATURE efficiency, and effectiveness of patient care (17). Thus, evidently
the process of ventilation-weaning, originally the responsibility
Mechanical Ventilation of the specialists, is done by nurses managing patients to expedite
Mechanical ventilators can sustain patients’ life in the event of medical decision-making (10). Hence, regardless of the blurred
inadequate spontaneous ventilation for breathing. However, the boundary, nurses are expected to lead the ventilation-weaning
machine cannot cure the disease but only assists breathing as the perform (18).
patient’s underlying condition needs to be corrected. Selecting The responsibility of ventilator-weaning allows nurses to
the suitable mode of operation for the MV requires expertise and expand their theory and practice, but nurses in Malaysia

Frontiers in Public Health | www.frontiersin.org 2 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

may not have sufficient evidence-based practice to absolve process for nurses to improve their knowledge and skills.
them from legal misconduct issues (19). In Australia, working This is because this model takes into account the opinions
across boundaries is common and protocols exist for the of experienced practitioners for the design of the structured
implementation of effective ventilator-weaning (16). On the training. The following seven steps of the Taba model are used in
other hand, some doctors believe cross-boundary work, such the designing of the CPG: (1) identify the needs of the learner and
as ventilation-weaning in the CICU, does not require protocols the expectations of society, (2) formulate the learning objectives,
as there are existing work instructions (20). Further, nurse-led (3) select the learning content based on the objectives, (4) decide
ventilation-weaning saves patients’ lives, as is within the scope of how the content is organized based on the learning needs,
the objective of the CICU is to reduce the period of patients’ stay (5) select the learning experiences required, (6) determine the
and rate of infections while in the unit. organization of the learning activities, and (7) identify evaluation
In Malaysia, the Code of Professional Conduct states that the criteria for the effectiveness of the curriculum (25). Hence, for
nurses’ responsibility is to protect the best interests of society. the structured training and CPG, the objectives, content, teaching
However, without structured training, nurses face the possibility strategies, and evaluation measures would be determined (26).
of professional misconduct, as stated in the Nurses Act and The experts with knowledge and experience in the health-care
Regulations, 1985 (Part V Practice and Part VI on Disciplinary setting were invited to contribute to the design of the structured
Proceedings). Nurses can undertake extended work roles only training for nurse-led ventilator-weaning process for nurses to
when they have participated in structured training (NBM, 1998). improve their knowledge and skills.
Although there exists a protocol for anesthesiologists to employ
safe procedures during the process of weaning (ICU Management Johns’ Model of Reflection
Protocol No. 10, Program Anestesiologi & Cawangan Kualiti The instructional design for the structured training using
Penjagaan Kesihatan BPP, KKM, 2006), this protocol is for the CPG for nurse-led ventilator-weaning process for nurses
general cases and needs to be modified for CICU patients and to improve their knowledge and skills would be based on
for nursing training. Hence, a CPG for nurse-led ventilator- Johns’ model of reflection with the Carper’s ways of knowing
weaning is required for structured nursing training in Malaysia, (27). Reflective practice is important in nursing education as
in compliance with the Nurses Act and Regulations 1985 (NBM, nurses learn through on-the-job training. The following four
1998) to ensure the professionalism of critical care nurses. fundamental patterns of knowing is suitable for nursing training:
(a) empirical knowing that comes from factual knowledge, (b)
Nursing Training in CICU aesthetic knowing arising from the awareness of the patient
Training systematically influences behaviors in changing and the wholeness of the situation, (c) personal knowing from
knowledge, attitudes, and skill. In nursing, practitioners are self-understanding and empathy toward the situation, and (d)
encouraged to reflect critically on their practice and to view ethical knowing arising from attitude and knowledge from
research as integral for quality care (21). Hence, training ethical frameworks (27). This enables nurses to critically evaluate
considers the variables influencing practice and explores existing practices and determine whether there is a need for
different conditions for practitioners adopt to enable generating change. In addition, it promotes meaningful learning as nurses
new knowledge and innovative practice (21). Nursing education have the opportunity to critique practice based on evidence and
and training need to build frameworks for evidence-based prior knowledge.
practice for critical care education and practice.
Training for skills development in the post basic intensive The Current Study
care unit, critical care unit, or trauma unit is conducted to Hence, for this study, the experts’ consensus for determining the
ensure practitioners are protected from issues of malpractice requirements of a structured training for nurse-led ventilator-
due to uncertain boundaries. The Institute of Medicine has weaning process for nurses to improve their knowledge and
developed structured protocols in their CPG to systematically skills were sought in order to answer the research questions
assist practitioners in decision-making for appropriate health as follows:
care in specific clinical circumstances (22). The CPG is a
1. What are the requirements for nurses should have before
reference against malpractice, unsafe treatment, negligence, and
being able to perform ventilator-weaning independently in
inattentiveness, and it is used to guide health-care providers
terms of knowledge, skills, and experience; and minimum
in patient-related procedures. The CPG is a resource for
work experience?
the continuing professional development (CPD) for nursing
2. How can the CPG for nurse-led ventilator-weaning process for
education (23). In the United Kingdom, CPG is used to train
nurses assist nurses?
health-care providers in clinical aspects for nursing education
3. What is required in a CPG for nurse-led ventilator-weaning
(24). However, this is uncommon for nursing education in
process for nurses to improve their knowledge and skills in
Malaysia. Hence, for CPD in addressing workplace issues and for
terms of:
career development, CPG for nurses is required.
a) aim
Taba Model for Curriculum Design b) learning objectives
The Taba model for curriculum design is suitable for designing c) essential content, additional content, technique
training based on the CPG for nurse-led ventilator-weaning for weaning,

Frontiers in Public Health | www.frontiersin.org 3 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

TABLE 1 | Education background and working experiences of the experts. TABLE 2 | The five point linguistic scale.

Frequency Percentage (%) Linguistic variable

Education background Strongly disagree (0.00, 0.10, 0.20)

Master in doctorate or nursing 9 30 Disagree (0.10, 0.20, 0.40)
Bachelor of nursing 8 27 Moderately agree (0.20, 0.40, 0.60)
Diploma of nursing 13 43 Agree (0.40, 0.60, 0.80)
Strongly agree (0.60, 0.80, 1.00)
Total 30 100
Working experiences
5–10 years 12 40 = 14, 47%). Table 1 below provides a summary of educational
11–20 years 14 47 background and working experiences of the experts.
21–30 years 4 13

Total 30 100
FDM Procedure
First, consent to conduct this study has been obtained from
the National Heart Institute (Institute Jantung Negara, IJN)
Malaysia and the selected experts should be the respondents
d) patient readiness for weaning, most appropriate step-on for the FDM. Then, these five experts from the different care
mode, and setting before weaning, and areas were interviewed to determine the items that would be
e) evaluation/ assessment? in a FDM questionnaire. The responses from the interviews
were transcribed and analyzed to develop the items for the
questionnaire. There were 73 items in the FDM questionnaire,
METHODOLOGY which was distributed to the panel of 30 experts. Their responses
Research Design were analyzed using the Fuzzy number technique to ensure
The experts’ consensus can be determined using the Fuzzy Delphi reliability and validity and a five-point linguistic scale was
Method (FDM) in order to address issues such as ambiguity and used (see Table 2) (29). The Triangular Fuzzy Number with
subjectivity of the experts’ responses (28). The FDM uses the three mean points (m1, m2, and m3) is used to calculate the
triangular fuzzy number and defuzzification process to represent defuzzification value (DV) for the ranking of the consensus (34,
the consensus on the information and the importance of each 35). First, the distance between two fuzzy numbers and threshold
item (28). FDM has been used for accurately predicting future value, d, was determined. When d ≤ 0.2, and the percentage of
trends (29), for quantifying experts’ opinions on regional and consensus is above 75%, this indicates consensus among panel
urban road safety for the improvement of road safety in the future members of the panel and the item was accepted (34, 35). Finally,
(30), and identifying key performance indices for mobile services the DV was calculated to rank the items.
providers (31). Clearly, FDM is a useful method for ensuring that
experts’ opinions are exempt of the influence of others while also FINDINGS
ensuring their completeness and consistency (32). Although the
FDM has the potential to be used to improve nursing education, The findings of this study would determine the design of
it has not been utilized much. Hence, in this study, FDM may be the structured training with the CPG for nurse-led ventilator-
beneficial in determining consensus on the design of a CPG for weaning for nurses. The analysis was employed to answer the
nurse-led ventilator-weaning process for nurses to improve their research questions and only items that were accepted, with d ≤
knowledge and skills. 0.2, are shown in the tables.

The Criteria of Experts Knowledge, Skills, and Experience

The panel of experts for the FDM could comprise between 10 Required for Nurses to Be Able to Perform
and 50 participants (33). In this study, a panel of 30 experts Ventilator-Weaning Independently
was selected for decision-making and to ensure the validity The basic knowledge required by all CICU staff before they
and reliability of the study; the criteria for their expertise and could independently care for CICU patients was determined.
experience were determined. The experts had to be professionals This would ease the concern that junior nurses may lack the
with more than 5 years’ experience in clinical practice such skills and knowledge for the procedure as a standard guideline
as critical intensive care and cardiac intensive care. Next, they with the requirements for ventilator-weaning would increase
need to be routinely handling and performing the ventilator- confidence (36). The experts achieved consensus with the highest
weaning process. These experts were anesthesiologists, cardiac ranking for the ability to interpret arterial blood gases (DV
anesthesiologists, cardiac intensivists, nurse educators, nurse = 0.76), followed by knowledge and skill on the basics of
managers, nurse mentors, and senior staff nurses in CICU and mechanical ventilation (DV = 0.75) (see Table 3). Items that
critical care areas. These experts mostly have Diploma in Nursing emerged during the interview such as knowledge and skill for
(n = 13, 43%) and have 11–20 years of working experience (n troubleshooting for simple mechanical ventilators, knowledge on

Frontiers in Public Health | www.frontiersin.org 4 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

TABLE 3 | Knowledge, skills, and experience required for nurses to be able to perform ventilator-weaning independently.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Able to interpret arterial blood gases (ABG) (16.8, 22.8, 28.8) 0.76 Accepted
Knowledge and skill on basic mechanical Ventilation (16.6, 22.6, 28.6) 0.75 Accepted
Able to look after a critically ill patients in ICU (15.5, 21.4, 27.4) 0.71 Accepted
Staff must be credentialed and privileged (15.4, 21.4, 27.4) 0.71 Accepted

TABLE 4 | Minimum work experience required for nurses to be able to perform ventilator-weaning independently.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

One (1) year in ICU (16.4, 22.4, 28.4) 0.75 Accepted

Six (6) months in CICU (11.3, 17.1, 23) 0.57 Rejected

TABLE 5 | Function of CPG for nurse-led ventilator-weaning process in assisting nurses.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

As a guide for straight forward surgical cases in process of weaning (16.4, 22.4, 28.4) 0.75 Accepted
Provide a standard technique of weaning in the ICU (15.4, 21.4, 27.4) 0.71 Accepted
To ensure standard of care are maintained and followed by all staff (15.4, 21.4, 27.4) 0.71 Accepted
Provide the nurse with a correct way to wean patients (15, 21, 27) 0.70 Accepted

TABLE 6 | Aim of the CPG for nurse-led ventilation weaning process.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Provide a guideline as a method of standardization of care for best practices (16.8, 22.8, 28.8) 0.76 Accepted
in ICU
CPG as a guide to the nurse to perform step by step in weaning (16.4, 22.4, 28.4) 0.75 Accepted
As a reference when weaning off ventilation (15.2, 21.2, 27.2) 0.71 Accepted

anatomy and physiology of respiratory system or cardiothoracic (see Table 5). However, during the interview with experts, an
and cardiovascular care, and having a basic life support (BLS) item emerged, which was providing a template to safely wean-
certification were rejected and deemed unnecessary for CPD. off patients but this was rejected (DV = 0.67), as it was believed
that this process is specific to the individual and could not be
Minimum Work Experience Required for generalized with a template.
Nurses to Be Able to Perform
The Aim of the CPG
Ventilator-Weaning Independently The aim of the CPG would determine the rationale for use. The
Nurses with work experience are able to undertake new roles highest consensus was for providing guidelines as a method of
such as ventilation-weaning to be more responsible and self- standardization of care for best practices in ICU (DV = 0.76),
sufficient (14). The experts determined that at least 1 year’s work followed by being a guide for the nurse to perform the process of
experience in the ICU (DV = 0.57) and 6-months experience in weaning step-by-step (DV = 0.75) (see Table 6). Items rejected
CICU were sufficient for nurses to be able to undergo the training were “to promote patient safety and reduce complication” (DV =
for ventilator-weaning (DV = 0.57) (see Table 4). 0.69), “as the correct approach for weaning off from mechanical
ventilation” (DV = 0.68), “help the nurses in clinical decision
Function of CPG for Nurse-Led making” (DV = 0.68), and “reduce weaning time” (DV = 0.59).
Ventilator-Weaning Process Hence, the emphasis was on the CPG being a guide for practice.
The function of the CPG should be determined to indicate when
and how it could be used. The consensus among the experts The Learning Objectives of the CPG
was that the CPG would be used as a guide for weaning with The panel of experts achieved consensus on three learning
straightforward surgical cases (DV = 0.75), to provide a standard objectives for the CPG with the highest ranking for nurses to be
technique of weaning in the ICU, and ensuring the standard able to identify criteria of patient eligible for weaning from MV
of care is maintained followed by staff (both with DV = 0.71) (DV = 0.76) (see Table 7). However, the item “reduce variation

Frontiers in Public Health | www.frontiersin.org 5 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

TABLE 7 | Learning objectives of the CPG for a nurse-led ventilator-weaning.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Must be able to identify criteria of patient eligible for weaning from (16.8, 22.8, 28.8) 0.76 Accepted
mechanical ventilation (MV)
Must be able to perform process of weaning without any risk and (16.4, 22.4, 28.4) 0.75 Accepted
complication to the patient
Must be able to identify criteria of failed weaning & extubation (15.2, 21.2, 27.2) 0.71 Accepted

TABLE 8 | Essential content in the CPG for a nurse-led ventilator-weaning.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Inclusion and exclusion criteria of weaning & extubation (16.4, 22.4, 28.4) 0.75 Accepted
Criteria & Technique for weaning (16.2, 22.2, 28.2) 0.74 Accepted
Weaning algorithm (16.2, 22.2, 28.2) 0.74 Accepted
Criteria when a nurse should escalate to Mentor/ Doctor (16.2, 22.2, 28.2) 0.74 Accepted
Acceptable range of haemodynamic parameters during processes of (16, 22, 28) 0.73 Accepted
weaning
Intubation and extubation technique (15.2, 21.2, 27.2) 0.71 Accepted
Understand the reason for ventilating a patient (15.4, 21.4, 27.4) 0.71 Accepted

TABLE 9 | Additional content for the CPG for a nurse-led ventilator-weaning.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Criteria of extubation (16.4, 22.4, 28.4) 0.75 Accepted

Weaning algorithm (16.2, 22.2, 28.2) 0.74 Accepted
Hemodynamic monitoring- normal parameter for weaning (15.8, 21.8, 27.8) 0.73 Accepted
Inclusion and exclusion criteria (15.6, 21.6, 27.6) 0.72 Accepted
Indication and complication (15.4, 21.4, 27.4) 0.71 Accepted
Basic mechanical ventilation—application, mode and setting (15, 21, 27) 0.70 Accepted

from common practice” was rejected (DV = 0.68) as the CPG was Techniques to Be Included in the CPG
only a guide. The techniques would be the skills that were needed to be
included in the CPG for nurses to perform ventilator-weaning.
There were six techniques identified with the highest consensus
Essential Content in the CPG
for clinical assessment (physical assessment) (DV = 0.75)
There were seven essential contents for the CPG, which emerged
followed by criteria for weaning (e.g., hemodynamic stability,
during the first round of interviews. All the seven contents that
low ventilator setting, resolution of the cause of intubation)
emerged were accepted to be included with the highest consensus
(DV = 0.73) (see Table 10). However, items such as “Change
for the inclusion and exclusion criteria of weaning (DV = 0.75)
to Pressure support (P/S) or Trachy Vent” and “Observe for
and the process of intubation and extubation (DV = 0.71) (see
signs and symptoms of Increase Work of Breathing such as
Table 8).
Tachypneic, Sweating, Reduce Saturation Partial Oxygen (SPO2)”
were rejected (DV = 0.69 and 0.60, respectively). Performing the
Additional Content for the CPG right techniques would depend on the staff ’s experience.
Other than the essential contents, the panel of experts identified
six additional contents that should be included in the CPG
to ensure it was relevant and effective. The highest consensus Strategies to Be Included in the CPG
was for criteria of extubation (DV = 0.75), weaning algorithm The strategies that were recommended for the CPG would
(DV = 0.74), and hemodynamic monitoring normal parameter ensure the knowledge and skills were transferred to the nurses.
for weaning (DV = 0.73) (see Table 9). However, items such The experts achieved consensus on conducting training and
as having a “background section” and “basic anatomy and education (DV = 0.75) and rejected items such as conducting
physiology of the respiratory system” were rejected (DV = 0.64 an audit, looking at other weaning protocol, and including
and 0.57, respectively). Only relevant content was prioritized for recent research/ continuous studies for improvement (see
CPD, so as to achieve excellent outcomes. Table 11). Some of the items rejected were related to designing

Frontiers in Public Health | www.frontiersin.org 6 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

TABLE 10 | Techniques to be included in the CPG for a nurse-led ventilator-weaning.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Clinical Assessment (Physical Assessment) before processes of weaning (16.4, 22.4, 28.4) 0.75 Accepted
Criteria for weaning (eg. Hemodynamic stability, low ventilator setting, (15.8, 21.8, 27.8) 0.73 Accepted
resolution of cause of intubation)
Check ABG (15.4, 21.4, 27.4) 0.71 Accepted
Decide whether patient fulfill extubation criteria (15.4, 21.4, 27.4) 0.71 Accepted

TABLE 11 | Strategies to be included in the CPG.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Conduct training and education (16.6, 22.6, 28.6) 0.75 Accepted

TABLE 12 | The patient information needed to decide patient readiness to be included in the CPG for a nurse-led ventilator-weaning.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Stable Hemodynamic parameter (16.4, 22.4, 28.4) 0.75 Accepted

Neurological status—Patient is full conscious/ Glasgow Coma Score (GCS)- (16, 22, 28) 0.73 Accepted
more than 13, Rass Score (+1)—(−1)
Minimal ventilation setting (15.6, 21.6, 27.6) 0.72 Accepted
Minimal inotropic support (15.4, 21.4, 27.4) 0.71 Accepted

TABLE 13 | Step-on mode and setting before weaning to be included in the CPG for a nurse-led ventilator-weaning.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Mechanical ventilation mode SIMV with VC + PS → start reduce the FiO2 (16.4, 22.4, 28.4) 0.75 Accepted
from 50 to 40% → Check ABG Result- If normal or hemodynamic normal
→ tail down the MV setting: Respiratory Rate until Minimal (eg., 12 until 8)
and PEEP until minimal → Check ABG – If Normal → reduce to MV Mode
CPAP/ PS → Initiate PSV (PEEP = 6–8 cmH2O, P/S = 10–14 cmH2O,
reduce P/S by 1–2 cmH2O/h, Until a minimum P/S = 6 cmH2O, Vt > 6
ml/kg IBW) → Assess for extubation criteria → extubate

and implementing the new CPG for evaluation and were the criteria to begin the processes of weaning. The pulmonary
not relevant. function parameter for predicting weaning lists that parameter
that can be determined at the bedside to predict weaning success.
Patient Information Needed to Decide Establishing a relationship of trust and support is essential in
avoiding the panic and anxiety that commonly prevents weaning
Patient Readiness to Be Included in the
attempts. There were four possible step-on modes and settings
CPG before weaning off the MV emerging for weaning, which emerged
The CPG would ensure nurses made quality and relevant during the interviews. The expert consensus was only on one
decisions to prevent harm and complications to the patient. The mode: Mechanical ventilation Mode SIMV with VC + PS → start
highest consensus was for stable hemodynamic parameter (DV reduce the FiO2 from 50 to 40% (DV = 0.75) (see Table 13). This
=0.75), as this would indicate patients’ readiness for extubation, is significant because this is a process of reducing MV support
followed by determining neurological status (DV = 0.73) (see based on a weaning algorithm and would involve strategies
Table 12). Patient readiness was important for decision-making to ensure patients received the best treatment with the fewest
to avoid bringing harm to the patient. complications during the weaning process.

Step-On Mode and Setting Before Weaning Evaluation of Training for the CPG
to Be Included in the CPG It is important to evaluate any training to determine the success
The process of discontinuing MV is divided into three phases: of a program (38). However, in this case, the evaluation of the
preweaning, weaning, and extubation (37). The assessment of CPG needs to be done for the effectiveness of the program.
physiological readiness of patients for weaning is to identify The evaluation tools were determined before the implementation

Frontiers in Public Health | www.frontiersin.org 7 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

TABLE 14 | Evaluation for the training for the CPG for a nurse-led ventilator-weaning.

Details for subitem Fuzzy evaluation Defuzzification value (DV) Consensus

Log book/competency book (16.4, 22.4, 28.4) 0.75 Accepted

of the CPG but the experts’ consensus were only on one will enable nurses to perform the procedure confidently
evaluation tool, a log book/ competency book (DV = 0.75), and safely.
which could be used as an evidence for the training in order This CPG focuses on postcardiac surgery for adult patients
to evaluate skills (38). Other items that emerged from the with minimum complication and not for high-risk cases or
interviews were rejected by the experts as evaluation tools difficult intubation, and it is only for CPD for training nurses at
(see Table 14). the CICU for the process of weaning. The CPG can be used as
a guide for workshops, training, or programs, to enhance CICU
DISCUSSIONS AND CONCLUSIONS nurses’ knowledge and skills in this area. However, it can be a
benchmark for staff competency based of CPG. Hence, in this
The CPG was important as it provided guidelines on a method study, a new perspective for nurse education was provided in
for standardization of care and best clinical practices in the combining Taba’s model for curriculum design (25) and John’s
CICU for nurse-led ventilation-weaning procedures. The study model of reflection (27) for designing a CPG. In addition, the
determined the knowledge, skill, and experience required before CPG for nurse-led ventilator-weaning process for training nurses
nurses could perform ventilation-weaning confidently according was designed with experts’ consensus using the FDM for nurses’
to the opinion of experts. This means that the prior skills training and CPD at the National Heart Institute CICU. This
which needed to be prioritized before training is conducted CPG enables practice in the clinical area, and protects the nursing
such ability to interpret the ABGs could be identified before profession with strong evidence for advancing education in the
patient readiness for extubation and techniques for ventilator- nursing profession. Hence, the CPG promotes collaboration
weaning including determining weaning mode and setting before and teamwork to hasten patients’ recovery process and reduce
extubation. Only nurses who had acquired sufficient skills in complications. Recommendations for future research can include
the CPG and experience (a minimum of 1 year in ICU or expanding on this study by developing a teaching model
6 months in the CICU) would be allowed to participate in for nurse-led ventilation-weaning process using interpretive
the training. structural modeling (ISM). In addition, an instructional module
The essential content and techniques to be applied were on nurse-led ventilation-weaning process could be developed
consolidated for the CPG for the institute in the context of the using a design and development research framework.
study. This process would be applicable to all nurses working The CPG clearly reflects recommendations to improve the
in cardiac intensive care settings in Malaysia. After undergoing implementation of MV process as proposed by Blackwood et al.
training, the effectiveness of training could be determined, and (9), which include: (a) establishing clear criteria for patient
the experts agreed that the log book/competency book was readiness to start weaning, (b) developing an organized guideline
the best evaluation tool. Nurses learnt through experience and for therapists or nurses in reducing patient’s ventilatory support,
reflected on the cases based on the ways of knowing (27). and (c) establishing a clear set of criteria to help them decide the
The CPG would be a resource for the algorithm, a technique, patient’s readiness for extubation.
and an essential content for nurses to perform ventilation- In conclusion, the CPG designed for a nurse-led ventilation-
weaning procedures. This is extremely beneficial to the CICU weaning process for nurses’ training may change the perception
nurses and especially junior nurses in managing patients’ of Malaysian nursing practice and professionalism in the
postcardiac surgery toward ventilation-weaning. Having the CPG international arena. Thus, in implementing the training
ensures standardization and prevents malpractice as it is an for nurses before they perform the ventilator-weaning
evidence-based method for nurses to performing the procedure, procedure will prevent any issues of medicolegality in
thus reducing the hospitalization cost on patient and CICU their practice.
hospital stay.
The CPG would also assist in nursing training by enabling DATA AVAILABILITY STATEMENT
a structured training program for nurses to recall and reflect
on their previous work practices in the CICU. Hence, nurses The original contributions presented in the study are included
could evaluate the existing and past practices to contemplate in the article/supplementary material, further inquiries can be
whether it was reliable and suitable and so advance the directed to the corresponding author.
nursing profession. The reflective model can improve nursing
education in a systematic manner and nurses can benefit ETHICS STATEMENT
from the different perspectives of reflective learning (27).
Hence, this design was helpful for the practice of learning The studies involving human participants were reviewed and
the process of weaning from MV in nursing education and approved by the Institut Jantung Malaysia (The National

Frontiers in Public Health | www.frontiersin.org 8 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

Heart Institute of Malaysia). The patients/participants SA, KJ, and MA: formal analysis and writing-review and
provided their written informed consent to participate in editing. All authors contributed to the article and approved the
this study. submitted version.

AUTHOR CONTRIBUTIONS ACKNOWLEDGMENTS

SA, NA, and DD: conceptualization, methodology, and original We would like to express our gratitude to the panel of experts
draft preparation. SA, NA, DD, KJ, and MA: data curation. who actively offered their knowledge to this research.

REFERENCES 17. Briggs D. Critical care nurse’s roles– traditional or expanded / extended.
Intensive Care Nurs. (1991) 7:223–99. doi: 10.1016/0266-612X(91)90047-U
1. Mancebo J. Weaning from mechanical ventilation. Eur Respir J. (1996) 18. Tye C, Ross F. Blurring boundaries:professional perspectives of the
9:1923–31. doi: 10.1183/09031936.96.09091923 emergency nurse practitioner role in a major accident and emergency
2. Mador MJ. Weaning parameters. Are they clinically useful? Chest. (1998) department. J Adv Nurs. (2000) 31:1089–96. doi: 10.1046/j.1365-2648.2000.
102:1642–3. doi: 10.1378/chest.102.6.1642 01380.x
3. Grossbach I, Chalan L, Tracy MF. Overview of mechanical ventilatory support 19. Goodman S. Implementing a protocol for weaning patients
and management of patient- and ventilator-related responses. Crit Care Nurse. off mechanical ventilation. Nurs Crit Care. (2006) 11:23–32.
(2011) 31:30–45. doi: 10.4037/ccn2011595 doi: 10.1111/j.1362-1017.2006.00146.x
4. Cederwall CJ. Prolonged mechanical ventilation in Swedish intensive care 20. Masterson A. Cross-boundary working: A macro-political analysis
units: patient characteristics, prevalence, weaning and challenges in care. of impact on professional roles. J Clin Nurs. (2002) 11:331–9.
Institute of Health and Care Sciences: Sahlgrenska Academy, University of doi: 10.1046/j.1365-2702.2002.00604.x
Gothenburg. (2021). 21. Thomson P, Angus NJ, Scott J. Building a framework for getting evidence
5. Gunther I, Pradhan D, Lubinsky A, Urquhart A, Thompson JA, into critical care education and practice. Intensive Crit. Care Nurs. (2000)
Reynolds S. Use of a multidisciplinary mechanical ventilation 16:164–74. doi: 10.1054/iccn.2000.1483
weaning protocol to improve patient outcomes and empower 22. Dancker M, Grosu H, De Jean R, Cruz RB. Nurse-driven, protocol-directed
staff in a medical intensive care unit. Dimensions of Critical weaning from mechanical ventilation improves clinical outcomes and is well
Care Nursing. (2021) 40:67–74. doi: 10.1097/DCC.00000000000 accepted by intensive care unit physicians. J Crit Care. (2013) 28:433–41.
00462 doi: 10.1016/j.jcrc.2012.10.012
6. Potter, A. Identification and implementation of a screening algorithm to 23. Hewitt-Taylor J. Clinical guidelines and care protocols. Intensive Critical Care
improve spontaneous breathing trials for mechanically ventilated adult Nursing. (2004) 20:45–52. doi: 10.1016/j.iccn.2003.08.002
patients: a quality improvement project. (2021). Available online at: http://hdl. 24. National Health and Medical Research Council. (NHMRC). A Guide to the
handle.net/10504/133656 Development, Implementation and Evaluation of Clinical Practice Guidelines
7. Martin JS, Ummenhofer W, Manser T, Spirig R. Interprofessional (CPG). Canberra: NHRMC. (1999).
collaboration among nurses and physicians: Making a difference in 25. Taba H. Curriculum Development: Thepry and Practice. New York, NY:
patient outcome. US National Library of Medicine National Institutes Harcourt Brace Jovanovich (1962).
of Heathy Journal. (2010) 140:w13062. doi: 10.4414/smw.2010. 26. Lunenburg FC, Irby BJ. Instructional strategies to facilitate learning.
13062 International Journal of Educational Leadership Preparation. (2011) 6:1–12.
8. Berg AO, Atkins D, Tierney W. Clinical practice guidelines in Available online at: https://files.eric.ed.gov/fulltext/EJ974330.pdf
practice and education. J Gen Intern Med. (1997) 12:S25-S33. 27. Johns C. Framing learning through reflection within Carper’s
doi: 10.1046/j.1525-1497.12.s2.4.x fundamental ways of knowing in nursing. J Adv Nurs. (1995) 22:226–34.
9. Blackwood B, Burns KE, Cardwell CR, O’Halloran P. Protocolized versus doi: 10.1046/j.1365-2648.1995.22020226.x
non-protocolized weaning for reducing the duration of mechanical 28. Siraj S, Alias N, DeWitt D, Hussin Z. Design and Developmental Research:
ventilation in critically ill adult patients. Cochrane Database of Systematic Emergent Trends in Educational Research. Kuala Lumpur, Malaysia: Pearson
Reviews 11. (2014) 2014:CD006904. doi: 10.1002/14651858.CD006 (2013).
904.pub3 29. Ishikawa A, Amagasa M, Shiga T, Tomizawa G. The max-min
10. Faizah A, Kamilah D, Sivasampu S, Tahrani PK, Kasturi M. Distribution Delphi method and fuzzy Delphi method via fuzzy integration. Fuzzy
of clinical specialists in Malaysian Hospitals. CRC, Ministry of Health Sets and Systems. (1993) 55:241–53. doi: 10.1016/0165-0114(93)9
Malaysia. (2016). 0251-C
11. Nursing Board Malaysia. Nursing Board Malaysia: Code of Professional 30. Ma Z, Shao C, Ma S, Ye Z. Constructing road safety performance indicators
Conduct for Nurses First Edition April 1998. Code of professional conduct using Fuzzy Delphi Method and Grey Delphi Method. Expert Syst Appl. (2010)
for nurses first edition April 1998 Code, (1998) 2–5. Available online at: http:// 38:1509–14. doi: 10.1016/j.eswa.2010.07.062
scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:No+Title#0 31. Kuo YF, Chen PC. Constructing performance appraisal indicators for mobility
12. Cull C, Inwood H. Weaning from mechanical ventilation. Professional Nurse. of the service industries using Fuzzy Delphi Method. Expert Syst Appl. (2008)
(1999) 14:535–8. 35:1930–9. doi: 10.1016/j.eswa.2007.08.068
13. Gelsthorpe T, Crocker C. A study exploring factor which influence the 32. Jamil MRM, Hussin Z, Noh NM. Penyelidikan Rekabentuk Pembangunan.
decision to commence nurse-led weaning. Nurs Crit Care. (2004) 9:213–21. Bandar Baru Bangi: Minda Intelek Agency. (2014).
doi: 10.1111/j.1362-1017.2004.00077.x 33. Hsu C. The Delphi Technique: making sense of consensus. Practical
14. Holden RJ. Responsibility and autonomous nursing practice. J Adv Nurs. Assessment, Research & Evaluation. (2007) 12:1–7. doi: 10.7275/pdz9-th90
(1991) 16:398–403. doi: 10.1111/j.1365-2648.1991.tb03428.x 34. Kaufmann A, Gupta MM. Fuzzy mathematical models in engineering and
15. Galley J, O’Riordan B. Guidance for Nurse Staffing in Critical 1020 Care. management science. New York, NY: Elsevier Science. (1988).
London, UK: Royal College of Nursing (2003). 35. Awang S, Ahmad S, Alias N, DeWitt D. Design of an instructional module
16. Rose L. Issues in weaning from mechanical ventilation: literature review. J Adv on Basic Life Support for homeschooled children. Cogent Education. (2016) 3.
Nurs. (2006) 54:73–85. doi: 10.1111/j.1365-2648.2006.03792.x doi: 10.1080/2331186X.2016.1188439

Frontiers in Public Health | www.frontiersin.org 9 November 2021 | Volume 9 | Article 726647

Awang et al. Nurse-Led Ventilator-Weaning Protocol

36. Blackwood B, Wilson-Barnett J. The impact of nurse-directed Publisher’s Note: All claims expressed in this article are solely those of the authors
protocolised-weaning from mechanical ventilation on nursing practice: and do not necessarily represent those of their affiliated organizations, or those of
A quasi-experimental study. Int J Nurs Stud. (2007) 44:209–26. the publisher, the editors and the reviewers. Any product that may be evaluated in
doi: 10.1016/j.ijnurstu.2005.11.031 this article, or claim that may be made by its manufacturer, is not guaranteed or
37. Rose L, Dainty KN, Jordan J, Blackwood B. Weaning from mechanical
endorsed by the publisher.
ventilation: A scoping review of qualitative studies. Am J Crit Care. (2014)
doi: 10.4037/ajcc2014539
Copyright © 2021 Awang, Alias, DeWitt, Jamaludin and Abdul Rahman. This is an
38. Kirkpatrick DL. Evaluating training programs: The four levels. San Francisco,
open-access article distributed under the terms of the Creative Commons Attribution
CA: Berrett-Koehler. (1996).
License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that the
Conflict of Interest: The authors declare that the research was conducted in the original publication in this journal is cited, in accordance with accepted academic
absence of any commercial or financial relationships that could be construed as a practice. No use, distribution or reproduction is permitted which does not comply
potential conflict of interest. with these terms.

Frontiers in Public Health | www.frontiersin.org 10 November 2021 | Volume 9 | Article 726647