title: Difficult to wean patients: cultural factors and their impact on weaning decision-making.
abstract: OBJECTIVE
  To examine the elements of the intensive care environment and consider the impact on nurses' involvement in decision-making when weaning from mechanical ventilation.
  
  
  BACKGROUND
  Optimal management of difficult to wean patients requires the dynamic collaboration of all clinicians and the contribution of their knowledge and skills. The introduction of weaning protocols has increased nurses' input in decision-making, but there are various elements of the decision environment that impact on their involvement, which have been given little consideration.
  
  
  METHODS
  Ethnography was used as the research design for this study.
  
  
  METHODS
  Fieldwork took place in two tertiary hospitals in Greece and Scotland for five months each to unveil clinicians' behaviour and interactions during the weaning practice. Observation was based on the weaning process of 10 Scottish and 9 Greek long-term ventilated patients. Semi-structured interviews followed with nurses (n = 33) and doctors (n = 9) in both settings to understand nurses' perceived involvement in weaning decision-making. Thematic analysis of interviews and field notes followed using the Qualitative Data Analysis software NVivo. Clinicians' participation was voluntary.
  
  
  RESULTS
  The main themes identified were the (1) organisation of the units (time and structure of the ward rounds, staff levels and staff allocation system), (2) the inter- professional relationships, (3) the ownership and accountability in weaning decision-making and (4) the role of the weaning protocols. These elements described the culture of the ICUs and defined nurses' role in weaning decision-making.
  
  
  CONCLUSIONS
  Clinical decision-making is a multi-dynamic process specifically in complex clinical situations such as weaning from mechanical ventilation. This paper suggests that weaning practice should be considered in relation to the elements of the clinical environment to provide an individualised and patient-centred weaning approach.
  
  
  CONCLUSIONS
  Methods to enhance nurses' role in teamwork and collaborative decision-making are suggested.
authors.affiliation: Critical Care Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Kalliopi
authors.initials: K
authors.lastname: Kydonaki
authors.forename: Guro
authors.initials: G
authors.lastname: Huby
authors.forename: Jennifer
authors.initials: J
authors.lastname: Tocher
mesh_terms: D000328:Adult; D003422:Critical Care; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015300:Ventilator Weaning; D055815:Young Adult
keywords: decision-making; ethnography; intensive care; mechanical ventilation; weaning