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Knowledge and observed practice of intensive care nurses regarding weaning criteria from mechanical ventilation in public and private hospitals in the Northern West Bank, Palestine

This study of 93 ICU nurses in the Northern West Bank reveals moderate knowledge and variable practice regarding mechanical ventilation weaning, characterized by the absence of written protocols and a significant gap between supportive actions and critical decision-making tasks like structured assessments and documentation.

Original authors: Amjad Qasim Suliman, Sajed Faisal Ghawadra, Loai M. Zabin

Published 2026-07-10

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Amjad Qasim Suliman, Sajed Faisal Ghawadra, Loai M. Zabin

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine the Intensive Care Unit (ICU) as a high-stakes cockpit where a patient is flying on autopilot because their own lungs are too tired to steer. The ultimate goal? To gently hand the controls back to the patient and let them fly solo. This process is called "weaning." But here's the twist: in the hospitals of the Northern West Bank, Palestine, the pilots (the ICU nurses) are flying without a written flight manual.

That's the big picture of this study. Researchers wanted to see how well these nurses knew the rules of the road for taking patients off ventilators and what they actually did when the moment came. They didn't just ask, "Do you know the rules?"; they also watched them work to see if their actions matched their knowledge.

The Missing Manual
First, a crucial fact: every single one of the 93 nurses interviewed confirmed that their hospitals had zero written protocols for weaning. It's like a driving school where everyone is taught to drive, but no one has ever been given a rulebook. Despite this, the nurses weren't flying blind; they were relying on their training and experience.

The Knowledge Check: A Bumpy Ride
When the researchers tested the nurses' knowledge with a 20-question quiz, the results were "moderate." Think of it like a student who gets about 54% of the questions right. They knew the basics, but they stumbled on the tricky details.

They were pretty good at spotting the easy stuff, like knowing that a specific breathing pattern means the patient is ready to try flying solo (about 79% got this right).
But they were less sure about the technical specs, like the exact pressure settings or the specific numbers that signal a failure.
Interestingly, the study found that a nurse's age, gender, or how many years they'd been working didn't really change their score. Being a veteran nurse didn't automatically mean you knew the textbook answers better than a newer nurse. However, nurses who had a special diploma in respiratory therapy did score significantly higher, suggesting that specific training is the secret sauce for knowing the theory.

The Observation: Doing the Easy Stuff, Skipping the Hard Stuff
This is where things get interesting. The researchers didn't just take a word for it; they watched the nurses for 15 to 30 minutes each. They used a checklist of 26 items to see what actually happened on the floor.

The nurses were great at the "comfort" moves.

94% of the time, they put the patient in a semi-sitting position (like propping them up with pillows).
84% of the time, they turned down the oxygen and pressure settings as the rules suggested.
80% of the time, they stopped the sedation drugs to wake the patient up.

But when it came to the "decision-making" moves—the stuff that actually determines if the patient is ready to go—the numbers dropped sharply.

Only 10% of the time did the nurses actually perform a structured "Spontaneous Breathing Trial" (a formal test to see if the patient can breathe on their own).
Only 8% of the time did they prepare the emergency equipment needed just in case the patient needed to be put back on the machine immediately.
Only 20% of the time did they write down what they did in the patient's chart.

The Verdict
The study suggests a clear gap: the nurses are excellent at the routine, supportive tasks (like positioning and turning down the oxygen), but they are inconsistent when it comes to the critical, structured steps that require a formal decision or documentation.

The authors are careful not to call this a disaster or a solved problem. They note that because they only watched each nurse for a short time, they might have missed some actions that simply didn't happen during that specific window. For example, if a patient didn't need to be taken off the machine during those 15 minutes, the nurse wouldn't have a chance to show they knew how to prepare the emergency gear. So, the low numbers for those specific actions might be due to a lack of opportunity, not a lack of skill.

However, the pattern is clear enough to suggest that without a written protocol to guide them, the "decision-making" part of the process is hit-or-miss. The study concludes that while the nurses have a decent grasp of the theory, the practice needs a boost, specifically in structured assessments and documentation. It's a call to action for local hospitals to perhaps create those missing rulebooks and offer more targeted training, especially since the data hints that specific respiratory training makes a real difference in how nurses perform.

In short: The nurses are trying their best without a manual, they know the basics, but they could use a little more help with the complex, high-stakes decisions to ensure every patient lands safely.

Technical Summary: Knowledge and Observed Practice of ICU Nurses Regarding Weaning Criteria in the Northern West Bank, Palestine

Problem Statement
Mechanical ventilation (MV) is a critical life-support intervention, yet prolonged use increases the risk of complications and functional decline. Safe liberation from MV requires structured readiness assessment, appropriate weaning interventions, and preparedness for extubation. While ICU nurses play a central role in monitoring patients and implementing weaning care, practice remains variable across settings due to differences in routines, staffing, and organizational factors. In the Northern West Bank, Palestine, evidence regarding the combination of nurses' knowledge and directly observed weaning-related practice is limited, particularly in hospitals where written weaning protocols are reportedly absent. This study addresses the gap in understanding how ICU nurses in this specific context assess readiness, manage weaning interventions, and prepare for extubation.

Methodology
The study employed a quantitative, cross-sectional observational design involving 93 registered nurses from public and private hospitals in the Northern West Bank. Participants were required to have at least three months of ICU experience and provide direct bedside care.

Data Collection:
- Knowledge Assessment: Nurses completed a 20-item multiple-choice questionnaire covering respiratory and hemodynamic screening, weaning modes, monitoring parameters, tolerance/failure indicators, and extubation criteria. The instrument was validated by experts and demonstrated acceptable internal consistency (Cronbach's $\alpha$ = 0.79).
- Observed Practice: A single trained observer assessed each nurse's practice during a 15–30 minute window using a 26-item checklist. The checklist covered readiness screening, spontaneous breathing trials (SBT), sedation management, ventilator adjustments, airway clearance, extubation preparation, and documentation.
Analysis: Descriptive statistics summarized knowledge and practice levels. Exploratory subgroup comparisons (t-tests and one-way ANOVA) examined differences based on demographics and training characteristics. The study design was descriptive and exploratory; no multivariable models were fitted.

Key Results

Contextual Finding: 100% of participating nurses reported the absence of a written weaning protocol in their respective hospitals.
Knowledge Levels: Overall knowledge was moderate, with a mean correct response rate of 54%. Domain-level scores ranged from 51% to 59%. Nurses performed better on items related to visible bedside decisions (e.g., identifying respiratory patterns for tolerance) but showed variability in specific physiologic thresholds and mode-transition decisions. Knowledge scores did not significantly differ by age, sex, or general ICU experience.
Observed Practice: Practice scores were variable, showing a mismatch between supportive actions and decision-critical behaviors.
- High Occurrence: Supportive actions were frequently observed, including semi-sitting positioning (94%), reduction of $FiO_2$ to $\le$ 40% with PEEP $\le$ 5 cm $H_2O$ (84%), and stopping sedation/muscle relaxants (80%).
- Low Occurrence: Critical decision-making and documentation steps were infrequently observed. Structured SBT assessment occurred in only 10% of observations. Preparation of extubation and re-intubation equipment was observed in 8%, and documentation of the weaning process was observed in 20%.
Training Correlations: Exploratory analyses indicated that nurses with specific training (ICU courses, weaning criteria training, or a respiratory therapy diploma) tended to have higher practice scores. Respiratory therapy diploma holders also demonstrated higher knowledge scores.

Key Contributions
This study provides the first combined assessment of knowledge and directly observed practice regarding mechanical ventilation weaning among ICU nurses in the Northern West Bank. Its primary contribution is identifying specific practice gaps in a resource-constrained setting lacking formal protocols. The findings highlight that while nurses are proficient in routine supportive tasks (positioning, basic parameter reduction), there is a significant deficit in structured readiness assessment, extubation preparedness, and documentation. The study also notes that demographic factors do not reliably predict knowledge, suggesting that structured learning opportunities and unit systems are more influential than background characteristics alone.

Significance and Claims
The authors claim that the findings highlight potential areas for local quality improvement, specifically targeting structured readiness assessment, extubation preparedness, and documentation. The study suggests that in the absence of written protocols, targeted, skill-focused interventions—such as nurse-led weaning bundles, competency-based training, and simple checklists—could improve adherence to evidence-based practices.

The paper maintains a modest tone regarding its conclusions. It explicitly states that the results should not be considered definitive estimates of routine performance due to the single, brief observation period and the potential for the Hawthorne effect (reactivity). Furthermore, the subgroup analyses are described as exploratory and hypothesis-generating rather than confirmatory, given the sample size and multiple comparisons. The authors conclude that larger studies with repeated observations and patient outcome data are necessary before stronger conclusions can be drawn.

Technical Summary: Knowledge and Observed Practice of ICU Nurses Regarding Weaning Criteria in the Northern West Bank, Palestine

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