Autonomous nurse-led weaning of high-flow nasal cannula therapy in infants with bronchiolitis

Michelle Elks

doi:10.25907/01125

Background: Bronchiolitis is a leading cause of hospitalisation among infants under 12 months, imposing a considerable clinical and economic burden. High flow nasal cannula (HFNC) oxygen therapy has emerged as a safe, non-invasive support for infants with bronchiolitis by delivering heated, humidified oxygen at high flow rates to improve oxygenation and comfort while reducing the work of breathing. Once confined to paediatric intensive care units (PICUs), HFNC use is now expanding into general paediatric and regional ward settings, reflecting broader changes in paediatric respiratory care. Paediatric nurses, providing continuous bedside monitoring and intervention, are ideally positioned to manage and wean HFNC therapy. However, while nurse-led protocols are well established in intensive care, limited understanding exists of nurse-led HFNC weaning and the decision-making processes guiding its use in general paediatric contexts. The purpose of this study was to evaluate the impact of a nurse-led HFNC weaning protocol on clinical outcomes in infants hospitalised with bronchiolitis in a regional paediatric setting and explore the cognitive and decision-making processes guiding nurses’ autonomous use of the protocol. The research aimed to generate an integrated understanding of how nurse-led HFNC weaning influences outcomes and how paediatric nurses apply evidence-based decision-making in practice. Methods: A pragmatic mixed-methods approach using a parallel convergent design was employed to address two objectives: (1) to examine the relationship between nurse-led HFNC weaning and infant outcomes; and (2) to explore nurses’ decision-making models in applying HFNC guidelines. Strand 1-Clinical Outcomes This strand addressed the research objective: To investigate the relationship of the application of a nurse-led high-flow nasal cannula oxygen protocol on the clinical outcomes of infants with viral bronchiolitis in a regional paediatric unit. A quasi-experimental, non-equivalent historical control design compared infants admitted with bronchiolitis over a 48-month period—24 months before and 24 months after the introduction of the nurse-led HFNC weaning protocol. The primary outcome was hospital length of stay; secondary outcomes included HFNC duration, weaning time, escalation of care, and adherence to protocol and time outside of physiological parameters. Variance from the guideline was recorded to assess protocol adherence. Descriptive and inferential analyses compared pre- and post-implementation results. Strand 2-Nurse Decision-Making Strand 2 comprised two phases and addressed research objective: To examine nurses’ decision-making skills managing infants with bronchiolitis receiving high-flow oxygen therapy in two regional Australian paediatric unit settings. Phase 1-Survey: A cross-sectional survey using the Nurse Decision-Making Instrument (NDMI) examined analytical, intuitive, and quasi-rational reasoning among paediatric nurses from two regional hospitals. The NDMI measured four phases of decision-making: data gathering, data processing, planning to act, and monitoring and evaluation. Phase 2-Think Aloud Study: A qualitative exploratory design using the think aloud was undertaken with paediatric nurses who verbalised their thought processes while completing simulated HFNC weaning scenarios. Audio data were transcribed and analysed to identify cognitive strategies, heuristics, and reasoning patterns. This integrated approach allowed triangulation of clinical and cognitive findings, providing a comprehensive understanding of nurse-led HFNC weaning in a regional paediatric context. Main Results. Strand 1: Eighty infants were included (37 pre-implementation, 43 post-implementation) in the study. The introduction of the nurse-led HFNC protocol was associated with a re-duction in hospital length of stay, indicating improved efficiency of care. While HFNC duration and weaning time also decreased, these changes were not statistically significant. Variations in adherence were identified, suggesting inconsistent application of the protocol across staff. Strand 2, Phase 1: Of the target population, 69 paediatric nurses from two regional sites completed the survey achieving a 78% response rate. Most nurses (80%) demonstrated a quasi-rational decision-making style, integrating analytical and intuitive reasoning. Analytical approaches were most common during data gathering and declined across later phases. Employment status influenced reasoning, with casual nurses showing greater use of analytical-systematic models, possibly due to reliance on procedural guidance. Strand 2, Phase 2: A total of 13 paediatric nurses comprised the Phase 2 sample. In simulations, paediatric nurses primarily relied on physiological parameters such as oxygen saturation and work of breathing. They used either a logical, hypothetico-deductive approach consistent with the protocol or heuristic reasoning based on clinical experience when faced with complexity. This flexibility supported safe decision-making tailored to patient stability. Conclusions and Implications: This study demonstrates that nurse-led HFNC weaning protocols can safely reduce hospital length of stay for infants with bronchiolitis in regional paediatric settings. Paediatric nurses predominantly use a quasi-rational reasoning model, integrating analytical assessment with intuitive judgement. Variation in protocol adherence and the influence of employment status highlight the need for consistent education and decision-support mechanisms. Findings from this thesis are reported across three peer-reviewed publications: Strand 1 in the Journal of Clinical Nursing, and Strand 2 (Phase 1 and 2) in the Journal of Pediatric Nursing. These findings have key implications for practice, education and policy: Nurse-led HFNC weaning is safe, reduces hospital length of stay, and supports the decentralisation of paediatric respiratory care beyond tertiary centres. Education should strengthen both analytical and intuitive reasoning, promoting flexibility in complex clinical decision-making. Decision-support tools and targeted training should be implemented to enhance protocol adherence and strengthen clinical reasoning. Further research is needed to refine nurse-led models, optimise adherence, and evaluate long-term outcomes across diverse paediatric settings. In summary, nurse-led HFNC weaning represents a feasible, evidence-based model of care that enhances the safety and efficiency of bronchiolitis management in regional hospitals. Supporting nurses’ cognitive flexibility through education, policy, and technology can improve both clinical decision-making and patient outcomes in paediatric respiratory care.

Autonomous nurse-led weaning of high-flow nasal cannula therapy in infants with bronchiolitis

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