[Downloaded free from http://www.nabh.ind.in on Thursday, March 22, 2018, IP: 202.80.214.

228]

Original Article

Exploratory study on the knowledge and skill of

critical care nurses on endotracheal suctioning
Abstract
Background and Objectives: A descriptive exploratory study to assess the knowledge
and skill of critical care nurses on endotracheal (ET) suctioning was conducted in
the eight Intensive Care Units of AIMS, Kochi. The objectives of the study were (1)
to assess the knowledge of critical care nurses on ET suctioning, (2) to assess the
clinical skill of critical care nurses in performing ET suctioning, and (3) to find out the
correlation between knowledge and clinical skill of critical care nurses on ET suctioning.
Materials and Methods: The sampling technique used was nonprobability
convenience (n = 50).
Results: Majority of the participants (70%) had an acceptable level of knowledge.
Most of the participants (64%) had least acceptable level of knowledge on the
actual suction event and 54% on postsuctioning practice. The nurses who had
an acceptable level of skill in performing ET suctioning were 56% whereas skill in
practices before suctioning was least acceptable in 86% of the nurses. A significant
difference (P < 0.001) was obtained between the current practice observed and the
best recommended practice on ET suctioning. The elements of ET suctioning which
were not followed by majority of the nurses include auscultation of chest (2%),
postsuctioning assessment (2%), wearing apron (6%), maintaining suction
pressure (10%), reassuring the patient before (30%) and after suctioning (18%), hand
washing before (42%) and after suctioning (28%), time of suction applied (36%),
and maintaining the suction catheter’s sterility (46%).
Interpretation and Conclusion: Even though nurses had an acceptable level of knowledge
Sruthy T Varghese, KT Moly and skill, inadequacies exist in the practice of various phases of ET suctioning. Hence,
training on ET suctioning could be focused specifically to those phases.
Department of Medical and
Surgical, Amrita College of
Nursing, Amrita Institute of Key words: Critical care nurses, endotracheal suctioning, knowledge, skill
Medical Sciences, (Affliated to
Amrita Vishwa Vidyapeetham
University), Kochi,
Kerala, India
INTRODUCTION
Address for correspondence:
Ms. Sruthy T Varghese, Mechanical ventilators are special pumps that can support the ventilatory function of the
Amrita College of Nursing, Amrita
Institute of Medical Sciences,
respiratory system and improve oxygenation through the application of high oxygen content gas
(Affliated to Amrita Vishwa and positive pressure. Another epidemiological study including 15,757 patients in the Intensive
Vidyapeetham University), Care Units (ICUs) from twenty countries reported that 5183 patients (33%) required mechanical
Kochi, Kerala, India.
ventilation.[1,2]
E‑mail: varghese_sruthy@yahoo.
com
The primary objectives of mechanical ventilation are to decrease their work of breathing,
relieve respiratory distress, rest the fatigued respiratory muscles, improve ventilation, stabilize
Access this article online the chest wall, and restore the acid–base balance. Therefore, the most common reasons for
Website: www.nabh.ind.in

DOI: 10.4103/2319-1880.187753 This is an open access article distributed under the terms of the Creative Commons
Quick Response code: Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon
the work non‑commercially, as long as the author is credited and the new creations are licensed under
the identical terms.

For reprints contact: [email protected]

How to cite this article: Varghese ST, Moly KT. Exploratory study on the knowledge and skill of critical
care nurses on endotracheal suctioning. J Nat Accred Board Hosp Healthcare Providers 2016;3:13-9.

13 © 2016 The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.nabh.ind.in on Thursday, March 22, 2018, IP: 202.80.214.228]

Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning

instituting mechanical ventilation are acute respiratory failure the Thesis Review Committee of AIMS, Kochi, after obtaining
with hypoxemia (acute respiratory distress syndrome, heart failure approval from the Research Committee of Amrita College of
with pulmonary edema, pneumonia, sepsis, and complications of Nursing. Written permission was obtained from the nursing
surgery and trauma), which accounts for 65% of all ventilated director, medical superintendent, and head of the department of
cases, followed by the causes of hypercarbic ventilatory failure each ICU. Nonparticipatory observation was conducted in the
such as coma (15%), exacerbations of chronic obstructive participants’ natural environment using Tool II. ET suctioning
pulmonary disease (13%), and neuromuscular diseases (5%).[2,3] practice was observed during morning and evening shifts in
nursing care and in extubation contexts. An average of 3–4
Inappropriate and inaccurate ventilatory support strategy can observations were possible per day, but varied with the number
result in increased mortality and complications. Pulmonary of ventilator patients per day in the unit. The researcher prepared
complications include barotrauma, oxygen toxicity, tracheal a list of participants observed, and written informed consent was
stenosis, and deconditioning of respiratory muscles. Even, obtained from the same participants after clearly explaining the
mechanical ventilation for airway support can be a source of purpose of the study. The Tool I was administered to the same
infection. Ventilator‑associated pneumonia (VAP) can worsen participants at the end of their shift.
gas exchange, increase the load of secretions, and can potentially
lead to deterioration of the function of other body organs such Data analysis
as the heart.[2]
Karl Pearson’s correlation coefficient was used to analyze the
correlation between the knowledge and skill of critical care
American nurses’ association listed ten essential care to be
nurses on ET suctioning. One sample t‑test was used to compare
provided for patients on mechanical ventilator, endotracheal (ET)
the observed practice score with the best recommended practice.
suctioning is one among them.[4] The main goal of ET suctioning
is to remove accumulated lung secretions to maintain the airway’s
permeability, provide adequate oxygenation, reduce the risk of RESULTS
VAP, and prevent pulmonary consolidation and atelectasis. As
suctioning is a fundamental aspect of airway management, the Description of sample characteristics
critical care nurses must be competent in this essential clinical The data shown in Table 1 regarding the sample characteristics
skill. Appropriate technique and adherence to evidence‑based show that 64% of the participants were graduate nurses, 36%
guidelines will result in fewer complications for the patients and were general nursing and midwifery (GNM), and there was not a
ultimately, financial benefit to the patients by avoiding prolonged single postgraduate. Fifty‑six percent of the nurses had 1–3 years
hospital stay.
Table 1: Description of sample characteristics (n=50)
MATERIALS AND METHODS Demographic variables Frequency (f) Percentage
Level of education
Study design and population GNM 18 36.0
BSc nursing 32 64.0
A quantitative research with descriptive exploratory design was MSc nursing 0 0.0
used to explore the knowledge and skill of critical care nurses Total experience as nurses
on ET suctioning. The study was carried out among fifty critical 6 months to 1 year 11 22.0
care nurses working in eight ICUs of AIMS, Kochi. 1-3 years 23 46.0
3-5 years 10 20.0
Data collection >5 years 6 12.0
Total experience in the current hospital
The data were collected using the following tools; Tool I: a 6 months to 1 year 17 34.0
structured questionnaire on knowledge regarding ET suctioning 1-3 years 25 50.0
and Tool II: observation checklist on ET suctioning (standardized 3-5 years 5 10.0
tool prepared by Mr. Seán J. Kelleher). Content validity of the >5 years 3 6.0
tool was obtained from 12 experts in the field of nursing and Total experience in the critical care unit
medicine. The knowledge and skill scores were rated as highly 6 months to 1 year 13 26.0
acceptable (≤50% of score), acceptable (50–75% of score), and 1-3 years 28 56.0
3-5 years 4 8.0
least acceptable (75% of score). The items on the both tools were
>5 years 5 10.0
classified into four phases; practices prior to suctioning, infection
Attended training program on ET
control practice, the suctioning event, and postsuctioning event. suctioning
Yes 11 22.0
Data collection for the study was conducted from December 7, No 39 78.0
2014 to January 15, 2015. Ethical clearance was obtained from ET: Endotracheal, GNM: General Nursing and Midwifery

The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1 14
[Downloaded free from http://www.nabh.ind.in on Thursday, March 22, 2018, IP: 202.80.214.228]

Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning

of experience in the critical care unit and only 18% had more Table 4 shows that the maximum score of the observation checklist
than 3 years of experience in the critical care unit. was 35. The overall skill in performing ET suctioning had a mean
score of 18.16 (mean percentage of 51.9%) with SD of  ±3.395.
Distribution of sample based on their knowledge
level on endotracheal suctioning Table 5 depicts that among the four different phases of ET
suctioning observed, 86% of the critical care nurses skill in the
Figure 1 depicts that 70% of the participants had an acceptable
level of knowledge, 8% of the nurses had highly acceptable level
of knowledge, and 22% had least acceptable level of knowledge
on ET suctioning. 8%

22%
Figure 2 represents the four different phases of ET suctioning,
of which majority of the participants (68%) had an acceptable Highly acceptable

level of knowledge on practices prior to suctioning and 50% on

Acceptable
infection control practices. Most of the participants (64%) had
least acceptable level of knowledge regarding the actual suction
Least acceptable
event and 54% on postsuctioning practice.
70%
From Table 2, it is clear that the maximum score of the
knowledge questionnaire was thirty. The overall knowledge level
of nurses on ET suctioning had a mean score of 17.28 (mean
Figure 1: Pie diagram on the distribution of sample based on the level
percentage of 57.6%) with standard deviation (SD) of  ±3.580.
of knowledge on endotracheal suctioning (n = 50)

Table 3 represents the four different phases of ET suctioning,

of which majority of the participants (68%) had an acceptable 100.0
Highly acceptable
90.0
level of knowledge on practices prior to suctioning and 50% on Acceptable
80.0
infection control practices. Most of the participants (64%) had Least acceptable
Percentage of subjects

70.0
least acceptable level of knowledge regarding the actual suction 60.0
68.0
64.0
event and 54% on postsuctioning practice. 50.0 50.0 54.0
40.0
40.0 42.0
Distribution of sample based on the skill level of 30.0
20.0
critical care nurses on endotracheal suctioning 10.0
24.0 24.0
12.0
8.0 10.0 4.0
Figure 3 describes that 56% of the participants had an acceptable 0.0
Prior to Infection Suctioning Post
level of skill, 44% had least acceptable level of skill, and none Suctioning Control Event Suctioning
of them had highly acceptable level of skill in performing ET Knowledge on phases of ET suctioning
suctioning.
Figure 2: Bar diagram on the distribution of sample based on the
level of knowledge on each phase of endotracheal suctioning (n = 50)
Figure 4 depicts that among the four different phases of ET
suctioning observed, 86% of the critical care nurses skill in the
practices prior to suctioning was least acceptable, whereas in 0%
the rest of the three phases, their skill was acceptable; the actual
suctioning event was 48%, infection control practice was 42%,
and postsuctioning practice was 40%.

Highly acceptable
Table 2: Mean, standard deviation, range, and mean 44%
percentage of knowledge level in each phase of
endotracheal suctioning among critical care nurses (n=50) Acceptable
Phases of ET suctioning Maximum Mean SD Mean Range 56%
(%) Least acceptable
Practices before suctioning 18 10.62 ±2.212 59.0 4-15
The suctioning event 6 3.14 ±1.229 52.3 0-6
Infection control practices 3 2.28 ±0.701 76.0 0-3
Postsuctioning practices 3 1.24 ±0.894 41.3 0-3
Overall knowledge 30 17.28 ±3.580 57.6 6-23 Figure 3: Pie diagram on the distribution of sample based on the level
ET: Endotracheal, SD: Standard deviation of skill in endotracheal suctioning (n = 50)

15 The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1
[Downloaded free from http://www.nabh.ind.in on Thursday, March 22, 2018, IP: 202.80.214.228]

Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning

Table 3: Distribution of sample based on their level of knowledge on each phase of endotracheal suctioning (n=50)
Phases of ET Level of knowledge on ET suctioning
suctioning Highly acceptable Acceptable Least acceptable
Frequency Percentage Frequency Percentage Frequency Percentage
Before suctioning 4 8.0 34.0 68.0 12.0 24.0
Infection control 20 40.0 25.0 50.0 5.0 10.0
Suctioning event 6 12.0 12.0 24.0 32.0 64.0
Postsuctioning 2 4.0 21.0 42.0 27.0 54.0
ET: Endotracheal, SD: Standard deviation

Table 4: Mean, standard deviation, range, and mean 100.0

Highly acceptable
percentage of skill level regarding endotracheal suctioning
80.0 Acceptable
among critical care nurses (n=50)

Percentage of subjects
86.0
Least acceptable
Phases of ET Maximum Mean SD Mean (%) Range 60.0
suctioning
46.0
Practices before 8 3.12 ±1.769 39.0 0-6 40.0 48.0
42.0 40.0
suctioning 38.0
20.0 30.0
Infection control 9 5.58 ±1.444 62.0 4-8 20.0 22.0
practices 0.014.0 14.0
0.0
The suctioning 9 5.10 ±1.403 56.7 2-8 Prior to Infection Suctioning Post
event Suctioning Control event Suctioning
Postsuctioning 9 4.36 ±1.758 48.4 1-8 Skill in phases of ET Suctioning
practices
Overall skill 35 18.16 ±3.395 51.9 11-26 Figure 4: Bar diagram on the distribution of sample based on the level
ET: Endotracheal, SD: Standard deviation of skill in each phase of endotracheal suctioning (n = 50)

practices prior to suctioning was least acceptable, whereas in There was no correlation (r = 0.077 and P = 0.596) between the
the rest of the three phases, their skill was acceptable; the actual knowledge and skill score of critical care nurses on ET suctioning.
suctioning event was 48%, infection control practice was 42%,
and postsuctioning practice was 40%. DISCUSSION

On analysing each step in detail, it was found that some The findings of the present study consisted of 64% of graduate
of the steps in ET suctioning were ignored by more than nurses, 36% of GNM, and there was not a single postgraduate.
50% of the critical care nurses, which include auscultation Eighty‑two percent of the participants had 6 months to 3 years of
of chest, postsuctioning assessment, wearing apron, experience in the ICU as the investigator considered a period of
maintaining suction pressure between 80 and 150 mm, 6 months of working in ICU a sufficiently adequate time to acquire
reassuring the patient after suctioning, hand washing knowledge and skill related to ET suctioning. In a study conducted
by Sharma et al. on the effectiveness of ET suctioning protocol in
postsuctioning, explaining the procedure to the patient,
terms of knowledge and practices of nursing personnel (n = 30) in
length of time applied to suction the airway, hand washing
Mullana, it was found that 100% of the sample had professional
prior to suctioning, and maintaining the suction catheter’s
qualification of GNM and 100% had within 5 years of experience
sterility. Normal saline instillation was performed by 30%
in ICU.[5] In the present study, 78% of the participants did not
of the critical care nurses though it remains unsupported by
attend training program on ET suctioning previously whereas in
scientific evidence (according to the American Association the study by Sharma et al., 56.67% had attended the in‑service
for Respiratory Care [AARC] Guideline, 2010). education related to ET suctioning.[5] A comparison with the above
study findings shows that the present study findings can be more
The maximum score represents perfect adherence to best
generalized to graduate nurses with <3 years of experience in ICU,
recommended practice, which was based on the scoring of mostly without a good background of training in ET suctioning.
standardized observation checklist by Kelleher and Andrews (Tool
III). The higher a participants’ observational score, the closer It is encouraging to note from the present study that 70% of
the participants’ adherence to the best recommended practice. the participants had an acceptable level of knowledge on ET
Similarly, the lower the participants’ observational score, less suctioning, though only 8% of the nurses had highly acceptable
likely was the adherence to best practice recommendation. From level of knowledge and 22% had least acceptable level of
the Table 6, it is clear that difference between the current practice knowledge on ET suctioning. In a study by Ansari et al. (2012) on
observed in all phases of ET suctioning and best recommended the gap between knowledge and practice in standard ET suctioning
practice was highly significant (P < 0.05). of ICU nurses (n = 44), 52.2% of the participants had desirable

The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1 16
[Downloaded free from http://www.nabh.ind.in on Thursday, March 22, 2018, IP: 202.80.214.228]

Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning

Table 5: Distribution of sample based on their level of skill on each phase of endotracheal suctioning (n=50)
Phases of ET Level of knowledge on ET suctioning
suctioning Highly acceptable Acceptable Least acceptable
Frequency Percentage Frequency Percentage Frequency Percentage
Before suctioning 0 0.0 7.0 14.0 43.0 86.0
Infection control 10 20.0 21.0 42.0 19.0 38.0
Suctioning event 11 22.0 24.0 48.0 15.0 30.0
Postsuctioning 7 14.0 20.0 40.0 23.0 46.0
ET: Endotracheal

Table 6: A comparison of current practice of critical

that indicate that nurses have more knowledge than practice. In
care nurses on endotracheal suctioning observed with the study by Ansari et al., the mean knowledge and practice score
the best recommended practice (n=50) obtained was 19.59 and 8.75, respectively, out of the maximum
Phases of ET suctioning Maximum Mean SD t** P 26 possible score. The findings of this study showed that 95.4%
Practices before suctioning 8 3.12 ±1.769 19.510* 0.000 of the participants’ practice score was undesirable (<50%), 4.6%
Infection control practices 9 5.58 ±1.444 16.747* 0.000 of the participants’ score was moderate (51–75%), and none of
The suctioning event 9 5.10 ±1.403 19.651* 0.000 them had desirable level of practice (>75%).[6] Another study by
Postsuctioning practices 9 4.36 ±1.758 18.658* 0.000
Day et al. (2002) on tracheal suctioning, an exploration of nurses’
Overall skill 35 18.16 3.395 35.076* 0.000
knowledge and competence in acute and high dependency ward
*Significant at 5% level (i.e., P<0.05), **One sample t‑test value.
ET: Endotracheal, SD: Standard deviation area, London (n = 28), was in tune with this finding, where the
average score obtained for knowledge and performance was 11.2
level of knowledge, 47.8% of the participants had moderate level and 10.3, respectively, out of 20 maximum score.[7] In contrast, in
knowledge, and none of them had undesirable level of knowledge another study by Sharma et al., practice was better than knowledge.
on ET suctioning,[6] whereas in the present study, 22% of the The mean percentage of pretest score of knowledge and practice
participants had least acceptable level of knowledge. This may obtained in the study was 42% and 38%, respectively. This may be
be because 100% of their participants were graduate nurses and related to the sample characteristics of the study, where 100% of
63.5% of the participants’ experience was more than 4 years.[6] the participants were GNM and 56.67% of the participants did
not receive in‑service education on ET suctioning previously.[5]
In the present study, the knowledge level of nurses was analyzed
separately under four phases, and acceptable level of knowledge Like the assessment of knowledge of nurses, the practice score
was found in two phases, i.e., practices prior to suctioning (68%) was also assessed under four phases. Among which the nurses
and infection control practices (50%); least acceptable level had an acceptable level of practice in three phases, i.e., the actual
of knowledge was found in two phases, i.e., actual suction suctioning event (48%), infection control practice (42%), and
event (64%) and postsuctioning practice (54%). However, postsuctioning practice (40%), with the mean percentage of
the mean percentage of knowledge score in three phases was 56.7%, 62%, and 48.4%, respectively, and the nurses had least
acceptable at 59%, 76%, and 52.3%, respectively, except for acceptable level in practice prior to suctioning (86%) with the mean
postsuctioning practice (41.3%). The present study findings differ percentage of 39%. The present study findings differ from the
from the study by Ansari et al., where the mean percentage of study by Ansari et al., where the mean percentage of practice score
knowledge score obtained before suctioning, during suctioning, obtained before suctioning, during suctioning, and postsuctioning
and postsuctioning was 71.25%, 77%, and 80.8%, respectively.[6] was 27%, 72.66%, and 68.1%, respectively.[6] An important point
to be considered here is that in both studies, the knowledge score
Even though nurses’ overall knowledge score was acceptable, of the participants on the phase prior to suctioning was much
while assessing in depth, it was found that deficiency exists in higher than their practice score in the same phase.
some phases of ET suctioning, i.e., the actual suctioning event
and postsuctioning practice. Hence, educational interventions Even though an acceptable level of skill was shown by 56% of
on ET suctioning need to be focused more on these phases. the critical care nurses, the finding of this study has brought
light to a few inadequacies in ET suctioning practice observed.
The present study revealed that 56% of the participants had
an acceptable level of skill, 44% had least acceptable level of The present study findings showed that 98% of the nurses literally
skill, and none of them had highly acceptable level of skill in failed to auscultate the chest of the patients prior to suctioning
performing ET suctioning. The findings also indicate that the as well as postsuctioning. Best practice recommendations on ET
mean percentage of overall knowledge score (57.6%) of critical suctioning suggest that when performing a respiratory assessment,
care nurses on ET suctioning was better than their practice nurses should auscultate the patient’s chest to verify the need for
score (51.9%). In this context, there are two studies from literature ET suctioning.[8] Most of the studies support this finding. An

17 The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1
[Downloaded free from http://www.nabh.ind.in on Thursday, March 22, 2018, IP: 202.80.214.228]

Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning

observational correlational study by Jansson et al. on the evaluation of saline. Bostick and Wendelglass (1987) argued that this is an
of ET suctioning practices conducted in ICUs (n = 40) also reported example of a widely practiced intervention that is not supported
that only 5.3% of the nurses performed chest auscultation before by research. In fact, there is considerable research evidence against
suctioning and 0% postsuctioning.[9] Given that the majority of the its use (Blackwood 1999). AARC also does not recommend using
participants failed to auscultate lung sounds before ET suctioning, normal saline instillation as a routine practice while performing ET
it might be possible that they were working from a combination of suctioning. Hence, this a controversial issue which further requires
clinical signs that indicated the necessity for ET suctioning, such scientific evidence. French (1999) argued that despite an increasing
as noisy breathing or visible secretions in the airway. A limitation body of knowledge about the effectiveness of interventions, there
of observational methods, however, meant that there was no way remains a discrepancy between theoretical knowledge and practical
of establishing whether participants’ decision to perform ET application. This argument certainly seems to apply.[10]
suctioning was informed by such indicators or whether they were
working from some other perspectives such as unit routine as is It was found in the present study that only 6% of the participants wore
suggested in the literature.[8] Failure in auscultation before and apron, only 42% of the participants washed hands before suctioning,
after suctioning in the present study and above‑mentioned studies and 28% postsuctioning. It is appreciable to note that 100% of the
most probably indicates that nurses continue to practice based on participants wore glove and 88% wore face mask during suctioning.
mostly symptoms and not signs. This also indicates the necessity A similar finding could be seen in the study by Kelleher and Andrews
of including physical examination mandatorily in nursing practice. where hand washing was poorly performed (GICU: 31% and CICU:
65%) and only a few wore goggles (CICU: 12%, GICU: 3%) during
Evidence from the present study revealed that only 30% of the ET suctioning procedure. However, all the participants had worn
the participants explained the procedure to the patient before gloves, face mask, and apron.[9] It is recommended strongly in many
suctioning and 18% reassured patient after suctioning. However, literature that hands should be washed before and after suctioning and
this was contradictory to the findings of a study by Jansson et al., that aprons, gloves, and goggles should be worn during suctioning to
where 61.5% of the participants explained the procedure to the reduce the risk of infection before suctioning as well as prevent cross
patient before suctioning and 62.5% reassured the patient after infection after suctioning.[9] This was contradictory to the findings of the
suctioning.[9] A similar picture was found in the study by Kelleher study by Jansson et al., where hand washing was performed by 72.2%
and Andrews which was an observational study on the open‑system of the participants before suctioning and 52.5% postsuctioning. One
ET suctioning practices of critical care nurses, Ireland (n = 45), hundred percent of the participants wore gloves, 97.5% wore face mask,
where only 28% of the participants in general ICU (GICU) failed 32.5% wore apron, and 25% protected their eyes from infection.[9]
to communicate in any form.[8] However, these contradictory results
are an eye opener that indicates good communication is possible These findings may suggest a perception among nurses that wearing
inside an ICU despite the condition of the patient. gloves and using a “non‑touch” aseptic technique when inserting
the suction catheter negate the need for frequent hand washing, yet
Despite the abundance of evidence on the negative consequences of the literature clearly suggests that gloves do not replace the need
suctioning‑induced hypoxemia, in the present study, only 54% of the for handwashing (Pratt et al. 2001). Protective eyewear is especially
participants performed presuctioning hyperoxygenation, though it is important, as the eye itself and surrounding delicate mucous’
worth noting that 74% of the participants performed hyperoxygenation membranes are very vascular. Any splashes of infective sputum
postsuctioning. Field notes by the researcher identified that the nurses could pose a serious infection control threat to the practitioner who is
used Ambu or ventilator for hyperoxygenation/hyperinflation, but performing the procedure.[8] The practice of wearing apron and goggle
the technique varies among ICUs. A similar picture could be seen in is an uncommon practice in many hospitals around the country; this
the study by Kelleher and Andrews, where 17 out of 45 participants might be the reason that only 6% of the participants in the present
failed to provide hyperoxygenation/hyperinflation either before or study had worn apron and that none of them wore goggle.
after ET suctioning.[8] The routine practice may have been learned
from each other without ever actually understanding the rationale Above all, sterility of the suction catheter until inserted into the
for its use. This also shows that practices among nurses might be airway was maintained only by 46% of the participants in the
routine, symptom‑oriented, and not proactive. present study. Even, Kelleher and Andrews have mentioned in
their study that 10 (59%) CICU and 8 (29%) GICU participants
Another area of concern was normal saline instillation which failed to maintain the sterility of the suction catheter before its
was practiced by 30% of the participants in the present study. insertion into the patient’s airway.[8]
This was reflected in the study by Jansson et al., where 25% of
the participants performed normal saline instillation.[9] Similar The field notes maintained by the researcher identified that
findings were seen in earlier work in the ICU setting too, with most often, catheter touches the patient linen and nonsterile
100% (n = 16) of nurses believing that saline should be used glove touches the catheter and small opening tip of normal
to loosen secretions. What is even more worrying is that most saline bottle, through which nurses try to squeeze in the catheter
of these nurses (n = 11, 69%) were aware of the complications for cleaning. The equipment listed by AARC guideline on ET

The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1 18
[Downloaded free from http://www.nabh.ind.in on Thursday, March 22, 2018, IP: 202.80.214.228]

Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning

suctioning has clearly stated that sterile water and cup and sterile recommended practice on ET suctioning. This may be because
glove have to be used for open ET suctioning technique.[11] the nurses practice ET suctioning as learned from others or due
to inadequate training during student/staff period. The need
In the present study, 64% of the participants failed to apply for skill training program specific to practice areas of nursing
suction to airway for < 15 s. The recommended practice suggests before independent patient care assignment in critical care unit
that suctioning should take between 10 and 15 s to perform, has become evident through the present study.
as longer durations are associated with an increased risk of
hypoxemia and trauma (Boggs 1993).[10] Acknowledgment
I thank Mr. Seán J. Kelleher for permitting me to use the
Another area of particular concern was that only 10% of the observation checklist. Moreover, I would like to thank every
participants maintained a suction pressure between 80 and person who supported and encouraged me to complete the
150 mmHg while performing ET suctioning. The field notes by research study successfully.
the researcher identified that participants maintained a suction
pressure between 250 and 450 mmHg, which was much higher Financial support and sponsorship
than the recommended pressure. High negative pressure will cause
mucosal trauma, which, in turn, predisposes the bronchial tree to Nil.
a higher risk of infection. Using high negative pressures does not
mean that more secretions will be aspirated, therefore limiting Conflicts of interest
pressures to between 80 and 150 mmHg is recommended.[8] There are no conflicts of interest.

Results from the study by Kelleher and Andrews indicated that REFERENCES
all participants used suction pressures outside the recommended
1. Sole, Klein, Mosley. Introduction to Clinical Nursing. Vol. 3; 2013.
levels for safe practice with suction pressures ranging from 230 Available from: http://www.nursingcenter.com. [Last accessed on
to 450 mmHg. Participants from GICU generally utilized lower 2016 Jul 27].
suctioning pressures, ranging from 230 to 380 mmHg, but 2. Frutos‑Vivar F, Ferguson ND, Esteban A. The Epidemiology of
Mechanical Ventilation. Update in Intensive Care Medicine; 2005.
again these still exceeded the recommended pressures for safe p. 24‑5. Available from: https://books.google.co.in/books?id=PPtpXXk
practice.[8] Another study by Jansson et al. also supported the O3j8C&pg=PA12&dq=another+epidemiological+study+including+157
same finding where only 15% of the participants maintained a 57+patients+in+ICU.+frutos-vivar&hl=en&sa=X&ved=0ahUKEwjfydO
f0NzNAhWJv48KHey_DCQQ6AEIKDAA#v=onepage&q=another%20
suction pressure between 80 and 150 mmHg.[9] epidemiological%20study%20including%2015757%20patients%20
in%20ICU.%20frutos-vivar&f=false. [Last accessed on 2016 Jul 27].
The above findings indicate that there are many concerns regarding 3. Fauci AS, jameson JL, Kasper DL, Longo DL, Adamson J,
Achermann JC, et al. Harrison’s Principles of Internal Medicine.
the adherence of critical care nurses on ET suctioning. This was 18th ed. United States of America: The McGraw Hill Publishers; 2012.
confirmed when a comparison was made between observed practice 4. Top 10 Essential Care of Ventilator Patient. American Nurses
and the best recommended practice on ET suctioning. A significant Association; 2010. Available from: https://americannursetoday.com/
top-10-care-essentials-for-ventilator-patients/. [Last accessed on 2016
difference (P < 0.01) was obtained between current practice and Jul 27].
best recommended practice. These findings were in line with the 5. Sharma S, Sarin J, Bala G. Evaluate the effectiveness of endotracheal
inference of two studies; by Kelleher and Andrews (2008)[8] and by suctioning protocol in terms of knowledge and practices of nursing
personnel. Nurs Midwifery Res J 2014;10:2. Available from: http://
Jansson et al.,[9] where it was found that in all categories, there was medind.nic.in/nad/t14/i2/nadt14i2p47.pdf. [Last accessed on 2016
significant difference (P < 0.001) between the quality of treatment Jul 27].
observed and quality of treatment required in ET suctioning. 6. Ansari A, Alavi A, Hajbagheri A, Afazal M. The gap between
knowledge and practice in standard endotracheal suctioning of ICU
nurses. Iran J Crit Care Nurs 2012;5:71‑6. Available from: http://www.
The above‑discussed studies indicate that there is a gap between inhc.ir/article-1-431-fa.pdf. [Last accessed on 2016 Jul 27].
the knowledge and skill of critical care nurses. However, a number 7. Day T, Farnell S, Haynes S, Wainwright S, Wilson‑Barnett J. Tracheal
suctioning: An exploration of nurses’ knowledge and competence in
of studies have demonstrated the gap between the theory and acute and high dependency ward areas. J Adv Nurs 2002;39:35‑45.
practice on ET suctioning. Larsen et al. (2002) believe that there is 8. Kelleher S, Andrews T. An observational study on the open‑system
no gap between theory and practice using the sociological theory endotracheal suctioning practices of critical care nurses. J Clin Nurs
2008;17:360‑9.
of Bourdieu, which challenged the “barrier paradigm” that has 9. Jansson M, Ala‑Kokko T, Yipalosaari P, Kyngas H. Evaluation of
traditionally highlighted the gap between knowledge and practice.[10] endotracheal suctioning practices. J Nurs Educ Pract 2013;3:7.
Available from: http://www.sciedu.ca/journal/index.php/jnep/article/
view/1586. [Last accessed on 2016 Jul 27].
CONCLUSION 10. Day T. An Evaluation of Individualized Performance Feedback on
Nurses’ and Physiotherapists’ Tracheal Suctioning Practice. Thesis;
The study has shown deficit areas of knowledge and skill 2007.
11. American Association for Respiratory Care. AARC clinical practice
in specific phases of ET suctioning as well as a significant guidelines. Endotracheal suctioning of mechanically ventilated
difference between the current practice observed and best patients with artificial airways 2010. Respir Care 2010;55:758‑64.

19 The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1