Research On An Article

Analyze how the researchers created the “observational schedule” (the checklist used by the researchers) in the article and assess the strengths and weaknesses of how it was developed, applying the concepts in the lecture and readings for this module.

Consider the following when writing your post:  where the researchers obtained the original checklist, how they revised it for this study, how they tested validity and reliability of the checklist before using it in this study.

  • CLINICAL NURSING PROCEDURES

    An observational study on the open-system endotracheal suctioning

    practices of critical care nurses

    Sean Kelleher MSc, PGDipN (Crit. care), RGN

    Lecturer, Catherine McAuley School of Nursing & Midwifery, Brookfield Health Sciences Complex, University College Cork,

    Ireland

    Tom Andrews PhD, PGDE, RN

    Lecturer, Catherine McAuley School of Nursing & Midwifery, Brookfield Health Sciences Complex, University College Cork,

    Ireland

    Submitted for publication: 11 January 2006

    Accepted for publication: 20 December 2006

    Correspondence:

    Sean Kelleher

    Brookfield Health Sciences Complex UCC

    Cork

    Ireland

    Telephone: 00353 21 4901477

    E-mail: s.kelleher@ucc.ie

    KELLEHER S & ANDREWS T (2008)KELLEHER S & ANDREWS T (2008) Journal of Clinical Nursing 17, 360–369

    An observational study on the open-system endotracheal suctioning practices of

    critical care nurses

    Aim and objectives. The purpose of this study was to investigate open system

    endotracheal suctioning (ETS) practices of critical care nurses. Specific objectives

    were to examine nurses’ practices prior to, during and post-ETS and to compare

    nurses’ ETS practices with current research recommendations.

    Background. ETS is a potentially harmful procedure that, if performed inappro-

    priately or incorrectly, might result in life-threatening complications for patients.

    The literature suggests that critical care nurses vary in their suctioning practices;

    however, the evidence is predominantly based on retrospective studies that fail to

    address how ETS is practiced on a daily basis.

    Design and method. In March 2005, a structured observational study was con-

    ducted using a piloted 20-item observational schedule on two adult intensive-care

    units to determine how critical care nurses (n ¼ 45) perform ETS in their daily practice and to establish whether the current best practice recommendations for ETS

    are being adhered to.

    Results. The findings indicate that participants varied in their ETS practices; did not

    adhere to best practice suctioning recommendations; and consequently provided

    lower-quality ETS treatment than expected. Significant discrepancies were observed

    in the participants’ respiratory assessment techniques, hyperoxygenation and

    infection control practices, patient reassurance and the level of negative pressure

    used to clear secretions.

    Conclusion. The findings suggest that critical care nurses do not adhere to best

    practice recommendations when performing ETS. The results of this study offer

    an Irish/European perspective on critical care nurses’ daily suctioning practices.

    Relevance to clinical practice. As a matter of urgency, institutional policies

    and guidelines, which are based on current best practice recommendations,

    need to be developed and/or reviewed and teaching interventions developed

    to improve nurses’ ETS practices, particularly in regard to auscultation

    360 � 2008 Blackwell Publishing Ltd doi: 10.1111/j.1365-2702.2007.01990.x

    skills, hyperoxygenation practices, suctioning pressures and infection control

    measures.

    Key words: clinical significance, critical care, evidence-based practice, nursing

    practice, observation

    Introduction

    The ultimate goal of nursing is to provide evidence-based care

    that promotes quality outcomes for patients, families, health-

    care providers and the health-care system (Craig & Smyth

    2002). While the literature has demonstrated that nurses are

    increasingly recognizing the role research has to play within

    modern health care (Hundley et al. 2000), it seems that many

    established nursing practices are not underpinned by sound

    evidence (Glacken & Chaney 2004). One area of nursing

    practice that has caused concern is the endotracheal suction-

    ing (ETS) of intubated patients (Swartz et al. 1996, Thomp-

    son 2000, Sole et al. 2003). ETS is an important intervention

    in caring for patients with an artificial airway (Thompson

    2000) and an essential aspect of effective airway management

    in the critically ill (Wood 1998b). It is an invasive, potentially

    harmful procedure, which when performed inappropriately

    or incorrectly can result in serious complications (Celik &

    Elbas 2000, Paul Allen & Ostrow 2000). It is important,

    therefore, that those carrying out such a procedure are aware

    of the potential risks and practice in a manner that ensures

    effectiveness and patient safety.

    Literature review

    While ETS is an important intervention when caring for

    critically ill patients, the practice surrounding ETS can vary

    widely between institutions and practitioners (Swartz et al.

    1996, Sole et al. 2003) with much of that practice based on

    anecdote and routine rather than research (Paul Allen &

    Ostrow 2000, Thompson 2000, Day et al. 2002b). This may

    partially have been influenced by a paucity of research

    evidence to guide practitioners in the care of a patient with

    an endotracheal tube (Thompson 2000). The last decade has

    seen a steady increase in the body of literature relating to how

    and when ETS should be performed (Glass & Grap 1995,

    Wainwright & Gould 1996, Wood 1998b, Thompson 2000,

    Day et al. 2002b, Moore 2003). Much of this evidence is in the

    form of succinct literature reviews (Wood 1998b, Day et al.

    2002a) and systematic reviews (Thompson 2000) enabling

    practitioners quickly and easily to determine current research

    recommendations irrespective of their ability to interpret the

    research findings. Nonetheless, there is still some disparity in

    regard to what exactly constitutes the best ETS practice

    (Swartz et al. 1996) owing largely to a dearth of quality

    research on ETS techniques. While Thompson (2000), in a

    systematic review of the literature, isolated aspects of the ETS

    procedure that are generally accepted as being the most

    important, a lack of homogeneity and methodological flaws in

    some of the studies (Thompson 2000) resulted in 13 non-

    prescriptive recommendations for practice. Conversely, the

    more conventional literature reviews (Wood 1998a, Day et al.

    2002a, Moore 2003), which are generally regarded as being

    less rigorous than systematic reviews (Dickson 2003), expli-

    citly describe how ETS should be performed, but overlook the

    quality of the evidence from which they originate. Notwith-

    standing the lack of rigorous research concerning ETS

    practice, it is generally accepted that the ETS techniques,

    when used inappropriately or incorrectly can have deleterious

    effects on patients (Wood 1998b, Celik & Elbas 2000, Paul

    Allen & Ostrow 2000). It is important therefore to establish

    how critical care nurses perform ETS and establish how it

    compares with the current best practice recommendations.

    Critical care nurses’ ETS practices

    A study conducted by Swartz et al. (1996) used a quantita-

    tive, descriptive design using a survey method to examine

    ‘national’ suctioning practices on 80 paediatric intensive-care

    units (ICU) across the United States. The results indicated

    that suctioning techniques among critical care nurses varied

    and were based on a combination of nursing judgement and

    ward routine. Paul Allen and Ostrow (2000) report similar

    findings in a quantitative descriptive study which aimed to

    identify the closed-system ETS practices of 241 randomly

    selected critical care nurses. One hundred and twenty nurses

    (50%) responded to a mailed questionnaire. The findings

    indicated variations in nurses’ suctioning techniques. While

    the results of both studies suggest that critical care nurses

    vary in their ETS practices, the ‘ex-post facto’ focus of the

    studies may not necessarily be an accurate reflection of

    nurses’ daily practice. Carter (1996), cited in Cormack

    and Benton (1996), suggests that the subjects’ written

    responses to questionnaire items about how they carry out

    a procedure may bear little resemblance to how they actually

    perform it.

    Clinical nursing procedures Critical care nurses’ suctioning practices

    � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369 361

    Day et al. (2002b)) triangulated observation, interview and

    questionnaire methods to explore nurses’ theoretical know-

    ledge and practical competence in ETS. Using convenience

    sampling, 28 critical care nurses were recruited from three

    critical care wards in a large teaching hospital in the UK. The

    results indicated that many nurses failed to demonstrate an

    acceptable level of theoretical knowledge and competence in

    practice and that there was no significant relationship

    between nurses’ theoretical knowledge and observed practice.

    Furthermore, many nurses were unaware of recommended

    practice and some demonstrated potentially unsafe practice.

    These findings are supported in the literature (Celik & Elbas

    2000) and have considerable implications for the safety of

    critically ill patients.

    The observational element of Day et al’s. (2002a) study

    ensures a more accurate reflection of what happens in

    practice than the descriptive retrospective studies discussed

    earlier (Swartz et al. 1996, Paul Allen & Ostrow 2000). This

    view is supported in the literature, which suggests that

    observational methods provide data on the realities of current

    practice from a first-hand perspective (Zeitz 2005). Day

    et al’s. (2002b) findings are, therefore, very significant as they

    support previous research that identified wide variations in

    nurses’ ETS practices (Swartz et al. 1996, Paul Allen &

    Ostrow 2000) and that nurses are inclined to rely on personal

    experience and ward routine to inform practice over any

    other source (Sole et al. 2003).

    Summary of the literature

    The literature search identified a paucity of empirical

    evidence relating to how well ETS is performed in the clinical

    area. The literature that does exist raises concerns about the

    standard of ETS practice among nurses (Paul Allen & Ostrow

    2000, Day et al. 2002b). This evidence is predominantly

    American and based on descriptive, retrospective studies that

    focus on closed suctioning systems (Swartz et al. 1996, Paul

    Allen & Ostrow 2000, Sole et al. 2003). While such studies

    are important for describing and documenting the aspects of

    ETS practice, they have one primary limitation. Participants

    may have a tendency to misrepresent attitudes or traits by

    giving answers that are consistent with prevailing social views

    (Polit et al. 2001). A few observational studies addressing

    nurses’ ETS practices are identifiable in the literature (Day

    et al. 2002b, McKillop 2004), with only one assessing how

    actual nursing practice are compared with the recommended

    practice (Day et al. 2002b).

    The inconclusive literature relating to nurses’ real ETS

    practices indicates the urgent need for more observational

    studies in this area. It is only by distinguishing between the

    real and perceived ETS practice that the degree of deviance, if

    any, from what the literature has established as being general

    best practice, can accurately be established.

    Method

    Aims

    The purpose of the study was to investigate open-system ETS

    practices of critical care nurses. Specific objectives were to:

    1 Examine critical care nurses’ practices prior to, during and

    post ETS;

    2 Compare nurses’ ETS practices with current research rec-

    ommendations.

    Based on the evidence, it is hypothesized that critical care

    nurses do not adhere to the best practice recommendations

    when performing ETS.

    Design

    A non-participant structured observational design was used

    for this study to gain insight into what is happening in

    practice. Structured observational studies involve the collec-

    tion of data that specify the behaviours or events selected for

    observation and are conducted in the participants’ natural

    environments (Polit et al. 2001). Fitzpatrick et al. (1994)

    suggest that direct observation is potentially a more compre-

    hensive method to ascertain how nurses perform in real

    situations and to identify differences, if any, in practice.

    Sample and setting

    The study took place in March 2005 on two adult ICU in

    Ireland. At the time of the study, the general ICU (GICU) had

    nine beds with the facility to ventilate patients in all beds at

    any one time. The cardiac ICU (CICU) had six beds and could

    facilitate the mechanical ventilation of six patients. GICU

    employed 53 full-time equivalent nurses and CICU employed

    34. The nurses were generally allocated to only one patient

    per shift. The targeted population of interest were critical-

    care nurses, as they predominantly perform ETS, while the

    sampling unit was the ETS event itself. Event sampling was

    deemed the most appropriate method of observation because

    of the erratic nature of the ETS procedure. By means of quota

    sampling, a total of 45 individual ETS events was observed,

    whereby each nurse performed only one event. Quota

    sampling is procedurally similar to convenience sampling;

    however, the researcher can guide the selection of subjects so

    that the sample includes an appropriate number of cases from

    each stratum (Polit et al. 2001), the strata in this instance

    S Kelleher and T Andrews

    362 � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369

    being GITU nurses and CICU nurses. The sample size

    (n ¼ 45) (51%) to be a representative sample of a combined total of 87 nurses (GITU 53, CITU 34) working on both ICUs

    and compares favourably with previous observational studies

    addressing ETS, wherein sample sizes ranged from n ¼ 9 (Blackwood 1998) to n ¼ 28 (Day et al. 2002b) observations. Inclusion and exclusion criteria were maintained.

    Inclusion criteria

    • Full-time ICU staff members; • Nurses with a minimum of one-year ICU experience on the

    study ICU.

    Participants were required to fulfil these inclusion criteria

    to be considered eligible for the study. This can be justified

    by the argument that an experienced ICU nurse from a

    different ICU, who has recently been appointed, may work

    from a different practice/knowledge base depending on the

    ICU he/she comes from. Equally, nurses who have minimal

    ICU experience may not have acquired/developed a satis-

    factory practice/knowledge base from which to work.

    Data collection

    Data were collected using a 20-item structured observational

    schedule (Appendix) adapted from a previously validated

    survey tool (McKillop 2004), which was constructed to

    reflect the observable behaviours associated with best-prac-

    tice suctioning of adults with an artificial airway (Thompson

    2000). Aspects of ETS practice that were not specified in the

    observational schedule developed by McKillop (2004) but

    implied in a systematic review by Thompson (2000) and

    established elsewhere as best-practice recommendations (Day

    et al. 2002a, Wood 1998a) were added to the instrument on

    the recommendation of experts in critical care nursing. The

    observational schedule was piloted to identify practical or

    local problems that might potentially affect the research

    process. No changes were made to the instrument based on

    the pilot study.

    All items on the observational schedule were weighted with

    the digits 0 and 1, or 0 and 2, respectively. The higher

    weighting (2) constituted adherence to the best ETS practice

    as recommended by Thompson (2000) following a systematic

    review of the literature. The lower weighting (1) represented

    adherence to what is marginally accepted as constituting best

    ETS practice as they emanate from traditional literature

    reviews (Day et al. 2002a, Moore 2003). The weighting of 0

    represented non-adherence to either of the aforementioned.

    High observation scores represented closer adherence to

    recommended best practice.

    Validity and reliability

    The observational schedule was distributed for appraisal to a

    range of experts in critical care nursing, including a university

    lecturer in critical care nursing, two senior nursing intensive

    care practitioners and the researcher who developed the

    original instrument. During the pilot study, the observational

    schedule was tested for interrater reliability using a second

    observer, and no significant discrepancies were identified.

    Ethical considerations

    Ethical approval to conduct the study was obtained from the

    appropriate ethics committee, and all participants were

    informed that their participation was voluntary and that

    their right to withdraw from the study would be respected at

    all times. Measures to ensure confidentiality and anonymity

    were implemented.

    Data analysis

    Descriptive statistics included frequency ratings and percent-

    ages for nominal-level data. A one-sample t-test was used to

    test the null hypothesis and compare participants’ ETS

    practices to ideal ETS best-practice recommendations.

    Analysis was performed using the Statistical Package for

    the Social Scientists (SPSS, version 9.0) software.

    Quality of treatment

    To assess how individual participants’ performances and

    subsequently a group’s performance compared with recom-

    mended best practice, a variable representing ‘recommended

    best practice’ had to be developed. This was developed by

    calculating the sum of the highest possible scores for each

    observation, which was established as being 35. Each of the

    20 items on the schedule was weighted with 0 and 1, or 0 and

    2 depending on the strength of supporting evidence for that

    particular aspect of ETS. The number 35 therefore represen-

    ted perfect adherence to best-practice recommendations, or

    ideal treatment. The higher a participant’s/group’s observa-

    tional score, the closer the participant/group adhered to

    best-practice recommendations. Similarly, the lower a parti-

    cipant’s/group’s score, the less likely was the adherence to

    best-practice recommendations. This additional variable was

    subsequently termed ‘quality of treatment’. For analysis, the

    variable was further divided into four subscales to describe

    the different aspects of the quality of treatment: practices

    prior to suctioning, infection control practices, the suctioning

    event and postsuctioning practices.

    Clinical nursing procedures Critical care nurses’ suctioning practices

    � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369 363

    Results

    In accordance with the observational schedule, the results

    were divided into five sections: practices prior to suctioning,

    infection control practices, the suctioning event, postsuction-

    ing practices and quality of treatment.

    Practices prior to suctioning

    When assessing the need for ETS, only two (12%) CICU and

    four (14%) GICU participants auscultated the patient’s chest

    (Table 1). All CICU participants communicated in some form

    to patients about the imminent procedure; however, eight

    (28%) GICU participants failed to communicate in any form.

    Similarly, a greater number of CICU participants were

    observed to perform hyperoxygenation on patients prior to

    ETS (n ¼ 16, 94%) compared with the GICU group (n ¼ 22, 79%).

    Infection control practices

    In relation to wearing gloves and an apron during the ETS

    procedure, there was no difference between the two groups as

    both were fully compliant with practice recommendations

    (Table 2). Disparities in practices were noted, however, in

    relation to hand washing prior to the procedure, maintaining

    the sterility of the suction catheter until its insertion into the

    airway and wearing goggles. Only nine (31%) GICU partic-

    ipants washed their hands before performing ETS in contrast

    to 11 (65%) from CICU. Ten (59%) CICU and eight (29%)

    GICU participants failed to maintain the sterility of the

    suction catheter prior to its insertion into the patient’s

    airway. Only two (12%) CICU, participants and one (3%)

    GICU participant wore goggles during the ETS procedure.

    The suctioning event

    Both groups complied fully with best-practice recommenda-

    tions in relation to suctioning time and application of

    pressure; however, all participants in both groups exceeded

    the recommended suctioning pressure of 80 and 150 mmHg

    (Table 3). Seven (40%) of the CICU group and eight (28%)

    of the GICU group selected a catheter that was larger than the

    recommended size for suctioning, and six (21%) GICU

    participants required more than the maximum number of

    recommended suction passes.

    Table 1 Practices prior to suctioning

    Variable Cardiac ICU (n ¼ 17) General ICU (n ¼ 28)

    Patient assessment

    No 15 (88%) 24 (86%)

    Yes 2 (12%) 4 (14%)

    Patient preparation

    No 0 8 (28%)

    Yes 17 (100%) 20 (72%)

    Prehyperoxygenation/hyperinflation

    Not given 1 (6%) 6 (21%)

    Given 16 (94%) 22 (79%)

    NaCl (sodium chloride)

    No 17 (100%) 28 (100%)

    Yes 0 0

    ICU, Intensive-care unit; n ¼ sample number.

    Table 2 Infection control practices

    Variable Cardiac ICU (n ¼ 17) General ICU (n ¼ 28)

    Hand washing

    No 6 (35%) 19 (69%)

    Yes 11 (65%) 9 (31%)

    Gloves wearing

    No 0 0

    Yes 17 (100%) 28 (100%)

    Apron wearing

    No 0 0

    Yes 17 (100%) 17 (100%)

    Catheter sterility

    No 10 (59%) 8 (28%)

    Yes 7 (41%) 20 (72%)

    Goggles

    No 14 (88%) 27 (97%)

    Yes 2 (12%) 1 (3%)

    ICU, Intensive-care unit; n ¼ sample number.

    Table 3 The suctioning event

    Variable

    Cardiac ICU

    (n ¼ 17) General ICU

    (n ¼ 28)

    Catheter size

    >Half internal diameter of ETT 7 (40%) 8 (28%)

    £ Half internal diameter of ETT 10 (60%) 20 (72%) Number of suctioning passes

    More than two 0 6 (21%)

    Two or less 17 (100%) 22 (79%)

    Suction time

    >15 seconds 0 0

    £ 15 seconds 17 (100%) 28 (100%) Suction pressure

    80–150 mmHg 0 0

    >150 mmHg 17 (100%) 28 (100%)

    Suction applied during

    Withdrawal 17 (100%) 28 (100%)

    Insertion 0 0

    ETT, endotracheal tube; ICU, Intensive-care unit; n ¼ sample number.

    S Kelleher and T Andrews

    364 � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369

    Postsuctioning practices

    Two (12%) participants from CICU and seven (24%) from

    GICU failed to provide post-ETS hyperoxygenation (Table 4).

    Only one (6%) CICU participant and two (7%) GICU

    participants auscultated the patients’ chest to evaluate the

    effectiveness of the ETS procedure. The main differences

    between the groups were in relation to hand washing and

    providing reassurance, with four (23%) CICU participants

    failing to wash their hands after the ETS procedure in

    comparison to 11 (38%) GICU participants. Patients were

    reassured by 15 (88%) CICU participants in contrast to 11

    (38%) from GICU.

    Quality of treatment

    Using a frequency distribution, the average treatment quality

    across both groups was 22Æ62 (SD ¼ 3Æ10) (Table 5). The

    quality of treatment scores ranged from 14–30. Within the

    subscales, the highest average score was found in postsuc-

    tioning practices (mean ¼ 6Æ47, SD ¼ 1Æ53) and the lowest average score was found in infection control measures

    (mean ¼ 4Æ67, SD ¼ 1Æ17). A symmetric distribution was identified in the variable ‘treatment quality’ and its subscales.

    Testing the null hypothesis

    To compare participants’ ETS practices with best-practice

    recommendations, a one-sample t-test was conducted, which

    compared the treatment quality observed with the ideal

    treatment quality score (Table 6). The test identified signifi-

    cant differences between the quality of treatment and its

    subscales (representing the combined ETS practices on both

    units) and the perfect score (representing recommended best

    practice). In all categories, the quality of treatment observed

    was significantly lower than the quality of treatment required

    (p ¼ 0Æ01). This indicates that our study’s sample group only partially adhered to best-practice recommendations when

    performing ETS and hence rejects the null hypothesis.

    Discussion

    The findings from this study have raised some interesting

    issues relating to the current ETS practice of critical care

    nurses. Best-practice ETS recommendations suggest that,

    when performing a respiratory assessment, nurses should

    auscultate the patient’s chest to verify the need for ETS

    (Thompson 2000, Day et al. 2002a, Wood 1998a). Our

    findings show that the participants generally failed to do this.

    Day et al. (2002b) reported similar findings in a study of

    acute and high-dependency ward nurses. Their findings

    showed that only two nurses were observed to have

    performed auscultation. Given that the majority of partici-

    pants failed to auscultate lung sounds prior to ETS, it is

    possible that they were working from a combination of

    clinical signs that indicated the necessity for ETS, such as

    Table 4 Postsuctioning practices

    Factor Cardiac ICU (n ¼ 17) General ICU (n ¼ 28)

    Oxygen reconnection

    >10 seconds 0 1 (3%)

    <10 seconds 17 (100%) 27 (97%)

    Postsuctioning hyperoxygenation

    No 2 (12%) 7 (24%)

    Yes 15 (88%) 21 (76%)

    Post-ETS assessment

    No 16 (94%) 26 (93%)

    Yes 1 (6%) 2 (7%)

    Patient reassured

    No 2 (12%) 17 (62%)

    Yes 15 (88%) 11 (38%)

    Hand washing postsuctioning

    No 4 (23%) 11 (38%)

    Yes 13 (77%) 17 (62%)

    Safety

    No 0 0

    Yes 17 (100%) 17 (100%)

    ICU, Intensive-care unit; n ¼ sample number.

    Table 5 Quality of Treatment

    Practices Prior

    to Suctioning

    Infection Control

    Practices

    Suctioning Event

    Practices Post Suctioning

    Quality of

    Treatment

    N 45Æ00 45Æ00 45Æ00 45Æ00 45Æ00 Mea 5Æ56 4Æ67 5Æ93 6Æ47 22Æ62 Median 6Æ00 5Æ00 6Æ00 7Æ00 23Æ00 Mode 6Æ00 5Æ00 7Æ00 8Æ00 25Æ00 Standard Deviation (SÆD) 1Æ27 1Æ17 1Æ12 1Æ53 3Æ10 Range 6Æ00 5Æ00 5Æ00 6Æ00 16Æ00 Minimum 2Æ00 3Æ00 2Æ00 3Æ00 14Æ00 Maximum 8Æ00 8Æ00 7Æ00 9Æ00 30Æ00

    Clinical nursing procedures Critical care nurses’ suctioning practices

    � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369 365

    noisy breathing or visible secretions in the airway (Thompson

    2000). A limitation of observational methods, however,

    meant that there was no way of establishing whether

    participants’ decision to perform ETS was informed by such

    indicators or whether they were working from some other

    perspective, such as unit routine, as is suggested in the

    literature (Swartz et al. 1996, Day et al. 2002a).

    Despite abundant evidence on the negative consequences of

    suctioning induced hypoxemia (Wood 1998a, Thompson

    2000, Day et al. 2002a) 17 participants still failed to provide

    hyperoxygenation/hyperinflation either before and/or after

    ETS. Day et al. (2002b)) reported similar findings, where only

    two out of 10 subjects in their study were observed to provide

    hyperoxygenation/hyperinflation in practice. Such findings

    are important as they have direct implications for patient

    safety and reflect poorly on a vital aspect of nursing care.

    Nosocomial infections are among the most common

    complications affecting hospitalized patients (Burke 2003).

    Consequently, the importance of aseptic technique in suc-

    tioning practices and hand washing before and after such

    procedures is strongly emphasized in the literature (Thomp-

    son 2000, Wood 1998a, Day et al. 2002a). Twenty-five

    participants in our study were not observed to wash their

    hands prior to the ETS procedure. Boyce and Pittet (2003)

    suggest that nurses do not wash their hands as expected

    because of the time it takes out of a busy work schedule,

    particularly, in high-demand situations, such as critical care

    units, under busy working conditions and at times of

    overcrowding or understaffing. One study conducted in an

    ICU demonstrated that it took nurses an average of 62 sec-

    onds to leave a patient’s bedside, walk to a sink, wash their

    hands and return to patient care (Boyce & Pittet 2003).

    Notably, however, all participants in our study were

    observed to wear gloves and an apron during ETS. This

    may suggest a perception among nurses that wearing gloves

    and using a ‘non-touch’ aseptic technique when inserting the

    suction catheter negates the need for frequent hand washing.

    However, the literature clearly suggests that gloves do not

    replace the need for hand washing (Pratt et al. 2001). These

    findings support earlier studies that report modest and even

    low levels of adherence to recommended hand-hygiene

    practices (Thompson 2000, Boyce & Pittet 2003).

    Another area of particular concern is the suction pressure

    used when performing ETS. High negative pressure can cause

    mucosal trauma, which in turn predisposes the bronchial tree

    to a higher risk of infection (Wood 1998a). Using high

    negative pressures does not necessarily mean that more

    secretions will be aspirated; therefore, limiting pressures to

    between 80–150 mmHg is recommended (Wood 1998a,

    Thompson 2000, Day et al. 2002a). The results indicated

    that all participants used suction pressures outside the

    recommend levels for safe practice with suction pressures

    ranging form 230 to 450 mmHg. Participants on GICU

    generally used lower suctioning pressures, ranging from 230–

    380 mmHg, which still exceeded the recommended pressures

    for safe practice. Again these findings support the study by

    Day et al. (2002b) which found nurses to be generally

    unaware of recommended best ETS practice.

    Recommendations for education, practice and research

    • As a matter of urgency, institutional policies and guide- lines, which are not based on current best-practice rec-

    ommendations, need to be developed and/or reviewed.

    • Teaching interventions to improve nurses’ knowledge and competence in the care of patients requiring ETS is indi-

    cated particularly with regard to auscultataion skills,

    hyperoxygenation practices, suctioning pressures and

    infection control measures.

    • The orchestration and implementation of effective educa- tional interventions to change practice may be time con-

    suming. Therefore, in the interim, it is recommended that

    nurses become familiar with the clinical indicators for ETS

    and how to perform a simple respiratory assessment on

    ventilated patients.

    • Infection control guidelines need to be reinforced and monitored to ensure compliance.

    • A regular audit of ETS practice is recommended to ensure that patient safety is being assured.

    Table 6 A comparison between

    current practice and best-practice

    recommendations Variable

    Maximum potential score

    (representing best practice)

    Mean (actual

    score) SD T DF

    Quality of treatment 35 22Æ62 3Æ10 �24Æ63* 44 Practices prior to suctioning 8 5Æ56 1Æ27 �12Æ90* 44 Infection control practices 9 4Æ67 1Æ17 �19Æ15* 44 The suctioning event 9 5Æ93 1Æ11 �18Æ43* 44 Postsuctioning practices 9 6Æ47 1Æ53 �11Æ10* 44

    *p < 0Æ01.

    S Kelleher and T Andrews

    366 � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369

    This observational study was successful in achieving its

    objectives; however, further observational studies need to be

    conducted to substantiate the findings. Observation coupled

    with a form of ‘think-aloud’ methodology may uncover the

    reasons behind nurses’ decisions (in ‘think-aloud’ techniques,

    subjects are questioned and asked to ‘think aloud’ in regard

    to a particular aspect of their ETS practice). Such method-

    ologies are recognized as a useful source of data collection in

    observational studies (Yang 2003).

    Limitations

    Observation, like other methods has its own limitations and

    ethical implications (Parahoo 1997). One of the main

    problems is the effect of the ‘observer’ on the ‘observed’.

    This is referred to as the Hawthorne effect and is an

    important threat to the validity of observational research,

    whereby participants’ knowledge of being in a study may

    cause them to change their behaviour (Polit et al. 2001). In

    our study, the Hawthorne effect may have resulted in

    participants rehearsing ETS according to evidence-based

    recommendations prior to the observations. This being the

    case, it could be suggested that participants’ practice is

    normally of a poorer quality than the results of our study

    suggests.

    Given the observational nature of the study, there were

    several aspects of the ETS procedure that could not be

    assessed. It was not possible to determine participants’

    reasons for their practice, for example, the only observable

    aspect of patient assessment was the practice of auscultation,

    and even then, it was not possible to determine what

    participants heard and how it was interpreted. This may

    have resulted in an inaccurate interpretation of some of the

    data.

    The sample size was not assessed for statistical significance.

    A power analysis would have established accurate sample size

    requirements for the study and consequently enhanced the

    representativeness of the findings (Polit et al. 2001). The

    evidence used to develop the observational tool for this study

    derived from what might be regarded as the best evidence

    available at the time of conducting the study; however, there

    is still some disparity in regard to what exactly constitutes

    best practice owing to the paucity of empirical research

    regarding ETS.

    Finally, while the study was conducted on two different

    ICUs, they were both part of one institution. The findings

    therefore may not be representative of the general population

    of ICU nurses and threatens the external validity of the

    findings. This could have been enhanced by spreading

    observations over a range of sites, in different geographical

    locations.

    Conclusion

    This study supports the general finding in the literature that

    nurses adhere only partially to best-practice recommenda-

    tions in relation to ETS (Celik & Elbas 2000, Paul Allen &

    Ostrow 2000, Day et al. 2002b). Under the code of

    professional practice, nurses are obliged to ensure patient

    safety and expected by the public and their employer to

    provide high-quality, efficient, well-executed and appropriate

    care of individuals (Huber 2000). By failing to adhere to what

    the literature has established as best ETS practice, nurses fall

    short of fulfilling any of the aforementioned expectations.

    Despite an increased uptake in postregistration education

    among critical care nurses and a heightened interest in the

    expansion of their role, the literature indicates that they

    remain poor at many of the aspects of care that might be

    considered basic. Nurses need to assess and improve their

    current practices continually to guarantee that evidence-

    based practice recommendations are being adhered to and

    patient safety is being assured. This can only be achieved

    when nurses become more aware of their professional

    responsibilities and receive adequate support in practice.

    Acknowledgement

    We would like to acknowledge the advice of a statistician Itai

    Beerei, University College Cork.

    Contributions

    Study design: SK and manuscript preparation; SK, TA.

    References

    Blackwood B (1998) The practice and perception of intensive care

    staff using the closed suctioning system. Journal of Advanced

    Nursing 28, 1020–1029.

    Boyce J & Pittet D (2003) Guideline for hand hygiene in health-

    care settings. Recommendations of the Healthcare Infection

    Control Practices Advisory Committee and the HICPAC/SHEA/

    APIC/IDSA Hand Hygiene Task Force Morbidity and Mortality

    Weekly Report. Centers for Disease Control and Prevention

    51(RR16), 1–44.

    Burke J (2003) Infection control – a problem for patient safety. The

    New England Journal of Medicine 348, 651–656.

    Celik S & Elbas N (2000) The standard of suction for patients

    undergoing endotracheal intubation. Intensive and Critical

    Care Nursing 16, 191–198.

    Clinical nursing procedures Critical care nurses’ suctioning practices

    � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369 367

    Cormack D & Benton D (1996) (ed) The Research Process in

    Nursing, 3rd edn. Oxford Blackwell Science, pp. 357–372.

    Craig J & Smyth R (2002) The Evidence based Practice Manual for

    Nurses. Churchill Livingstone, London.

    Day T, Farnell S & Wilson-Barnett J (2002a) Suctioning: a review of

    current research recommendations. Intensive and Critical Care

    Nursing 18, 79–89.

    Day T, Farnell S, Haynes S, Wainwright S & Wilson-Barnett J

    (2002b) Tracheal suctioning: an exploration of nurses’ knowledge

    and competence in acute and high dependency ward areas. Journal

    of Advanced Nursing 39, 35–45.

    Dickson R (2003) Systematic reviews. In Achieving Evidence Based

    Practice. A Handbook for Practitioners (Hamer S & Collinson G

    eds). Balliere Tindall, London.

    Fitzpatrick JM, While AE & Roberts JD (1994) The measurement of

    nurse performance and its differentiation by course of preparation.

    Journal of Advanced Nursing 20, 761–768.

    Glacken M & Chaney D (2004) Perceived barriers and facilitators to

    implementing research findings in the Irish practice setting. Journal

    of Clinical Nursing 13, 731–740.

    Glass CA & Grap MJ (1995) Ten tips for safer suctioning. American

    Journal of Nursing 5, 51–53.

    Huber D (2000) Leadership and Nursing Care Management, 2nd

    edn. Saunders, Philadelphia.

    Hundley V, Milne J, Leighton-Beck L, Graham W & Fitzmaurice A

    (2000) Raising research awareness among midwives and nurses:

    does it work? Journal of Advanced Nursing 31, 78–88.

    McKillop A (2004) Evaluation of the implementation of a best

    practice information sheet: tracheal suctioning of adults with an

    artificial airway. Joanna Briggs Institute Reports 2, 293–308.

    Moore T (2003) Suctioning techniques for the removal of respiratory

    secretions. Nursing Standard 18, 47–53.

    Parahoo K (1997) Nursing research, principles, process and issues,

    Palgrave Macmillan: London.

    Paul Allen J & Ostrow L (2000) Survey of nursing practices with

    closed system suctioning. American Journal of Critical Care 9,

    9–17.

    Polit D, Beck C & Hungler B (2001) Essentials of Nursing Research.

    Methods, Appraisal and Utilization, 5th edn. Lippincott, Williams

    and Wilkins, Philadelphia.

    Pratt RJ, Pellowe C, Loveday HP, Robinson N & Smith GW (2001)

    The epic project: developing national evidence based guidelines for

    preventing health care associated infections. Phase 1: guidelines for

    preventing hospital acquired infections. Journal of Hospital

    Infection 47, S1–S82.

    Sole M, Byers J, Ludy J, Zhang Y, Banta C & Brummel K (2003) A

    multisite survey of suctioning techniques and airway management

    practices. American Journal of Critical Care 12, 220–232.

    Swartz K, Noonan D & Edwards-Beckett J (1996) A national survey

    of endotracheal suctioning techniques in the pediatric population.

    Heart and Lung: The Journal of Acute and Critical Care 25,

    52–60.

    Thompson L (2000) Suctioning adults with an artificial airway. A

    systematic review. The Joanna Briggs Institute for Evidence Based

    Nursing and Midwifery. Systematic Review No. 9.

    Wainwright S & Gould D (1996) Endotracheal suctioning in adults

    with severe head injury: a literature review. Intensive and Critical

    Care Nursing 12, 303–308.

    Wood C (1998a) Can nurses safely assess the need for endotra-

    cheal suction in short term ventilated patients, instead of using

    routine techniques? Intensive and Critical Care Nursing 14, 170–

    178.

    Wood C (1998b) Endotracheal suctioning: a literature review.

    Intensive and Critical Care Nursing 14, 124–136.

    Yang SC (2003) Reconceptualizing think aloud methodology: refi-

    ning the encoding and categorizing techniques via contextualized

    perspectives. Computers in Human Behaviour 19, 95–115.Avail-

    able at: http://www.elsevier.com/locate/comphumbeh (accessed 11

    January 2005).

    Zeitz, K. (2005) Nursing observations during the first 24 hours after

    a surgical procedure: what do we do? Journal of Clinical Nursing

    14, 334–343.

    Appendix: observational schedule

    Practices prior to suctioning

    1: Patient assessment

    Did the nurse auscultate the patient’s chest before ETS?

    0 ¼ No 2 ¼ Yes (Wood 1998a, Thompson 2000, Day et al. 2000)

    2: Patient preparation

    Did the nurse explain to/communicate with the patient

    about the procedure?

    0 ¼ No 2 ¼ Yes (Wood 1998a, Thompson 2000, Day et al. 2000)

    3: Presuctioning hyperoxygenation/ hyperinflation

    0 ¼ Not given 2 ¼ Given by means of manual resuscitation bag/given by ventilator (Thompson 2000, Day et al. 2000)

    4: Sodium chloride instillation

    0 ¼ Yes 2 ¼ No (Wood 1998a, Thompson 2000, Day et al. 2000)

    Infection control practices

    5: Hands are washed prior to suctioning

    0 ¼ No 2 ¼ Yes (Wood 1998b, Thompson 2000, Day et al. 2000)

    6: Gloves are worn

    0 ¼ No 2 ¼ Yes (Wood 1998a, Thompson 2000, Day et al. 2000)

    7: Apron is worn

    0 ¼ No 1 ¼ Yes (Wood 1998a, Day et al. 2000)

    8: Sterility of suction catheter maintained until inserted into

    airway

    0 ¼ No 2 ¼ Yes (Wood 1998a, Thompson 2000, Day et al. 2000)

    S Kelleher and T Andrews

    368 � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369

    9: Goggles/face mask worn

    0 ¼ No 2 ¼ Yes (Wood 1998a, Thompson 2000, Day et al. 2000)

    The suctioning event

    10: Size of suction catheter ………………… Size of ETT ………………………….. 0 ¼ >Half of the internal diameter of ETT 2 ¼ £Half of the internal diameter of ETT (Wood 1998a, Thompson 2000, Day et al. 1998)

    11: Number of suction passes.……………………… 0 ¼ >2 1 ¼ <2 (Thompson 2000)

    12: Length of time suction applied to airway

    0 ¼ More than 15 seconds 2 ¼ Less than 15 seconds (Wood 1998a, Thompson 2000, Day et al. 2000)

    13: Level of suction pressure

    0 ¼ <80 mmHg/ >150 mmHg 2 ¼ 80–150 mmHg (10Æ6–20 kPa) (Thompson 2000, Day et al. 2000)

    14: Position of catheter when suction applied

    0 ¼ suction applied during insertion 2 ¼ suction applied during withdrawal from airway only (Thompson 2000, Day et al. 2000)

    Postsuctioning practices

    15: Patient reconnected to oxygen

    0 ¼ >10 seconds post suctioning 1 ¼ within 10 seconds post suctioning (Day et al. 2000)

    16: Postsuctioning hyperoxygenation/hyperinflation

    0 ¼ Not given 2 ¼ Given by means of manual resuscitation bag/ventilator (Wood 1998a, Thompson 2000, Day et al. 2000)

    17: Post-ETS assessment

    Did the nurse auscultate the patient’s chest?

    0 ¼ No 1 ¼ Yes (Day et al. 2000)

    18: Patient reassured

    0 ¼ No 1 ¼ Yes (Day et al. 2000) 19: Hands washed postsuctioning

    0 ¼ No 2 ¼ Yes (Wood 1998a, Thompson 2000, Day et al. 2000)

    20: Used catheter and gloves are disposed of in a manner that

    prevents contamination from secretions

    0 ¼ No 2 ¼ Yes (Thompson 2000)

    Clinical nursing procedures Critical care nurses’ suctioning practices

    � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 17, 360–369 369

 
Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount!
Use Discount Code "Newclient" for a 15% Discount!

NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.