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Original Article
Exploratory study on the knowledge and skill of
critical care nurses on endotracheal suctioning
Abstract
Sruthy T Varghese, KT Moly
Department of Medical and
Surgical, Amrita College of
Nursing, Amrita Institute of
Medical Sciences, (Affliated to
Amrita Vishwa Vidyapeetham
University), Kochi,
Kerala, India
Address for correspondence:
Ms. Sruthy T Varghese,
Amrita College of Nursing, Amrita
Institute of Medical Sciences,
(Affliated to Amrita Vishwa
Vidyapeetham University),
Kochi, Kerala, India.
E‑mail: varghese_sruthy@yahoo.
com
Access this article online
Website: www.nabh.ind.in
DOI: 10.4103/2319-1880.187753
Quick Response code:
13 © 2016 The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Published by Wolters Kluwer - Medknow
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
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.
Key words: Critical care nurses, endotracheal suctioning, knowledge, skill
INTRODUCTION
Mechanical ventilators are special pumps that can support the ventilatory function of the
respiratory system and improve oxygenation through the application of high oxygen content gas
and positive pressure. Another epidemiological study including 15,757 patients in the Intensive
Care Units (ICUs) from twenty countries reported that 5183 patients (33%) required mechanical
ventilation.[1,2]
The primary objectives of mechanical ventilation are to decrease their work of breathing,
relieve respiratory distress, rest the fatigued respiratory muscles, improve ventilation, stabilize
the chest wall, and restore the acid–base balance. Therefore, the most common reasons for
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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.
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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

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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
than 3 years of experience in the critical care unit.
Distribution of sample based on their knowledge
level on endotracheal suctioning
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.
Table 4 shows that the maximum score of the observation checklist
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.
Table 5 depicts that among the four different phases of ET
suctioning observed, 86% of the critical care nurses skill in the
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)

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

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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

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

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Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning
observational correlational study by Jansson et al. on the evaluation
of ET suctioning practices conducted in ICUs (n = 40) also reported
that only 5.3% of the nurses performed chest auscultation before
suctioning and 0% postsuctioning.[9] Given that the majority of the
participants failed to auscultate lung sounds before ET suctioning,
it might be possible that they were working from a combination of
clinical signs that indicated the necessity for ET suctioning, such
as noisy breathing or visible secretions in the airway. A limitation
of observational methods, however, meant that there was no way
of establishing whether participants’ decision to perform ET
suctioning was informed by such indicators or whether they were
working from some other perspectives such as unit routine as is
suggested in the literature.[8] Failure in auscultation before and
after suctioning in the present study and above‑mentioned studies
most probably indicates that nurses continue to practice based on
mostly symptoms and not signs. This also indicates the necessity
of including physical examination mandatorily in nursing practice.
Evidence from the present study revealed that only 30% of
the participants explained the procedure to the patient before
suctioning and 18% reassured patient after suctioning. However,
this was contradictory to the findings of a study by Jansson et al.,
where 61.5% of the participants explained the procedure to the
patient before suctioning and 62.5% reassured the patient after
suctioning.[9] A similar picture was found in the study by Kelleher
and Andrews which was an observational study on the open‑system
ET suctioning practices of critical care nurses, Ireland (n = 45),
where only 28% of the participants in general ICU (GICU) failed
to communicate in any form.[8] However, these contradictory results
are an eye opener that indicates good communication is possible
inside an ICU despite the condition of the patient.
Despite the abundance of evidence on the negative consequences of
suctioning‑induced hypoxemia, in the present study, only 54% of the
participants performed presuctioning hyperoxygenation, though it is
worth noting that 74% of the participants performed hyperoxygenation
postsuctioning. Field notes by the researcher identified that the nurses
used Ambu or ventilator for hyperoxygenation/hyperinflation, but
the technique varies among ICUs. A similar picture could be seen in
the study by Kelleher and Andrews, where 17 out of 45 participants
failed to provide hyperoxygenation/hyperinflation either before or
after ET suctioning.[8] The routine practice may have been learned
from each other without ever actually understanding the rationale
for its use. This also shows that practices among nurses might be
routine, symptom‑oriented, and not proactive.
Another area of concern was normal saline instillation which
was practiced by 30% of the participants in the present study.
This was reflected in the study by Jansson et al., where 25% of
the participants performed normal saline instillation.[9] Similar
findings were seen in earlier work in the ICU setting too, with
100% (n = 16) of nurses believing that saline should be used
to loosen secretions. What is even more worrying is that most
of these nurses (n = 11, 69%) were aware of the complications
The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1
of saline. Bostick and Wendelglass (1987) argued that this is an
example of a widely practiced intervention that is not supported
by research. In fact, there is considerable research evidence against
its use (Blackwood 1999). AARC also does not recommend using
normal saline instillation as a routine practice while performing ET
suctioning. Hence, this a controversial issue which further requires
scientific evidence. French (1999) argued that despite an increasing
body of knowledge about the effectiveness of interventions, there
remains a discrepancy between theoretical knowledge and practical
application. This argument certainly seems to apply.[10]
It was found in the present study that only 6% of the participants wore
apron, only 42% of the participants washed hands before suctioning,
and 28% postsuctioning. It is appreciable to note that 100% of the
participants wore glove and 88% wore face mask during suctioning.
A similar finding could be seen in the study by Kelleher and Andrews
where hand washing was poorly performed (GICU: 31% and CICU:
65%) and only a few wore goggles (CICU: 12%, GICU: 3%) during
the ET suctioning procedure. However, all the participants had worn
gloves, face mask, and apron.[9] It is recommended strongly in many
literature that hands should be washed before and after suctioning and
that aprons, gloves, and goggles should be worn during suctioning to
reduce the risk of infection before suctioning as well as prevent cross
infection after suctioning.[9] This was contradictory to the findings of the
study by Jansson et al., where hand washing was performed by 72.2%
of the participants before suctioning and 52.5% postsuctioning. One
hundred percent of the participants wore gloves, 97.5% wore face mask,
32.5% wore apron, and 25% protected their eyes from infection.[9]
These findings may suggest a perception among nurses that wearing
gloves and using a “non‑touch” aseptic technique when inserting
the suction catheter negate the need for frequent hand washing, yet
the literature clearly suggests that gloves do not replace the need
for handwashing (Pratt et al. 2001). Protective eyewear is especially
important, as the eye itself and surrounding delicate mucous’
membranes are very vascular. Any splashes of infective sputum
could pose a serious infection control threat to the practitioner who is
performing the procedure.[8] The practice of wearing apron and goggle
is an uncommon practice in many hospitals around the country; this
might be the reason that only 6% of the participants in the present
study had worn apron and that none of them wore goggle.
Above all, sterility of the suction catheter until inserted into the
airway was maintained only by 46% of the participants in the
present study. Even, Kelleher and Andrews have mentioned in
their study that 10 (59%) CICU and 8 (29%) GICU participants
failed to maintain the sterility of the suction catheter before its
insertion into the patient’s airway.[8]
The field notes maintained by the researcher identified that
most often, catheter touches the patient linen and nonsterile
glove touches the catheter and small opening tip of normal
saline bottle, through which nurses try to squeeze in the catheter
for cleaning. The equipment listed by AARC guideline on ET
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Varghese and Moly: Knowledge and skill of critical care nurses on endotracheal suctioning
suctioning has clearly stated that sterile water and cup and sterile
glove have to be used for open ET suctioning technique.[11]
In the present study, 64% of the participants failed to apply
suction to airway for < 15 s. The recommended practice suggests
that suctioning should take between 10 and 15 s to perform,
as longer durations are associated with an increased risk of
hypoxemia and trauma (Boggs 1993).[10]
Another area of particular concern was that only 10% of the
participants maintained a suction pressure between 80 and
150 mmHg while performing ET suctioning. The field notes by
the researcher identified that participants maintained a suction
pressure between 250 and 450 mmHg, which was much higher
than the recommended pressure. High negative pressure will cause
mucosal trauma, which, in turn, predisposes the bronchial tree to
a higher risk of infection. Using high negative pressures does not
mean that more secretions will be aspirated, therefore limiting
pressures to between 80 and 150 mmHg is recommended.[8]
Results from the study by Kelleher and Andrews indicated that
all participants used suction pressures outside the recommended
levels for safe practice with suction pressures ranging from 230
to 450 mmHg. Participants from GICU generally utilized lower
suctioning pressures, ranging from 230 to 380 mmHg, but
again these still exceeded the recommended pressures for safe
practice.[8] Another study by Jansson et al. also supported the
same finding where only 15% of the participants maintained a
suction pressure between 80 and 150 mmHg.[9]
The above findings indicate that there are many concerns regarding
the adherence of critical care nurses on ET suctioning. This was
confirmed when a comparison was made between observed practice
and the best recommended practice on ET suctioning. A significant
difference (P < 0.01) was obtained between current practice and
best recommended practice. These findings were in line with the
inference of two studies; by Kelleher and Andrews (2008)[8] and by
Jansson et al.,[9] where it was found that in all categories, there was
significant difference (P < 0.001) between the quality of treatment
observed and quality of treatment required in ET suctioning.
The above‑discussed studies indicate that there is a gap between
the knowledge and skill of critical care nurses. However, a number
of studies have demonstrated the gap between the theory and
practice on ET suctioning. Larsen et al. (2002) believe that there is
no gap between theory and practice using the sociological theory
of Bourdieu, which challenged the “barrier paradigm” that has
traditionally highlighted the gap between knowledge and practice.[10]
CONCLUSION
The study has shown deficit areas of knowledge and skill
in specific phases of ET suctioning as well as a significant
difference between the current practice observed and best
19 The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jan-Jun 2016 | Vol 3 | Issue 1
recommended practice on ET suctioning. This may be because
the nurses practice ET suctioning as learned from others or due
to inadequate training during student/staff period. The need
for skill training program specific to practice areas of nursing
before independent patient care assignment in critical care unit
has become evident through the present study.
Acknowledgment
I thank Mr. Seán J. Kelleher for permitting me to use the
observation checklist. Moreover, I would like to thank every
person who supported and encouraged me to complete the
research study successfully.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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