http://doi.org/10.33698/NRF0175 Savita Sharma, Jyoti Sarin, Gurneet Kaur Bala
Abstract: Intubated patients are unable to clear secretions effectively; as glottis closure is compromised and normal mucociliary function is impaired. Therefore, all patients with an artificial airway require endotracheal suctioning to remove secretions, prevent airway obstruction and
complications (Ventilator Associated Pneumonia). The study was aimed to evaluate the effectiveness
of endotracheal suctioning protocol in terms of knowledge and practices of nursing personnel. The
structured knowledge questionnaire and an observation checklist regarding endotracheal suctioning
was developed and used for data collection and the endotracheal suctioning protocol was also
developed and nurses were educated as per protocol.An experimental approach was used with quasi
experimental design. Pre and post-implementation data from 30 purposively selected ICU nursing
personnel of Maharishi Markandeshwar Institute of Medical Science &Research Hospital, Mullana was
collected. Subsequent reinforcements were given until >80% practice score was achieved. Findings of
the study revealed that the mean post-implementation knowledge score and practice score of nursing
personnel regarding endotracheal suctioning was significantly higher than the mean preimplementation
knowledge and practice score (p<0.001). Hence, the protocol was effective in
enhancing the knowledge and improving the practices of nursing personnel regarding the endotracheal
suctioning.
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 48
Although mechanical ventilation is
essential to maintain ventilation and
oxygenation, it can cause adverse effects.
Patients on mechanical ventilation are prone
to develop complications such as alveolar
hypoventilation, alveolar hyperventilation,
f l u i d a n d e l e c t r o l y t e i m b a l a n c e ,
pneumothorax and Ventilator Associated
3 Pneumonia (VAP) . Studies have shown that
Ventilator Associated Pneumonia is one of
the most common infectious complications
among patients admitted in intensive care
units and accounts for up to 47% of all
infections among intensive care unit
patients.It prolongs the length of stay in
intensive care unit and increase the risk of
4 death in critically ill patients .
The nurse monitors the client’s
response to ventilation, intervenes to
maintain oxygenation and ventilation and
ensures that the client’s complex needs are
met. Therefore, in order to provide a better
comprehensive care to the mechanically
ventilated patient and to reduce the cases of
common complications of endotracheal
suctioning, it is important that the nurse has
knowledge based on valid scientific evidence
concerning the different methods of
endotracheal suction and aspects related to
it. Despite this, the practice of endotracheal
1 tube (ETT) suctioning continues without
adequate evidence for the different
techniques used. The available guidelines do
not address any dimensions of the suction
catheters other than the cross sectional
diameter, factor of variation in mucus
characteristics; nor do they seem to consider
the relationships between endotracheal tube
and catheter size (length and diameter) and
suction pressures; and the potential effects
5 these may have on the lung(s) .
A study done in United Kingdom
revealed that many nurses have failed to
demonstrate an acceptable level of
competence and some of the practices
6 observed were potentially unsafe.
Compliance with hand washing guidelines
was reported by 82%, 75% reported wearing
gloves, 50% reported elevating head of bed,
33% reported performing suctioning and
7 50% reported having oral care protocol . An
experimental study was conducted to assess
the knowledge of nurses before, immediately
after and 4 weeks after the intervention
through a self-developed validated tool.
Knowledge scores of participants increased
significantly after the educational
intervention in the first post-test. The 5-hour
teaching module significantly enhanced
nurse’s knowledge towards evidence based
guidelines for the prevention of Ventilator
8 Associated Pneumonia . Therefore, nurses
should ensure that their knowledge and skills
are maintained. Nurses should also make
sure that they under take role in accordance
with their original protocols, policies and
9 guidelines .
A study was conducted to determine the
knowledge and practice of 48 nurses of
cardiovascular surgery intensive care unit
before and after training and the
development of standard practice guidelines
for open and closed system suctioning
methods in patients with endotracheal tube
using a questionnaire and nurse observation
forms. This study concluded that the
compliance of the nurses to the standard
practice guidelines for open and closed
suctioning and their knowledge levels on the
subject were increased after training, while
the implementation of standards was
10 satisfactory .
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 49
A study assessed the performance of
tracheal suctioning by direct observation and
knowledge on the procedure was assessed
using a self-administered questionnaire. The
study concluded that the nurses have
scientific knowledge of the suctioning
procedure better than their practice
11 competency .
A study explored the knowledge and
competence of nurses in performing tracheal
suctioning. Twenty eight nurses were
observed using nonparticipant observation
and structured observation schedule. The
study demonstrated that the majority of the
subjects (n=14) failed to perform the
suctioning as accurately as subjects had
reported. The mean score for knowledge was
11.1 and 10.3 for practice (maximum score
20). The study concluded that a poor level of
knowledge for many subjects was reflected
in practice. This study suggested that nurse
require support, education, and training
12 relating to tracheal suctioning .
Knowledge and experience can
determine a nurse’s ability to adequately
perform endotracheal tube suctioning. All
nurses who perform suction must receive
approved training and demonstrate
competence under supervision. They should
ensure that their knowledge and skills are
maintained. Nurses should also make sure
that they under take role in accordance with
their original protocols, policies and
guidelines. But many researchers have
identified that nurses are unaware of the
current suctioning recommendations and
practice is often based on ritual and tradition
as opposed to empirical evidence. Hence the
researcher has taken up the study to evaluate
the effectiveness of endotracheal suctioning
protocol in terms of knowledge and practices
of nursing personnel.
Objectives
To evaluate the effectiveness of
endotracheal suctioning protocol in terms of
knowledge and practices of nursing
personnel.
Materials and Methods
The study was carried out in four
intensive care units, i.e ICU, ICCU, Pediatric
ICU and Neonatal ICU of Maharishi
Markandeshwar Institute of Medical Science
& Research Hospital, a 815 bedded multispecialty
hospital situated in the campus of
MM Universiy, Mullana, Ambala in rural area.
The endotracheal suctioning protocol is
scientific and systematic written guidelines
regarding endotracheal suctioning which
includes aims and indications of
endotracheal suctioning, equipment
required and steps of per forming
endotracheal suctioning, nursing care and
special considerations during endotracheal
suctioning which was developed and
validated by experts in the field of nursing
and medical science. Feasibility of
implementing protocol was checked through
pilot study and necessary language
modifications were incorporated in the
protocol.
Data was collected by using other tools
consisted of sample characteristics
p r o f o r m a , s t r u c t u r e d k n o w l e d g e
questionnaire consists of 30 knowledge
items regarding endotracheal suctioning
with maximum possible score of 30,
observation checklist consists of 58 items
regarding endotracheal suctioning with
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 50
maximum possible score of 58. The tools in
the study were developed based on extensive
review, expert’s guidance and informal
observation of present setting by researcher
and validated by experts in the field of Child
Health Nursing, Medical-Surgical Nursing
and Paediatric Medicine. Reliability of
structured knowledge questionnaire was
found to be 0.653 and percentage of
agreement for inter-rater reliability of
observation checklist was found to be 80%.
Sample includes nursing personnel
available, working in intensive care units and
rendering direct patient care. Total sample of
30 nursing personnel were selected by using
purposive sampling technique.
The study proposal was approved by
the ethical committee of M.M. University,
Mullana, Ambala, Haryana and from
authorities of M.M College of Nursing
Mullana, Ambala and M.M Institute of
Medical Sciences and Research Hospital
Mullana, Ambala, Haryana. Written informed
consent was taken from each subject.
Data was collected using structured
knowledge questionnaire and observation
checklist regarding endotracheal suctioning
from Dec., 2012 to Jan., 2013. On day one,
pre-implementation knowledge and
practices regarding endotracheal suctioning
were assessed. On day two, endotracheal
suctioning protocol was implemented. On
day seventh, 1st post-implementation
practices of nursing personnel regarding
endotracheal suctioning was assessed. On
alternate days, four times postimplementation
practices were assessed,
individualized feedback and reinforcement of
protocol was done for nursing personnel
until >80% practice score was achieved. The
4th post-implementation practices were
assessed for the nursing personnel who had
not met the benchmark of practice score
>80% in 3rd post-implementation
assessment of practices day 13th. There was
no attrition of sample subjects in postimplementation
assessments. Data was
analyzed by using both descriptive and
inferential statistics.
Results
Description of sample characteristics:
The data presented in table 1 depicted
that the majority of nursing personnel
(96.67%) were females. Most of the nursing
personnel (73.33%) were in the age group of
20-25 years and rest 26.67% were in age
group of 26-30 years. All of the nursing
personnel had professional qualification of
G.N.M. Majority of nursing personnel
(96.50%) had previous working experience
in private hospital. Less than half of nursing
personnel (43.33%) had previous
experience in adult coronary care, 20% in
neonatal intensive area and 13.33% in adult
coronary care. Less than half of nursing
personnel (43.33%) had total working
experience of 1-3 years followed by 40%
having working experience of less than one
year and 16.67 % having working experience
of 3-5 years. Two-third of nursing personnel
(66.67%) had less than one year of
experience in ICU and rest 33.33% had 1-5
years of experience in ICU. More than half of
nursing personnel (56.67%) have attended
the in-service education related to
endotracheal suctioning organized in their
past working institutions.
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 51
Table 1: Frequency and Percentage Distribution of Characteristics of Nursing Personnel
N=30
Sample Characteristics Frequency %
Gender
Male 01 3.33
Female 29 96.67
Age
20-25 years 22 73.33
26-30 years 08 26.67
Type of hospital (previously worked in) (n=29)
Private Hospital 28 96.50
Charitable Hospital 01 3.50
Previous area of experience :
Neonatal Intensive Care 06 20.00
Adult intensive Care 13 43.33
Adult Coronary Care 04 13.33
Any other, specify 07 23.34
Total years of experience :
<1 year 12 40.00
1-3years 13 43.33
3-5years 05 16.67
Years of experience in ICU
<1 year 20 66.67
1-5 years 10 33.33
Any in-service education related to endotracheal suctioning :
Attended 17 56.67
Not-attended 13 43.33
Evaluation of the effectiveness of
endotracheal suctioning protocol in terms
of knowledge of the nursing personnel:
Table 2 the mean post-implementation
knowledge scores of nursing personnel
regarding different aspects of endotracheal
suctioning (ETS) i.e. concept, event and
assessment was 8.77, 9.33, 6.63
respectively which was higher than the mean
pre-implementation knowledge score i.e.
4.73, 5.20 and 2.67 respectively. The
difference in enhancement of knowledge was
statistically significant as per ‘t’ test in all the
areas of structured knowledge questionnaire
(p<0.05) which represents that the protocol
was effective in enhancing the knowledge of
n u r s i n g p e r s o n n e l r e g a r d i n g t h e
endotracheal suctioning.
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 52
Evaluation of the effectiveness of
endotracheal suctioning protocol in terms
of practices of the nursing personnel:
st nd rd Table 3 depicts that the mean 1 , 2 , 3
th and 4 post-implementation practice scores
of nursing personnel regarding endotracheal
suctioning was 32.60, 39.07, 47.77 and
50.25 respectively which was higher than the
mean pre-implementation practice score
(22.80). The difference in the increase in
practice score was statistically significant as
per’t’test (p<0.05)which represents that
protocol was effective in improving practice
skill of nursing personnel regarding the
endotracheal suctioning.
Table 2: Pre-implementation and Post-implementation Knowledge Score of Nursing
Personnel regarding Endotracheal Suctioning
N=30
S. Areas Max. Min. Mean M SD SE ‘t’ D D MD
No. Possible Possible
Score Score
1. Concept of ETS
Pre-implementation 10 00 4.73 4.03 2.04 0.31 10.81
Post-implementation 8.77
2. ETS Event
Pre-implementation 5.20
Post-Implementation 12 00 9.33 4.13 1.93 0.33 11.76*
3. Post ETS Assessment
Pre-implementation 2.67
Post-implementation 08 00 6.63 3.97 1.52 0.24 14.29*
‘t’ (29) = 2.05; *Significant ( p £ 0.05 )
Table 3: Comparison of Pre-implementation with Post-implementation Practice Scores
of Nursing Personnel regarding Endotracheal Suctioning
N=30
Practice Score Mean Mean SD SE ‘t’ D D MD
Pre-implementation 22.80
st 1 Post-implementation 32.60 9.80 2.98 0.50 17.97*
nd 2 Post-implementation 39.07 16.27 1.96 0.32 45.36*
rd 3 Post-implementation 47.77 24.97 2.30 0.39 59.54*
th 4 Post-implementation 50.25 27.38 1.41 0.54 9.58*
‘t’ ( 29) = 2.05, (7) = 2.37; *significant ( p £ 0.05 )
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 53
From 30 nursing personnel, 22 had
achieved benchmark of >80% practice score
by 3rd post-implementation assessment and
th rest 8 of them could do it in 4 postimplementation
assessment. Data presented
in table 4,5 and 6 depicts the item wise
th cumulative percentage distribution after 4
post-implementation assessment practice
scores of nursing personnel regarding
endotracheal suctioning in pre-performance,
performance and post-performance area.
In pre-performance area while
preparing for endotracheal suctioning it was
observed that during the fourth assessment
most of equipment was kept ready and other
required preparation as per protocol were
done by all nurses except few aspects were
not taken care by few nurses i.e. 80.00%
nursing personnel had kept kidney tray and a
paper bag, 83.33% had kept dry cotton
gauge in bowl, 90.00% practiced standard
precautions and checked the proper
functioning of the equipments and 96.70
kept ready sterile glove and wore mask.
Table 4: No. of Nursing Personnel did correct preparation of Endotracheal Suctioning
th procedure during 4 post implementation performance assessment
N=30
Preparing for the endotracheal suction procedure Correctly Performed
n (%)
A sterile tray containing :
1. Laryngoscope 30 (100.00)
2. Ambu bag and mask 30 (100.00)
3. ETT 30 (100.00)
4. Tegaderm 30 (100.00)
5. Scissors 30 (100.00)
6. Suction device with connected tubing 30 (100.00)
7. Standard suction catheter 30 (100.00)
8. Normal saline or sterile water for clearing tubing 30 (100.00)
9. 2 ml syringe 30 (100.00)
10. Sterile gloves and mask 29 (96.70)
A clean tray containing :
11. Dry cotton gauze in bowl 25 (83.33)
12. Kidney tray and a paper bag 24 (80.00)
13. Pulse oximeter 30 (100.00)
14. Stethoscope 30 (100.00)
15. a) Identifies client. 30 (100.00)
b) Identifies indications for suctioning. 30 (100.00)
c) Provides privacy. 30 (100.00)
16. Explains procedure to family members/ relatives, if significant. 30 (100.00)
17. a) Uses standard precautions (i.e wearing gown and goggles). 27 (90.00)
b) Washes hands. 30 (100.00)
18 . Assembles necessary equipments. 30 (100.00)
19. Checks the proper functioning of equipments. 27 (90.00)
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 54
Table 5: No. of Nursing Personnel performed correct steps of procedure while performing
Endotracheal Suctioning during 4th post implementation performance assessment
N=30
Steps of performing endotracheal suction Correctly Performed
n (%)
Safety
1. Maintains dexterity. 28 (93.30)
2. Prepares to maintain airway and initiate resuscitation measures. 25 (83.30)
Prepares for suctioning:
3. Places the patient in supine position with head slightly extended. 30 (100.00)
4. Places the patient on pulse oximeter to assess oxygenation. 30 (100.00)
5. Hyperoxygenates for 30-60 seconds before suctioning. 29 (96.70)
6. Checks the suction levels as follows: 30 (100.00)
· 60-80 mmHg for infants,
· 80-100 mmHg for under 10–12 years,
· 100–120 mm Hg for older children.
7. Open and prepares suction catheter and normal saline container maintaining clean technique. 30 (100.00)
8. If using saline instillation prior to suctioning, draw up 0.25 – 0.5 ml into 2 ml syringe 30 (100.00)
9. Washes hands in sterile manner. 29 (96.70)
10. Puts on mask. 24 (80.00)
11. Glove both hands. 30 (100.00)
12. Disconnects the ventilator and instill NS into ETT. 30 (100.00)
13. Reconnects the patient to the ventilator and allow 5 breaths to be delivered. 24 (80.00)
14. Removes the suction catheter from the package and attach it to the suction tubing. 29 (96.70)
15. Checks the suction pressure once the suction catheter is connected. 30 (100.00)
16. Disconnects the ventilator tubing from patient’s ETT. 30 (100.00)
17. Inserts the suction catheter down the ETT to the predetermined length 29 (96.70)
i.e length of ETT at lip margin minus 0.5 cm.
18. Makes sure not to apply suction while inserting the suction catheter. 30 (100.00)
19. Applies continuous suction by covering the suction control hole. 30 (100.00)
20. Removes catheter in rotating movement. 30 (100.00)
21. The single episode of suctioning from removing of ventilator to reattachment 30 (100.00)
of ventilator should not exceed 10-15 seconds.
22. Monitors O2 saturation level of patient between each episode of suctioning. 28 (93.30)
23. Wipes the catheter and suction tubing and flush it with normal saline until clear. 30 (100.00)
24. Hyperoxygenates the client for at least 1 min, then gradually decrease oxygen 24 (80.00)
to the level prior to suctioning, as tolerated by the patient.
Oral Suctioning :
25. Uses a padded tongue blade to depress the tongue and slides catheter along 30 (100.00)
one side until it reaches the back of the mouth.
26. Suctions cheeks, beneath the tongue, back of the mouth or oropharynx as needed. 24 (80.00)
Nasal Suctioning :
27. Inserts catheter slight downward and slant through one nostril along the floor 29 (96.70)
of the nasal cavity and suctions the nasal cavity.
28. Observes color, quantity and type of secretions. 22 (73.33)
29. Reassess patient’s respiratory status. 30 (100.00)
While performing the procedure most
of the steps of procedure were performed by
all the nurses except few steps such as only
73.33% nurses observed color, quantity and
type of secretions, 80.00% puts on mask,
reconnected the patient to the ventilator and
allow 5 breaths to be delivered, hyper
oxygenated the client for at least 1 min, then
gradually decrease oxygen to the level prior
to suctioning,as tolerated by the patient and
suctioned cheeks,beneath the tongue, back
of the mouth or oropharynx as needed,
83.30% prepared to maintain airway and
initiate resuscitation measures, 93.30%
maintained dexterity and monitored O 2
saturation level of patient between each
episode of suctioning, 96.70% nursing
personnel hyper oxygenated for 30-60
seconds before suctioning, washed hands in
sterile manner, removed the suction catheter
from the package and attach it to the suction
tubing, inserted the suction catheter down
the ETT to the predetermined length i.e.
length of ETT at lip margin minus 0.5 cm and
inserted catheter slight downward and slant
through one nostril along the floor of the
nasal cavity and suctions the nasal cavity.
While terminating the procedure during
th 4 post implementation performance
assessment most of nurses have performed
all the steps of terminating the procedure
except few i.e. 86.67% nursing personnel
discarded used supplies as per procedure
a n d 9 3 . 3 0 % d o c u m e n t e d t h e
recommendations for additional ventilator
settings, FiO , flow rate etc. 2
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 55
Table 6: No. of Nursing Personnel correctly terminating Endotracheal Suctioning
procedure during 4th post implementation performance assessment
N=30
Steps of terminating procedure of endotracheal suction Correctly Performed
n (%)
1. Discards used supplies as per procedure. 26 (86.67)
Documents the following :
2. Size of the suction catheter used. 30 (100)
3. Suction pressure applied. 30 (100)
4. Type of secretions recovered following the procedure ( thick or thin ). 30 (100)
5. Amount of secretions recovered following the procedure(……. ml). 30 (100)
6. Color and Characteristics of secretions recovered following the 30 (100)
procedure. (White, Pink, Red, Yellow, Brown or Green).
7. Recommendations for additional ventilator settings, FiO2, flow rate etc. 28 (93.30)
Data presented in table 7 reveals that the
mean 4th post-implementation practice score in
pre-performance, performance and postperformance
areas was 19.10, 23.50, 6.07
respectively as compared to mean preimplementation
practice score i.e.10.57, 11.93,
0.60 respectively. The mean difference in pre and
post implementation score in three areas was
8.76, 11.56 and 5.46 respectively. The calculated
‘t’ value of 35.39, 27.02 and 41.00 was found to
be statistically significant (p<0.05). It represents
that the protocol was effective in improving the
practices of nursing personnel in the area of preper
formance, per formance and postperformance
of endotracheal suctioning.
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 56
Table 7: Pre-implementation and 4th Post-implementation Practice Score of Nursing
Personnel regarding Endotracheal Suctioning
N=30
Areas Max. Min. Mean Mean SD SE ‘t’ D D MD
Possible Possible
Score Score
Pre-performance
Pre-implementation 10.57
22 00 8.76 1.3 50.22 35.39
Post-implementation 19.10
Performance
Pre-implementation 11.93
29 00 11.56 2.34 0.43 27.02*
Post-Implementation 23.50
Post-performance
Pre-implementation 0.60
07 00 5.46 0.73 0.10 41.00*
Post-implementation 6.07
‘t’ (29) = 2.05; *Significant ( p £ 0.05 )
Table 8represents that the mean 4th postimplementation
practice score (50.25) of
nursing personnel was higher than the mean
3rd post-implementation practice score
(45.50) regarding endotracheal suctioning.
The mean 3rd post-implementation practice
score (47.77) was higher than the mean 2nd
post-implementation practice score (39.07)
which was further higher than the 1st postimplementation
practice score (32.60) of
nursing personnel regarding endotracheal
suctioning. This difference was statistically
significant as per t test (p<.05) which
represented that each consecutive feedback
and reinstitution of protocol was effective in
improving the practice of nursing personnel
regarding endotracheal suctioning in
consecutive observations of practices.
Table 8: Comparison of Post-implementation Practice Scores of Nursing Personnel
regarding Endotracheal Suctioning
N=30
Practice Score Mean Mean SD SE ‘t’ D D MD
st 1 Post-implementation 32.60
nd 2 Post-implementation 39.07 6.47 2.89 0.51 12.22*
rd 3 Post-implementation 47.77 8.70 2.31 0.31 20.66*
th 4 Post-implementation 50.25 4.75 1.28 0.48 9.51*
t ( 29) = 2.05, (7) = 2.37; *significant ( p £ 0.05 ) Maximum Score = 58 Minimum Score = 0
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 57
Table 9: Correlation between Knowledge Score and Practice Scores of Nursing
Personnel regarding Endotracheal Suctioning
N=30
st nd rd Correlation Matrix Pre- 1 Post- 2 Post- 3 Post-
Implementation Implementation Implementation Implementation
Practice Score Practice Score Practice Score Practice Score
NS Pre-Implementation 0.290
Knowledge Score
NS NS NS Post-Implementation -0.291 -0.207 -0.063
Knowledge Score
Co-relation between knowledge and
practices of nursing personnel regarding
the endotracheal suctioning:
Table 9 depicts the calculated ‘r’ value
between pre-implementation knowledge
score and pre-implementation practice
score; between post-implementation
knowledge score and post-implementation
practice scores which was not significant at
0.05 level of significance. It shows no
significant relationship between preimplementation
knowledge score and preimplementation
practice score; between
post-implementation knowledge score and
post-implementation practice score.
Association of levels of knowledge and
levels of practices with the selected
variables of nursing personnel regarding
endotracheal suctioning:
The result depicts the chi-square values
for association of knowledge and practices of
nursing personnel with selected variables
i.e. age, previous area of experience, years of
experience in ICU, total years of experience
and any in-service education attended were
not found statistically significant at 0.05 level
of significance which infers that the
effectiveness of protocol in terms of
knowledge and practices of nursing
p e r s o n n e l r e g a r d i n g e n d o t r a c h e a l
suctioning was not associated with age,
previous area of experience, years of
NS r (28) = 0.361; *Significant ( p £ 0.05 ); Not-significant (p >0.05)
experience in ICU, total years of experience
and any in-service education attended.
Discussion
Endotracheal suction is a procedure
which aims to keep airways patent by
mechanically removing accumulated
pulmonary secretions, above all in patients
1 with artificial airways. Infants and children
with life-threatening conditions frequently
require admission to the paediatric intensive
care unit, where they may be intubated and
mechanically ventilated. Paediatric intensive
care unit patients not only encompass a wide
range of ages different from adult intensive
care unit patients but also differ in their
developmental physiology, underlying
disorders, and treatment needs.
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 58
These patients can be prone to various
complications while on a mechanical
ventilator. Considering the endotracheal
suctioning complexity, a prior evaluation of
the need for suction is indispensable, as this
is an invasive, complex procedure that must
be undertaken by judicious indication, as it
13 can cause harm to the patient . Studies have
shown that Ventilator Associated Pneumonia
is one of the most common infectious
complications among patients admitted in
intensive care units and accounts for up to
47% of all infections among intensive care
14 unit patients. For this procedure, it is
important that the nurse has knowledge
based on valid scientific evidence concerning
the different methods of endotracheal
suction and aspects related to it.
The present study adopted an
Experimental with Quasi-Experimental
research approach on thirty nursing
personnel working in intensive care units.
The findings of the present study indicated
that the mean post-implementation
knowledge score and practice scores in all
areas of knowledge questionnaire and
observation checklist was significantly
higher than the mean pre-implementation
knowledge score and practice score as
evident from ‘t’ test (< 0.05). These findings
were partially consistent with the findings of
an evaluatory study done to assess the
effectiveness of planned teaching
programme (PTP) on knowledge and
practice of endotracheal suctioning among
50 staff nurses who were selected
purposively in different intensive care units
of selected hospitals of Mangalore”.The
overall mean post-test knowledge score
(27.5) after 12 days of teaching and mean
post-test practice score (28.7) was
significantly higher than the overall mean
pre-test knowledge score (17.0) and mean
pre-test practice score (13.2). Study
concluded that there is a significant increase
in the level of knowledge and practice among
staff nurses after the PTP. So PTP was
effective in terms of gain in knowledge and
15 practice scores . The findings were also
consistent with the findings of the study
16 conducted by Ozden et al 2012 to determine
the knowledge and practice of nurses before
and after training and the development of
protocol for open and closed system
suctioning methods in patients with ETTs
which had shown a significant increase in the
post-implementation knowledge and
practice score.
The present study findings indicated
that nursing personnel had below average
knowledge and poor practices regarding
endotracheal suctioning during preimplementation
phase. These findings were
consistent with the findings of the study
17 conducted by Dayalan T et al 2008 to
explore the nurse’s knowledge and
competence regarding endotracheal
suctioning in acute and high dependency
ward areas which demonstrated a poor level
of knowledge and potentially unsafe practice
among nurses regarding tracheal suctioning.
The results of the present study had
shown no significant relationship between
knowledge and practices of nursing
p e r s o n n e l r e g a r d i n g e n d o t r a c h e a l
suctioning. These findings were consistent
with the findings of study conducted by
18 Shirazi HZ et al 2008 to evaluate the training
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 59
and educational needs in nurses working
with ICUs which showed mild relationship
between knowledge and performance of
endotracheal suctioning, which was not
significantly significant (p> 0.05, r= 0.33).
The study concluded that there is no
relationship between knowledge and
performance indicating that even if nurses
have knowledge they may not put it into
practice.
It is concluded that endotracheal
suctioning protocol was effective in
enhancing the knowledge and improving the
practices of nursing personnel working in
intensive care units. It is recommended that
complications caused by emergency
procedures, like endotracheal suctioning
procedure in mechanically ventilated
patients of ICU’s should not be neglected.
Nursing personnel should be aware of new
advancements in the field of critical care
nursing i.e. endotracheal suctioning to
reduce the respiratory complications. Efforts
should be made to educate all levels of staff
dealing with critical patients. Clinical
practices of nursing personnel regarding
endotracheal suctioning should be
monitored and feedback should be provided.
The nurse administrator should plan and
organize a teaching programme frequently
for the nursing personnel working in
intensive care units regarding endotracheal
suctioning.
References
1. American Association of Respiratory
Care. AARC clinical practice guideline:
endotracheal suctioning of mechanically
ventilated patients with artificial airways
2010.Respir Care 2010; 55(6): 758-64.
2. Talban OC, Anderson LJ, Besser R,
Bridges C, Hajjeh R. Guidelines for preventing
h e a l t h – c a r e a s s o c i a t e d p n e u m o n i a :
recommendations of CDC and Healthcare
Infection Control Practices Advisory
committee. MMWR Recommendations Rep
2004; 26: RR 31-36.
3. Woodruff DW. Pneumothorax. R N
1999; 62(9): 62.
4. Dudeck MA, Horan TC, Peterson KD.
National Healthcare Safety Network (NHSN)
Report, Data Summary for 2011.Devicea
s s o c i a t e d M o d u l e . A v a i l a b l e f r o m
URL:http://www.cdc.gov/nhsn/PDFs/data
Stat/2012NHSNReport. pdf
5. Lewis SM, Collier IC, Heitkemper MM.
Medical surgical nursing: assessment and
management of clinical problems. 4th ed. New
York: Health Professions Division. 2002.
6. George P, Sequiera A. Antimicrobial
sensitivity pattern among organisms which
were isolated from endotracheal aspirates.
Journal of Clinical and Diagnostic Research
2010; 4(3): 397-401.
7. Sole ML, Byers JF, Ludy JE.A multisite
survey of suctioning techniques and airway
management practices. Am J Crit Care 2009;
12(3):220-32.
8. Salima Moez Meherali, Yasmin Parpio,
Tazeen S. Ali, Fawad Javed. Nurses’ knowledge
of evidence-based guidelines for Prevention of
ventilator-associated pneumonia. J Ayub Med
Coll Abbottabad 2011; 23(1): 146-9.
9. Higgins D.Tracheal suctioning. Nursing
Times 2005; 101(8): 36.
Nursing and Midwifery Research Journal, Vol-10, No.2, April 2014 60
10. Ozden D, Gorgulu RS. Development of
standard practice guidelines for open and
closed system suctioning. J Clin Nurs 2012;
21(10): 1327-38.
11. Gongalez AN, Mingo MA. Assessment
of practice competence & scientific knowledge
of ICU nurses in tracheal suctioning.
EnfermariaIntensia 2009; 15(3): 236-40.
12. Day T, Farrell S, Hayes S. Tracheal
suctioning an exploration of nurse’s knowledge
and competence in acute and high dependency
ward area.Journal of Advanced Nursing. 2002;
39(1): 35-45.
13. Black JM, Hawks JH. Medical Surgical
Nursing. 8th ed. Philadelphia: Elsevier
Publishers.
14. Dudeck MA, Horan TC, Peterson KD.
National Healthcare Safety Network (NHSN)
Report, Data Summary for 2011, Deviceassociated
Module. Available from URL:
http://www.cdc.gov/nhsn/PDFs/dataStat/2012
NHSNReport. pdf
15. Mathew B. Effectiveness of planned
teaching programme on knowledge and
practices of endotracheal suctioning procedure
among staff nurses in the different units of
selected hospital in Mangalore. Unpublished
Masters in Nursing dissertation submitted to
RGUHS, Bangalore.
16. Özden D, Görgülü RS.Development of
standard practice guidelines for open and
closed system suctioning. J Clin Nurs 2012
May;21(9-10):1327-38
17. Dayalan T, Fernadesh S, Harayan S.
Tracheal suctioning: an exploration of nurses’
knowledge and competence in acute and high
dependency ward areas. Journal for Advance
Nursing. India 2008; 39(1): 35-45.
18. Shirazi HZ, Karger M, Edraki M. The
effect of instructing the principles of
endotracheal tube suctioning on knowledge
and performance of nursing staff working in
neonatal intensive care units. IJME
2010;9(4):365-70.
Nursing and