An observational study on the open-system endotracheal suctioning

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.

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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

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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.

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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.

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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

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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.

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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.

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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

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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