Research On An Article

CLINICAL NURSING PROCEDURES

An observational study on the open-system endotracheal suctioning

practices of critical care nurses

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

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

Ireland

Tom Andrews PhD, PGDE, RN

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

Ireland

Submitted for publication: 11 January 2006

Accepted for publication: 20 December 2006

Correspondence:

Sean Kelleher

Brookfield Health Sciences Complex UCC

Cork

Ireland

Telephone: 00353 21 4901477

E-mail: s.kelleher@ucc.ie

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

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

critical care nurses

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

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

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

nurses’ ETS practices with current research recommendations.

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

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

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

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

address how ETS is practiced on a daily basis.

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

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

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

are being adhered to.

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

adhere to best practice suctioning recommendations; and consequently provided

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

in the participants’ respiratory assessment techniques, hyperoxygenation and

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

used to clear secretions.

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

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

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

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

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

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

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

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

skills, hyperoxygenation practices, suctioning pressures and infection control

measures.

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

practice, observation

Introduction

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

that promotes quality outcomes for patients, families, health-

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

2002). While the literature has demonstrated that nurses are

increasingly recognizing the role research has to play within

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

established nursing practices are not underpinned by sound

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

practice that has caused concern is the endotracheal suction-

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

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

in caring for patients with an artificial airway (Thompson

2000) and an essential aspect of effective airway management

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

harmful procedure, which when performed inappropriately

or incorrectly can result in serious complications (Celik &

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

therefore, that those carrying out such a procedure are aware

of the potential risks and practice in a manner that ensures

effectiveness and patient safety.

Literature review

While ETS is an important intervention when caring for

critically ill patients, the practice surrounding ETS can vary

widely between institutions and practitioners (Swartz et al.

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

anecdote and routine rather than research (Paul Allen &

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

partially have been influenced by a paucity of research

evidence to guide practitioners in the care of a patient with

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

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

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

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

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

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

2002a) and systematic reviews (Thompson 2000) enabling

practitioners quickly and easily to determine current research

recommendations irrespective of their ability to interpret the

research findings. Nonetheless, there is still some disparity in

regard to what exactly constitutes the best ETS practice

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

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

systematic review of the literature, isolated aspects of the ETS

procedure that are generally accepted as being the most

important, a lack of homogeneity and methodological flaws in

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

prescriptive recommendations for practice. Conversely, the

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

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

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

citly describe how ETS should be performed, but overlook the

quality of the evidence from which they originate. Notwith-

standing the lack of rigorous research concerning ETS

practice, it is generally accepted that the ETS techniques,

when used inappropriately or incorrectly can have deleterious

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

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

how critical care nurses perform ETS and establish how it

compares with the current best practice recommendations.

Critical care nurses’ ETS practices

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

tive, descriptive design using a survey method to examine

‘national’ suctioning practices on 80 paediatric intensive-care

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

that suctioning techniques among critical care nurses varied

and were based on a combination of nursing judgement and

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

findings in a quantitative descriptive study which aimed to

identify the closed-system ETS practices of 241 randomly

selected critical care nurses. One hundred and twenty nurses

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

indicated variations in nurses’ suctioning techniques. While

the results of both studies suggest that critical care nurses

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

studies may not necessarily be an accurate reflection of

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

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

responses to questionnaire items about how they carry out

a procedure may bear little resemblance to how they actually

perform it.

Clinical nursing procedures Critical care nurses’ suctioning practices

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

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

questionnaire methods to explore nurses’ theoretical know-

ledge and practical competence in ETS. Using convenience

sampling, 28 critical care nurses were recruited from three

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

results indicated that many nurses failed to demonstrate an

acceptable level of theoretical knowledge and competence in

practice and that there was no significant relationship

between nurses’ theoretical knowledge and observed practice.

Furthermore, many nurses were unaware of recommended

practice and some demonstrated potentially unsafe practice.

These findings are supported in the literature (Celik & Elbas

2000) and have considerable implications for the safety of

critically ill patients.

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

ensures a more accurate reflection of what happens in

practice than the descriptive retrospective studies discussed

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

view is supported in the literature, which suggests that

observational methods provide data on the realities of current

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

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

support previous research that identified wide variations in

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

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

experience and ward routine to inform practice over any

other source (Sole et al….