Intensive care nurses’ knowledge and practice of evidence-based recommendations for endotracheal suctioning: a multisite cross-sectional study in Changsha, China

Endotracheal suctioning (ETS) is a component of bronchial hygiene therapy and mechanical ventilation and involves the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place [1, 2]. The purpose of this procedure is to maintain the patient airway, to optimize ventilation and oxygenation and to prevent respiratory tract infection from the lodgement of secretions [3]. ETS is among the most frequently conducted invasive procedures in the intensive care unit (ICU) for mechanically ventilated patients [4]. As a crucial procedure, if ETS is not performed with correct techniques, it will lead to numerous adverse effects, such as tracheobronchial oedema, ulceration, and denudation of the epithelium [5‐7]. These areas of mucosal damage increase the risk of infection and bleeding [8]. Moreover, ETS is considered an extremely distressing and painful experience for ICU patients [9]. Study findings showed that ETS performance by well-educated health care professionals based on the best evidence can diminish its side effects [10, 11]. It is, therefore, essential for health care professionals to have updated knowledge on the evidence-based practices of ETS so that they can perform the procedures scientifically and thereby reduce patients’ complications and potential risks [12].

Clinical practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” [13]. As a type of high-level evidence in the evidence hierarchy, guidelines provide clinicians trustworthy recommendations and can be used to reduce inappropriate practice variations and promote the delivery of high-quality care [8, 13]. Several ETS guidelines have been developed in recent years by authoritative organizations. For example, in 2010, the American Association of Respiratory Care (AARC) released the AARC Clinical Practice Guidelines on ETS of mechanically ventilated patients with artificial airways [1]. Despite the enormous efforts made in developing those guidelines, there continues to be large discrepancies between evidence and the actual practice on ETS. Researchers in countries such as Canada [8], France [14], Australia [15], and Italy [4] analysed the application of guidelines for endotracheal suctioning among intensive care nurses. Their studies revealed that nurses were often not aware of the existence of those guidelines, and there was a lack of relevant knowledge regarding ETS, leading to ETS practices that were inconsistent with evidence-based recommendations.

In China, intensive care nurses are responsible for performing ETS in ICUs. According to the “Guidelines for the Construction and Management of Critical Care Medicine in China,” the ratio of intensive care nurses to ICU beds should be 2.5–3:1 or greater [16]. However, the ICU nurse-to-bed ratios decreased from 1.8:1 in 2002 to 1.5:1 in 2018, indicating an unsolved severe shortage of ICU nurses in China [17]. Facing such a shortage, in addition to expanding the number of nursing staff, it is critical to understand nursing practice in Chinese ICUs and ensure that nurses are equipped with updated knowledge and skills in performing intensive care practices to ensure patient safety and positive patient outcomes. As one of the most frequently performed procedures in the ICU, nurses’ knowledge and practice of ETS in China have been examined by only a few studies. Gu et al. [18] and Qin et al. [19] found that intensive care nurses had adequate knowledge about the purpose of preoxygenation and humidification, while few were aware of the suction pressure, indications and adverse effects of suction. Gu [18] also revealed that most nurses’ ETS knowledge came from work experience instead of scientific journal research, indicating a lack of knowledge about up-to-date suctioning recommendations among nurses. Zhang et al. [20] evaluated nurses’ compliance with the aseptic technique during ETS by observation and found that nurses frequently forgot to wash their hands before and after performing ETS. Those studies were limited by the small number of survey items and only covered a few aspects of ETS practices, such as catheter size, insertion depth, humidification, aseptic technique suction pressure, and adverse effects [18‐20]. Other essential aspects were not included, for example, the thorough assessment of the patient before suctioning to establish the needs and monitoring indicators such as breath sounds, oxygen saturation, and the respiratory rate and pattern throughout the suctioning procedure [21]. Furthermore, all the abovementioned studies were conducted at least 10 years ago, and ETS practice has evolved during the past decade. It is therefore necessary to conduct a comprehensive, current investigation into intensive care nurses’ knowledge of ETS and the practices they perform to establish a robust evidence base for both policy-making and intensive care nurse training in China.

In 2018, Hu et al. [21] developed an adapted guideline on ETS for adult patients with artificial airways. With the guidance of the ADAPTE framework, the guideline was developed through literature review, expert panel consultation (i.e., nurses, physicians and patients, n = 9), and external reviewer meeting (n = 20) [22]. The final guideline includes 26 recommendations covering 3 procedure phases and 17 points of care. This study aims to examine (1) intensive care nurses’ awareness of and adherence to ETS guidelines and (2) factors influencing nurses’ awareness and practice adherence.

Studies regarding the knowledge and practice of ETS among nurses have been conducted in several countries, as ETS concerns the safety of mechanically ventilated patients [4, 8, 14, 15]. However, little has been revealed from Chinese ICUs in recent years. The results of our study show that Chinese intensive care nurses were aware of the majority of the evidence-based ETS practices and believed their practices followed over half of the guideline items. However, over half of them were unaware of the difference between open and close suctions and the pros and cons of using hyperinflation. Almost 50 % of nurses believed some of their clinical practices did not follow the evidence-based recommendations, such as not routinely using normal saline and using 80–120 mmHg suction pressure during endotracheal suctioning. Receiving ETS training is a significant influencing factor for both the awareness and adherence level of intensive care nurses.

However, there can be no direct comparison between our results and others due to the different tools used. We consider our results to be consistent with those from the studies of Negro et al. [4], Varghese and Moly [25], Heidari and Shahbazi [12], who revealed that over one-third of nurses were unaware of guidelines regarding the tracheal suctioning procedure.

In China, such an awareness level of evidence-based ETS recommendations may be partly due to the inaccessibility of the guidelines to clinical nurses [26]. Even though several English ETS guidelines exit, there was none in Chinese before the adapted guideline by Hu et al. [21]. Many intensive care nurses in Chinese hospitals felt unable to access those English guidelines due to language barriers [26]. In addition, insufficient training experiences may also explain this low to moderate level of awareness and adherence [18]. As shown in our study, nurses who received training demonstrated significantly higher awareness and adherence than those who did not. Nevertheless, one-third of the participants in our study did not receive any ETS-specific training. This is similar to a study by Xu et al. [27] that found that nearly 25 % of intensive care nurses did not receive ICU nursing skills training over 6 months, including those related to ETS. This may be related to the large number of intensive care nurses and lack of systematic training in Hunan Province [17]. In 2018, there were 1847 intensive care nurses in tertiary hospitals along in Hunan [27]. The Specialized ICU Skills Training Center was founded in 2009, but they only conducted 23 systematic trainings that accommodated approximately 1300 nurses up to the end of 2020 [28]. In addition, many hospitals provide one-on-one coaching or a few days of prework training for new nurses entering ICUs, but these are usually not based on up-to-date recommendations for ETS practice and are scarcely considered systematic trainings [27]. Thus, we suggest that (1) more provincial or even nationwide specialized ICU skill training sessions should be conducted to disseminate evidence-based practices, including for ETS, and (2) these hospital- or unit-level coaching and training sessions should incorporate ETS recommendations and target both new and experienced nurses to update their knowledge and skills regarding ETS.

Our study findings showed that a large proportion of the nurses lacked knowledge of certain aspects of the guidelines. For example, almost two-thirds of intensive care nurses were unaware of the insignificant differences between open and closed suctioning in clinical outcomes (i.e., oxygen saturation, cardiovascular instability, secretion removal, environmental contamination, and cost). This was an unsurprising result, as there have been contradictory findings in the past two decades regarding the comparisons of these two suctioning methods [29, 30]. Some researchers found that the two suctioning methods differed in affecting the heart rate [29, 31], while no difference was found in other investigations [32, 33]. Nevertheless, the methodological flaws of some studies made their research findings less convincing and led to the failure to generate strong recommendations [1, 30]. Recommendations in our study were developed by incorporating the best available evidence [21]. It, therefore, has the potential to be widely applied in clinical ETS practices in China. However, the guidelines were developed in 2017. For further survey and evaluation, the guidelines and survey items need to be updated.

Likewise, over half of the nurses did not know the pros and cons of using hyperinflation (i.e., patients may feel dyspnoeic when the tidal volume is over 900 cc, hyperinflation may relate to increases in mean arterial blood pressure, and using volumes of hyperinflation that are indexed to the size of the patient may assist in minimizing potential difficulties). Elbokhary et al.[34] had similar research findings that nurses retained poor knowledge regarding the adverse effects of hyperinflation. We suggested that ETS training programs should place particular emphasis on low-awareness items to change intensive care nurses’ traditional views towards ETS and promote their acceptance of evidence-based recommendations [25].

Our results revealed that gaps exist between evidence-based ETS practices and current clinical practices [35]. For instance, almost half of the participants believed that their clinical practice differed from or contradicted the evidence-based recommendations, such as not routinely using normal saline and using 80–120 mmHg suction pressure during endotracheal suctioning. To bridge the evidence-practice gap, theoretical education or training alone may not be adequate to influence practice change [10, 12, 36]. Routine training together with individual or group support—such as posttraining follow-up, coaching, the use of support documents such as unit- or hospital-level ETS regulations, web or mobile applications, checklists, reminders, user-friendly pictures, and pocket versions of the guidelines—could potentially elevate the knowledge level and practical ETS skills of intensive care nurses [36‐38]. Moreover, leader support alongside guideline implementation is recommended, as leadership has been listed as one of the most important factors influencing knowledge translation in clinical practices [39, 40].

Few studies have described nursing practices regarding ETS in mainland China. In the present study, we disclose intensive care nurses’ knowledge and practice of ETS in Chinese ICUs and propose recommendations for current clinical nursing practices and training. Limitations existed in this study despite our efforts to minimize the defects during the research process. First, we did not conduct systematic psychometric testing on the questionnaire. Although it was developed based on current ETS recommendations and underwent a brief test-retest reliability and face validity test before the final version, a lack of systematic psychometric testing may limit the comparability of our findings with others. Second, we used a questionnaire survey to investigate ICU nurses’ adherence to ETS recommendations rather than onsite shadowing. There might be a discrepancy between their perceptions and the actual practices of ETS.

The study findings revealed that Chinese intensive care nurses lacked awareness of several essential evidence-based endotracheal suctioning practices. It also showed that there were considerable gaps between ETS evidence and clinical practices. Further research should emphasize revealing barriers against and facilitators of implementing evidence-based endotracheal suctioning practices and developing context-suitable interventions for guideline implementation. We suggest systematic training on the ETS guidelines along with innovative strategies from implementation science to promote ETS practice changes.