Asian J. Nursing Edu.

and Research 6(4): October- December 2016

ISSN 2231-1149 (Print) www.anvpublication.org

2349-2996 (Online) www.ajner.com

RESEARCH ARTICLE

The Obstacles Perceived by Critical Care Nurses in Performing

Endotracheal Suctioning
Sruthy T. Varghese1, Prof. K. T. Moly2
1
II year MSc Nursing, Amrita College Of Nursing, AIMS, Kochi, Affliated to Amrita Vishwa Vidyapeetham
University, Coimbatore.
2
Principal, Amrita College Of Nursing, AIMS, Kochi, Affliated to Amrita Vishwa Vidyapeetham University,
Coimbatore.
*Corresponding Author Email:

ABSTRACT:
A descriptive exploratory study to identify the performance obstacles perceived by critical care nurses in
performing end tracheal suctioning was conducted in eight intensive care units of AIMS, Kochi. Objectives: The
objectives of the study were to; (1) Identify the performance obstacles perceived by critical care nurses while
performing ET suctioning (2) Find out the opinion of critical care nurses on overcoming the performance
obstacles identified in ET suctioning (3) Prepare a strategy to improve the practices of critical care nurses on ET
suctioning. Research methodology: The design used for the study was exploratory descriptive design with non-
probability convenience sampling technique (N=50). Results: The performance obstacles during suctioning as
perceived by nurses were; difficult procedure without assistance (84%), restless patient (84%), distractions
(52%), inadequate training either during student period (78%) or as a staff nurse (46%) or before practicing in
the unit (62%) and unaware of research finding on ET suctioning (76%). All of them suggested the need for;
training at the beginning of clinical posting in the unit, clear cut guideline/protocol on ET suctioning and
updating of guideline/equipment. Conclusion: The performance obstacles were categorized into knowledge,
skill, technology and tool and organization and were rated by the nurses as minimum , medium and many. The
performance obstacles perceived by nurses were mostly related to skill in ET suctioning. The major knowledge
related performance obstacles perceived by nurses’ was inadequate training on ET suctioning in a real patient as
a student (78%). Training on ET suctioning should be given in the beginning of clinical posting in critical care
unit.

KEYWORDS: Performance obstacles, critical care nurses, endotracheal suctioning, intensive care units.

INTRODUCTION: The nursing management of the mechanically ventilated

ET suctioning is a difficult procedure often performed by
the critical care nurses in the intensive care units.
Moreover, the irritation caused by the procedure makes
patient gets restless. Performance obstacle refers to those
inhibiting work factors perceived by critical care nurses
while performing ET suctioning in terms of knowledge
and skill of critical care nurses, technology and tool,
organization that are closely associated with the
immediate work setting and tend to affect the
performance of nurses.
Received on 08.01.2016 Modified on 27.01.2016
Accepted on 29.06.2016 © A&V Publications all right reserved
Asian J. Nur. Edu. and Research.2016; 6(4): 491-496.
DOI: 10.5958/2349-2996.2016.00092.6
patient is challenging on many levels: from the
acquisition of highly technical skills; expert knowledge
on interventions; and implementation of interventions to
care for the patient. Thus, the main areas of performance
obstacles faced by critical care nurses are related to
knowledge, skill, technology, tool and organization.
Hence, adequate measures to overcome these
performance obstacles are needed to ensure effective and
safe patient care.

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 Asian J. Nursing Edu. and Research 6(4): October- December 2016

METHOD AND MATERIAL: d) More than 5 Years 6 12.0

3 Total experience in the current
Purpose : To identify the performance obstacles and
hospital
explore the suggestions to overcome so as to prepare a a) 6 Months - 1 Year 17 34.0
strategy to improve the ET suctioning procedure by the b) 1 - 3 Years 25 50.0
nurses. c) 3 - 5 Years 5 10.0
d) More than 5 Years 3 6.0
4 Total experience in the critical care
Study Design and Population
unit
A quantitative research with descriptive exploratory a) 6 Months - 1 Year 13 26.0
design was used to identify the performance obstacles b) 1 - 3 Years 28 56.0
perceived by critical care nurses in performing end c) 3 - 5 Years 4 8.0
tracheal suctioning. The study was carried out among 50 d) More than 5 Years 5 10.0
critical care nurses working in eight intensive care units 5 Attended training programme on ET suctioning
a) Yes 11 22.0
of AIMS, Kochi. b) No 39 78.0

Tool and Technique The data presented in the table 1 regarding the sample
The data was collected using the tool: Questionnaire to characteristics show that 64% of the subjects were
identify performance obstacles and the opinion of critical graduate nurses, 36% were GNM and not a single post
care nurses to overcome the performance obstacles graduate. 56% of the nurses had one to three years of
during ET suctioning. It has sections; Section A: experience in the critical care unit and only 18% had
Performance obstacles perceived by critical care nurses more than three years of experience in the critical care
during ET suctioning and Section B: Opinion of critical unit. Training programme on ET suctioning was not
care nurses to overcome the performance obstacles in ET received by 78% of the subjects. (n=50)
suctioning. Content validity of the tool was obtained
from twelve experts in the field of nursing and medicine.
The content validity index obtained for the tool was
0.99. Reliability of the tool I section A and section B
was 0.825 and 0.879 respectively. The level of
performance obstacle was rated as minimum obstacle
(≤50%), medium obstacle (50-75%) and many obstacle
(75%).

Data Collection
Data collection for the main study was conducted from
7th December, 2014 to 15th January, 2015. Written
permission was obtained from the Nursing Director,
Medical Superintendent and Head of the department of
each ICU. Written informed consent was obtained from
the subjects after clearly explaining the purpose of the
study. The Tool was administered to the subjects at the
Figure 1: Pie Diagram on Distribution of Sample Based on Level of
end of their shift. Performance Obstacles Perceived by Nurses During ET Suctioning

Data Analysis
Frequency and percentage were used to analyse the data
collected based on the Tool.
From the figure 1 it is clear that all subjects perceived to
RESULTS: have performance obstacles related to ET suctioning.
Table 1: Description of Sample Characteristics (N=50) Majority of the subjects (92%) perceived minimum to
Sl. No Demographic Frequency Percentage
Variables (f) (%) medium performance obstacles during ET suctioning
1 Level of Education while only 8% perceived many performance obstacles
a) GNM 18 36.0 during the procedure
b) BSc Nursing 32 64.0
c) MSc Nursing 0 0.0
2 Total experience as a
nurse
a) 6 Months - 1 Year 11 22.0
b) 1 - 3 Years 23 46.0
c) 3 - 5 Years 10 20.0

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 Asian J. Nursing Edu. and Research 6(4): October- December 2016

METHOD AND MATERIAL: d) More than 5 Years 6 12.0

3 Total experience in the current
Purpose : To identify the performance obstacles and
hospital
explore the suggestions to overcome so as to prepare a a) 6 Months - 1 Year 17 34.0
strategy to improve the ET suctioning procedure by the b) 1 - 3 Years 25 50.0
nurses. c) 3 - 5 Years 5 10.0
d) More than 5 Years 3 6.0
4 Total experience in the critical care
Study Design and Population
unit
A quantitative research with descriptive exploratory a) 6 Months - 1 Year 13 26.0
design was used to identify the performance obstacles b) 1 - 3 Years 28 56.0
perceived by critical care nurses in performing end c) 3 - 5 Years 4 8.0
tracheal suctioning. The study was carried out among 50 d) More than 5 Years 5 10.0
critical care nurses working in eight intensive care units 5 Attended training programme on ET suctioning
a) Yes 11 22.0
of AIMS, Kochi. b) No 39 78.0

Tool and Technique The data presented in the table 1 regarding the sample
The data was collected using the tool: Questionnaire to characteristics show that 64% of the subjects were
identify performance obstacles and the opinion of critical graduate nurses, 36% were GNM and not a single post
care nurses to overcome the performance obstacles graduate. 56% of the nurses had one to three years of
during ET suctioning. It has sections; Section A: experience in the critical care unit and only 18% had
Performance obstacles perceived by critical care nurses more than three years of experience in the critical care
during ET suctioning and Section B: Opinion of critical unit. Training programme on ET suctioning was not
care nurses to overcome the performance obstacles in ET received by 78% of the subjects. (n=50)
suctioning. Content validity of the tool was obtained
from twelve experts in the field of nursing and medicine.
The content validity index obtained for the tool was
0.99. Reliability of the tool I section A and section B
was 0.825 and 0.879 respectively. The level of
performance obstacle was rated as minimum obstacle
(≤50%), medium obstacle (50-75%) and many obstacle
(75%).

Data Collection
Data collection for the main study was conducted from
7th December, 2014 to 15th January, 2015. Written
permission was obtained from the Nursing Director,
Medical Superintendent and Head of the department of
each ICU. Written informed consent was obtained from
the subjects after clearly explaining the purpose of the
study. The Tool was administered to the subjects at the
Figure 1: Pie Diagram on Distribution of Sample Based on Level of
end of their shift. Performance Obstacles Perceived by Nurses During ET Suctioning

Data Analysis
Frequency and percentage were used to analyse the data
collected based on the Tool.
From the figure 1 it is clear that all subjects perceived to
RESULTS: have performance obstacles related to ET suctioning.
Table 1: Description of Sample Characteristics (N=50) Majority of the subjects (92%) perceived minimum to
Sl. No Demographic Frequency Percentage
Variables (f) (%) medium performance obstacles during ET suctioning
1 Level of Education while only 8% perceived many performance obstacles
a) GNM 18 36.0 during the procedure
b) BSc Nursing 32 64.0
c) MSc Nursing 0 0.0
2 Total experience as a
nurse
a) 6 Months - 1 Year 11 22.0
b) 1 - 3 Years 23 46.0
c) 3 - 5 Years 10 20.0

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 Asian J. Nursing Edu. and Research 6(4): October- December 2016

Table 2: Distribution of sample based on performance obstacles perceived by nurses during ET suctioning (n=50)
Sl.No Statement on performance obstacles f (%)
I Performance obstacles related knowledge
1. I don’t have adequate knowledge regarding ET suctioning procedure 19 (38.0%)
2. I did not receive adequate hands on training on ET suctioning in a real patient when I was a student 39 (78.0%)
3. I did not receive adequate hands on training on ET suctioning as a staff nurse 23 (46.0%)
4. I don’t have adequate knowledge in assessment of patient to identify the need for suctioning 8 (16.0%)
5. I don’t know the changes to be monitored in a patient while suctioning 6 (12.0%)
6. I don’t know that ventilator can be used hyper oxygenation before and after ET suctioning 12 (24.0%)
II Performance obstacles related to skill in ET suctioning
7. I am not confident in ET suctioning* 9 (18.0%)
8. I lack technical skill in handling equipments related to ET suctioning 5 (10.0%)
9. I don’t get time to do patient assessment 6 (12.0%)
10. I complete the ET suctioning procedure in a hurry due to lack of time 13 (26.0%)
11. It is difficult to do ET suctioning without assistance 42 (84.0%)
12. The irritation caused by the procedure creates restlessness in patient which makes the procedure more difficult 42 (84.0%)
13. I have experienced distractions while performing ET suctioning 26 (52.0%)
14. Additional responsibility assigned to me other than nursing care affects my work 23 (46.0%)
III Performance obstacles related technology and tool
15. Hand washing facility and articles are not available within easy reach 8 (16.0%)
16. Equipment for ET suctioning are in poor condition/not available 7 (14.0%)
17. There are conflicts in the usage of technology related to ET suctioning in the unit 14 (28.0%)
IV Performance obstacles related to organization
18. A mechanism to ensure the performance of ET suctioning in a sterile manner is not available 16 (32.0%)
19. I was not given training on ET suctioning before starting my experience in the unit. 31 (62.0%)
20. Research findings on ET suctioning and its complications on patients was not revealed to us 38 (76.0%)

The performance obstacles perceived by nurses were
mostly related to skill in ET suctioning which include;
difficulty to do ET suctioning without assistance (84%),
restlessness in patient during the procedure makes the
procedure difficult (84%) and experiencing distractions
while performing ET suctioning (52%).
The major knowledge related performance obstacles
perceived by nurses’ was inadequate training on ET
suctioning in a real patient as a student (78%).The nurses
also identified two major performance obstacles related
to organization which include; not receiving training
before starting experience in their unit (62%) and
research finding related to ET suctioning and its
complications was not being revealed to them (76%).

Table 3: Distribution of Sample based on Suggestions of Critical Care Nurses for Overcoming the Performance Obstacles in ET
Suctioning (n=50)
Sl.No Suggestion for overcoming the performance obstacles f (%)
I Suggestions for overcoming performance obstacles related to knowledge
1. Training on ET suctioning should be given at the beginning of clinical posting in critical care unit 50 (100.0%)
2. Time to time updating of ET suctioning should be made in the guideline/equipment’s and must be taught to 50 (100.0%)
critical care nurses
3. Participation in continuing nursing education / research activities related to ET suctioning creates open 49 (98.0%)
mindedness among nurses to accept changes in guidelines/protocol
II Suggestions for overcoming performance obstacles related to skill in ET suctioning
4. Adequate time for ET suctioning should be ensured by
a. Identifying the nursing and non-nursing activities 46 (92.0%)
b. Bringing a system to meet the needs of bystanders 33 (66.0%)
c. Have a system for other health professionals/workers 37 (74.0%)
III Suggestions for overcoming performance obstacles related to technology and tool
5. Adequate hand washing facility and articles are required 48 (96.0%)
6. Suctioning equipments should be in good condition 47 (94.0%)
7. Strict adherence to guidelines/protocol minimizes conflicts related to usage of technology in ET suctioning 49 (98.0%)
IV Suggestions for overcoming performance obstacles related to organization
8. The critical care unit must develop a guideline/protocol on ET suctioning 50 (100.0%)
9. Charge nurses should make sure that staff nurses have access to the guidelines/protocol 47 (94.0%)
10. Time to time peer review evaluation/audit of the procedure in the critical care unit can help in improvement 40 (80.0%)

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 Asian J. Nursing Edu. and Research 6(4): October- December 2016
From the above table it is clear that majority were in
agreement with all the ten suggestions provided to
overcome the performance obstacles related to ET
suctioning. All of them (100%) agreed on three
suggestions which were; training on ET suctioning
should be given in the beginning of clinical posting in
critical care unit, the critical care unit must have a clear
cut guideline/protocol on ET suctioning and timely
updating the guideline/equipment on ET suctioning
should be made.
DISCUSSION:
Present study findings consisted of 64% of graduate
nurses, 36% were GNM and not a single post graduate.
82% of the had six months to three years of experience
in the ICU as the investigator considered a period of six
months of working in ICU a sufficiently adequate time
to acquire knowledge and skill related to ET suctioning.
In a study conducted by Sharma S, Sarin J, Bala G K
(2014) on effectiveness of endotracheal suctioning
protocol in terms of knowledge and practices of nursing
personnel (N=30) in Mullana, it was found that, 100% of
sample had professional qualification of GNM and 100%
had within five years of experience in ICU.1
In the present study 78% of the subjects did not attend
training programme on ET suctioning previously
whereas in the study by Sharma S, Sarin J, Bala G K
(2014) 56.67% had attended the in-service education
related to ET suctioning.1 Comparison with the above
study findings shows that the present study findings can
be more generalized to graduate nurses with less than
three years of experience in ICU mostly without a good
background of training in ET suctioning.
In the present study, majority of the subjects (92%)
perceived minimum to medium performance obstacles
during ET suctioning while only 8% perceived many
performance obstacles during ET suctioning. The results
of this study indicate that critical care nurses experience
a wide variety of performance obstacles during ET
suctioning.
Hardly any study was available in literature to identify
the performance obstacles perceived by critical care
nurses on ET suctioning. But few available general
literature on performance obstacles perceived by critical
care nurses in their work environment support the
findings of the present study. The performance obstacles
perceived by critical care nurses were categorized under
four headings;
1. Knowledge related performance obstacle
2. Skill related performance obstacle
3. Technology and tool related performance obstacle
4. organization related performance obstacle
494
The performance obstacles perceived by nurses’ were
mostly related to skill in ET suctioning which include;
difficulty to do ET suctioning without assistance (84%),
restlessness in patient during the procedure makes the
procedure difficult (84%) and experiencing distractions
while performing ET suctioning (52%).
This result was entirely different from the study by
Keshk LI, Qalawa SA, Aly AA (2012) on performance
obstacles experienced among 60 critical care nurses in
damanhur teaching hospital which reflect that, only
48.3% of them had only one assistant nurse to help them
in nursing care and 65% of them reported inadequate
help from nursing assistants. The performance obstacles
related to environment in work system highlighted
distractions experienced by nurses which included;
insufficient work place for completing paper work
(40%), patients’ room full with visitors (36.7%),
receiving many phone calls from patients (33.4%),
distractions from family members (31.7%) receiving
many phones calls from family members (25%).2 A
multisite, cross-sectional study was conducted by Gurses
AP, Carayon P reported that most frequently experienced
performance obstacles included noisy work environment
(46%), distractions from families (42%), hectic (40%)
and crowded work environments (37%), delay in getting
medications from pharmacy (36%), spending
considerable amount of time teaching families (34%),
insufficient workspace for completing paperwork (26%),
seeking for supplies (24%) or patients' charts (23%),
receiving many phone calls from families (23%), delay
in seeing new medical orders (21%), From the studies
discussed above it is clear that performance obstacles
related to nursing assistance is a major issue.3 Wolfe
(2012) added that a good ward clerk should have the
presence of mind to give assistance when necessary and
this will enhance the work of staff nurse in their unit.
In the present study nurses reported minimal
performance obstacle related to technology and tool
which included; conflict in the usage of technology and
tool related to ET suctioning in the unit (28%), hand
washing facility and articles are not available within easy
reach (16%) and poor condition of ET suctioning
equipment (14%). The study by Keshk LI, Qalawa SA,
Aly AA (2012) also reported minimal performance
obstacles related to Technology or Tools in work system
which included; having to use equipment that was in
poor condition (21.7%). waiting to use a piece of
equipment because someone else was using it. (20%). 2
The study by Gurses AP also reported less performance
obstacles on Technology or Tools in work system which
included; equipment not being available-someone else
using it (32%), patient rooms not well-stocked (32%)
and misplaced equipment (20%).3
 Asian J. Nursing Edu. and Research 6(4): October- December 2016

In the present study the major knowledge related minimize the gap between knowledge and skill.
performance obstacles perceived by nurses’ was Moreover appreciating the nurses contribution while
regarding inadequate training on ET suctioning in a real implementing this research finding will be encouraging
patient as a student (78%).The nurses also identified two the participants to take part in further educational
major performance obstacles related to organization attempt to minimize the gap between knowledge and
which include; not receiving training before starting practice.
experience in their unit (62%) and research finding
related to ET suctioning and its complications not being CONCLUSION:
revealed to the nurses (76%). The nurses perception on performance obstacles reported
was that, most of them had only minimum to medium
On comparing the results of the present study with the obstacles. This may be due to lack of awareness on
study discussed above, it can be concluded that the knowledge and skill required specifically in phases of
critical care nurses experience a variety of performance ET suctioning. However 100% of the subjects suggested
obstacles while performing ET suctioning. Majority the need for ET suctioning training before practicing in
were in agreement with all the ten suggestions provided critical care unit. The need for skill training programme
to overcome the performance obstacles related to ET specific to practice areas of nursing before independent
suctioning. All of them (100%) agreed on three patient care assignment in critical care unit has become
statements which were; training on ET suctioning should evident through the present study.
be given in the beginning of clinical posting in critical
care unit, the critical care unit must have a clear cut
The Strategy
guideline/protocol on ET suctioning and time to time The strategy prepared by the researcher is an overall plan
updating of ET suctioning procedure should be made in to improve the knowledge and skill of critical care
the guideline/equipment’s. nurses on ET suctioning in the study setting based on the
opinion given by nurses. Strategy was prepared as shown
These suggestions pave the way to prepare appropriate in the figure 2.
strategy to overcome these performance obstacles and

FIGURE 2: STRATEGY TO IMPROVE PRACTICE OF ET SUCTIONING

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ACKNOWLEDGEMENT:
I would like to thank every person who supported and
encouraged me to complete the research study
successfully.

REFERENCE:
1. Sharma S, Sarin J, Bala G, Evaluate the effectiveness of
endotracheal suctioning protocol in terms of knowledge and
practices of nursing personnel. Nursing and Midwifery Research
Journal [serial online] 2014 April;10(2). Available from:
http://medind.nic.in
2. Keshk LI, Qalawa SA, Aly AA. Performance obstacles
experiences among critical care nurses in damanhur teaching
hospital. Life Science Journal [serial online] 2012;9(2). Available
from: www.lifesciencesite.com
3. Gurses AP, Carayon P. Performance obstacles of intensive care
nurses. Nurs Resp [serial online] 2007 May-Jun;56(3):185-94
Available from: www.pubmed.com

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