KNOWLEDGE ASSESSMENT OF NURSES ABOUT TRACHEOSTOMY CARE

Transcription

1 KNOWLEDGE ASSESSMENT OF NURSES ABOUT TRACHEOSTOMY CARE PROJECT REPORT Submitted in partial fulfillment of the requirements for the Diploma in Neuro Nursing Submitted by SREEJAT.P ROLL NO : 5667 SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY TRIVANDRUM OCTOBER 2007.

2 CERTIFICATE FROM SUPERVISORY GUIDE This is to certify that Mrs.SREEJAT.P has completed the project work on "Knowledge assessment of nurses about tracheostomy care", under my direct supervision and guidance for the partial fulfillment for the 'Diploma in Neuro Nursing' in the University of Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum. It is also certified that no part of this report has been included in any other thesis for procuring any other degree by the candidate. Mrs. Saramma. P. P. Lecturer in Nursing, Sree Chitra Tirunallnstitute for Medical Sciences and Technology Trivandrum Trivandrum October 2007.

3 CERTIFICATE FROM CANDIDATE This is to certify that the project on "Knowledge assessment of nurses about tracheostomy care", is a genuine work done by me at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, under the guidance of Mrs.Saramma. P. P. It is also certified that this work has not been presented previously to any university for award of degree, diploma or other recognition. SREEJAT.P Roll No : 5667 Sree Chitra Tirunallnstitute for Medical Sciences and Technology, Trivandrum Trivandrum October 2007.

4 APPROVAL SHEET This is to certify that Mrs. Sreeja T.P bearing Roll No: 5667 has been admitted to the Diploma in Neuro Nursing in January 2007 and she has undertaken the project entitled "Knowledge assessment of nurses about tracheostomy care", which is approved for the Diploma in Neuro Nursing awarded by the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, as it is found satisfactory. (Examiners) Guide(s) Date:

5 ACKNOWLEDGEMENT First of all let me thank God all mighty for the unending love, care and blessing especially during the tenure of this study. I take this opportunity to express my sincere gratitude to Mrs. Saramma. P. P. Lecturer in Nursing, Sree Chitra Tirunallnstitute for Medical Sciences and Technology, Trivandrum, for the guidance, she provided for executing this study. Her advices regarding the concept, basic guidelines and analysis of data were very much encouraging. Her contributions and suggestions have been of great help for which I am extremely grateful. With profound sentiments and gratitude the investigator acknowledges the encouragement and help received from the following persons for the successful completion of this study. I am thankful to Mrs. Girija Devi (Ward Sister) Neuro Medical Intensive Care Unit and Mrs. Thankamma (Ward Sister) Neuro Medical Ward for their support and encouragement All the staff and colleagues in the department have helped for completion of study at some time for which I am indebted to them. SREEJA T.P

6 ABSTRACT "KNOWLEDGE ASSESSMENT OF NURSES ABOUT TRACHEOSTOMY CARE" Tracheotomy is a surgical incesion into the Trachea. Tracheostomy is the stoma (opening) that results from the tracheotomy. Tracheostomy care means suctioning the airway cleaning around the stoma also changing tracheostomy ties. Tracheostomy care is an important procedure done in ICUs frequently. Objectives of the study was to assess the knowledge of nurses about tracheostomy care and to find out relationship between nurses knowledge about tracheostomy care and selected variables. The study was conducted in the Neuro Medical ICU and Neuro Medical ward and General Medical Ward of SCTIMST. Purposive sampling technique was used for selecting the sample. The sample size was 30. In this studythe investigator used self prepared questionnaire. Major findings of the study were there was no significient difference in mean knowledge according to age and experience.

7 CONTENTS TITLE Page No LIST OF TABLE LIST OF FIGURE ABBREVIATION VIII IX X CHAPTER I INTRODUCTION 1.1 INTRODUCTION BACKGROUND OF THE STUDY NEED AND SIGNIFICIENT OF THE STUDY STATEMENT OF THE PROBLEM OBJECTIVE OF THE STUDY OPERATIONAL DEFINITIONS METHODOLOGY DELIMITATIONS ORGANISATION OF THE REPORT 8

8 CHAPTER II REVIEW OF LITERATURE 9 STUDIES ABOUT KNOWLEDGE 2.1 ASSESSMENT OF TRACHEOSTOMY 9-13 CARE 2.2 MANAGEMENT STUDIES ABOUT TRACHEOSTOMY CHAPTER Ill METHODOLOGY RESEARCH APPROACH SETTING SAMPLE AND SAMPLING TECHNIQUE 23 DEVELOPMENT OF DATA COLLECTION 3.4 TOOL DISCRIPTION OF TOOL PILOT STUDY OAT A COLLECTION 25

9 3.8 PLAN OF ANALYSIS SUMMARY 25 CHAPTER IV ANALYSIS AND INTERPRETATION OF 26 DATA 4.1 DISTRUBUTION OF SAMPLE ACCORDING 27 TO AGE CATEGORY 4.2 DISTRIBUTION OF SAMPLE ACCORDING 28 TO QUALIFICATION DISTRIBUTION OF SAMPLS ACCORDING 4.3 TO EXPERIENCE 29 DISTRIBUTION OF SAMPLE ACCORDING TO KNOWLEDGE SCORE 4.5 PERCENTAGE OF KNOWLEDGE ON 31 TRACHEOSTOMY 4.6 MEAN, STANDARD DEVIATION AND 'P' 32 VALUE OF KNOWLEDGE SCORE BY AGE

10 4.7 MEAN, STANDARD DEVIATION AND 'P' 32 VALUE OF KNOWLEDGE SCORE BY QUALIFICATION CHAPTER SUMMARY 33 CHAPTER V SUMMARY, CONCLUSION, DISCUSSION 34 AND RECOMMENDATION 5.1 SUMMARY CONCLUSION DISCUSSION LIMITATION RECOMMENDATION 36 REFERENCES APPENDIX A & B 41-43

11 LIST OF TABLES S.No Title Page No 2.1 Keywords used for literature search Distribution of samples according to age Distribution of samples according to qualification Distribution of samples according to 29 experience 4.4 Distribution of samples according to knowledge score Distribution of samples according to 31 percentage of knowledge 4.6 Mean and standard deviation of knowledge score by age Mean and standard deviation of knowledge by qualification 32 VIII

12 LIST OF FIGURES S.No Title Page No 4.1 Distribution of sample according age category Distribution of sample according qualification Distribution of sample according to experience 29 IX

13 ABBREVIATIONS ICU NMICU NMW GMW GNM B.Sc(N) Intensive care unit Neuro Medical Intensive care unit Neuro Medical Ward General Medical Ward General Nursing and Midwifery Bachelor of Nursing X

14 CHAPTER I INTRODUCTION 1.1 Introduction The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and carbondioxide between the atmosphere and the blood. The respiratory system is divided into two parts: the upper respiratory tract and lower respiratory tract. The upper respiratory tract starts from the nose and ends in trachea. The trachea or windpipe is about five inches (1 0 to 12cm) long. The support of U shaped cartilages keeps the trachea open but allows adjacent esophagus to expand for swallowing. The trachea bifurcates into the right and left main-stem bronchi at a point called carina. The carina is located at the level of the manubriosternal junction, also called angle of Louis. The carina is highly sensitive and touching it during suctioning causes vigorous coughing. Tracheotomy is a surgical incision into the trachea. Tracheostomy is the stoma (opening) that result from the tracheotomy. Indications for tracheostomy are to bypass an upper ail"\vay obstruction, to facilitate removal of secretions, to permit long term mechanical ventilation and to permit oral intake and speech in the patient who requires long term mechanical ventilation. Tracheostomy care means suctioning the air way to remove secretions and cleaning around the stoma. In addition tracheostomy care includes changing tracheostomy ties.

15 2 1.2 Background of the Study Most patients who require mechanical ventilation are initially managed with an endotracheal tube, which can be quickly inserted in an emergency. A tracheostomy requires surgical dissection and is therefore not typically an emergency procedure. Several advantages make a tracheostomy the better option for long term care. With a tracheostomy there is less risk of long term damage to the airway. Patient comfort may be increased because no tube is present in the mouth. The patient can eat with a tracheostomy because the tube enters lower in the airway, because the tracheostomy tube is more secure, mobility may be increased. The cleaning procedure removes mucus from the inside of the tube. Tracheostomy care is a basic nursing skill. While it is a matter of routine procedure in the practice of otolaryngology and critical care nurses, general nurses in other areas may perform infrequently (Rudy, 1997). 1.3 Need and Significance of the Study. Tracheostomy is a common procedure done in aiiicus. Care of a patient with tracheostomy includes suctioning the air way to remove secretions, cleaning around the stoma and changing tracheostomy ties. A variety of tubes are available to meet the individual patient needs. Tracheostomy tube with cuff and pilot balloon:-it is properly inflated, low pressure; high volume cuff distributes cuff pressure over large area and minimizing pressure on tracheal wall.

16 3 Fenestrated tracheostomy tube (Shilley,Portex) with cuff, inner cannula and decannulation plug:- when the inner cannula is removed, cuff deflated and decannulation plug inserted airflows around tube, through fenestration in outer cannula and over vocal cords, patient can speak. Speaking tracheostomy tube (Portex, National) with cuff, two external tubings: - has two tubings, one leading to cuff and second to opening above the cuff. When port is connected to air source, air flows out of opening and up over the vocal cords, allowing speech with cuff inflated. Tracheostomy tube (Bivona Foam cuff) foam filled cuff: - cuff is filled with plastic foam. Before insertion cuff is deflated. After insertion cuff is allowed to fill passively with air. Pilot tubing is not capped, and no cuff pressure monitoring is required. All tracheostomy tubes contain a faceplate or flange, which rests on the neck between clavicles and outer canula. Some tracheostomy tubes have inner canula which can be removed for cleaning. If a disposable or nondisposable inner canula is used, tracheostomy care also involves inner canula care. Both cuffed and uncuffed tubes are available. A tracheostomy tube with an inflated cuff is used if the patient is at risk of aspiration or needs mechanical ventilation. Because an inflated cuff exerts pressure on tracheal mucosa, it is important to inflate the cuff with the minimum volume of air required to obtain an air way sea. The cuff inflation pressure should not exceed 25mmof Hg because higher pressure may compress tracheal capillaries, limit blood flow, and predispose to tracheal necrosis.

17 4 An alternative method involves minimal leak technique, involves inflating the cuff with the minimum amount of air to obtain a seal and then withdrawing 0.1 ml of air. A disadvantage of MLT is risk of aspiration from secretions leaking around the cuff. ML T should not be used when the tracheostomy is placed to bypass an upper airway obstruction. The nurse should assess the ability of the patient to protect the airway from aspiration and remain with the patient when the cuff is deflated unless the patient can protect the air way from aspiration and does not require mechanical ventilation, a cuffless tracheostomy tube should be used. Retention sutures is often placed in the tracheal cartilage when the tracheostomy is performed. Care should be taken not to dislodge the tracheostomy tube during the first few days when the stoma is not mature. Because tube replacement can be difficult several precautions are required. A replacement tube of equal or small size is kept at the bed side, readily available for emergency reinsertion. Tracheostomy tapes are not changed for at least 24 hours after the insertion procedure and the first tube change is performed by a physician usually no sooner than seven days after the tracheostomy. If the tube is accidentally dislodged, the nurse should immediately attempt to replace it. The retention sutures are grasped and the opening is spread. A hemostat can also be used to facilitate replacing the tube.

18 5 Tracheostomy suctioning is a sterile procedure. It should be done two hourly or when coarse crackles or rhonchi over large airways, moist cough, increase in peak inspiratory pressure on mechanical ventilator, and restlessness or agitation if accompanied by decrease in Sp02or Pa02. Suction should not be done routinely or if the patient is able to clear secretions with cough. Provide preoxygenation by adjusting the ventilator to deliver 100% oxygen. Suctioning should not exceed seconds. Gently insert the catheter without suction to minimize the amount of oxygen removed from the lungs. A patient with a new tracheostomy will face threatening changes upon discharge from hospital support. Nurses, particularly in the critical care unit, frequently and closely support a patient and family through new and often difficult situations during hospitalization. The patient leaving the hospital with a new tracheostomy will face problems with secretion management, increased risk of infections, alterations in body image, and impaired vocalization. Nurses can help a patient successfully manage these problems through comprehensive discharge planning. Although the critical care nurses who initiate the multidisciplinary discharge planning process may not remain involved in that process throughout the patient's hospitalization, their early efforts can provide an orderly, comprehensive discharge plan optimally suited to ensure that the patient and family acquire the necessary skills, confidence, supplies, and support for the eventual transition home {Eiy1990). Tracheal suctioning is essential to maintain permeability ofthe artificial airway. This procedure may be associated to risks for the patients. {Wilson 2004 ).

19 6 Tracheostomy care is.a complex nursing activity and has many potential complications. However, aspects of tracheostomy care appear to be carried out without uniformity and with some confusion as to correct techniques, especially outside the ear, nose and throat and intensive care environments. Some aspects of the literature appear contradictory, leaving nurses to make individual judgments about correct procedures. It is the nurse who is accountable for the care given; therefore, with the wealth of evidence available, it is important that the nurse is adequately trained and fully competent in the care of a patient with a tracheostomy (Buglas 1999). Suctioning techniques are a necessary nursing intervention to remove.. respiratory secretions and maintain optimum ventilation and oxygenation in patients who are unable to get rid of these secretions independently. Nurses should be competent in assessing the need for suctioning (Moor, 2003). Most of the patients in Neuro Medical Intensive Care Unit(NMICU) require prolonged mechanical ventilation with tracheostomy. In NMICU, from January 2005 to 2007, 161 patients were on artificial ventilation for months. Tracheostomy care is an important procedure done in ICU frequently. So the care of the tracheostomy is important and the investigator selected this interesting topic. 1.4 Statement of the Problem Knowledge assessment of staff nurses about tracheostomy

20 7 1.5 Objectives of the Study To assess the knowledge of nurses about tracheostomy care. To find out relationship between nurses knowledge about tracheostomy care and selected variables. 1.6 Operational Definitions Tracheostomy:- tracheostomy is the opening or stoma made in the trachea. Knowledge: - Knowledge in this study means the score obtained in the knowledge test on tracheostomy prepared by the investigator. Nurses: - Nurses in this stl:jdy means registered nurses(temporary or permant) working in Neuro Medical Intensive Care Unit (NMICU), NeuroMedical Ward (NMW), General Medical Ward (GMW) of Sree Chitra Tirunallnstitute for Medical Sciences and Technology (SCTIMST) Methodology Setting:- Neuro Medical Intensive Care Unit (NMICU), NeuroMedical Ward (NMW), General Medical Ward (GMW) of Sree Chitra Tirunallnstitute for Medical Sciences and Technology (SCTIMST). Study design: - Descriptive survey Sample:- Nurses working in Neuro Medical Intensive Care Unit (NMICU), NeuroMedical Ward (NMW}, General Medical Ward (GMW) of Sree Chitra Tirunallnstitute for Medical Sciences and Technology (SCTIMST).

21 8 Sample size:-30 numbers. Sampling technique: - Purposive sampling. Tool: - The investigator assess the knowledge of nurses about tracheostomy care by using self prepared questionnaire. 1.8 Delimitations: The study is limited to temporary or permanent nurses working in Neuro Medical Intensive Care Unit (NMICU), Neuro Medical Ward (NMW), General Medical Ward (GMW) of Sree Chitra Tirunallnstitute for Medical Sciences and Technology (SCTIMST). 1.9 Organisation of the Report This chapter deals with introduction, background of the study, need and significance of the study, statement of the problem, objectives, operational definitions, methodology and delimitations. Chapter II deals with the review of literature, chapter Ill deals the methodology, chapter IV presents analysis and interpretation of data and chapter V include summary, discussion, conclusion, implications and recommendation. References and appendices are given towards the end.

22 9 CHAPTER II REVIEW OF LITERATURE Review of literature is an important aspect of any research project from beginning to end. It gives character insight into the problem and helps in selection methodology, developing tool, and analyzing data. With these in view an intensive review of literature has been done. Review of literature relevant to this study is presented in the following sections. 2.1 Studies about knowledge assessment of tracheostomy care. 2.2 Studies about tracheostomy management. 2.1 Studies about knowledge assessment of tracheostomy care. Myers et al. (2004), conducted a study on emergency ventilation of the tracheostomy patient, Part 1: Knowledge assessment of healthcare professionals. A nurse-driven investigation, using a convenience sample and comparative descriptive design, was conducted within a large medical center to identify healthcare professionals' (N=885) knowledge of emergency ventilation strategies for the tracheostomy patient. Registered nurses and physicians comprised the majority of survey respondents ( n=587) who answered a three-item questionnaire to assess specific knowledge. Findings focused primarily on differences in knowledge among subgroups of nurses, including those in critical

23 10 care and noncritical acute care settings.. Although increasing knowledge levels are documented since the mid 1980's, concern for the knowledge available to manage the emergency ventilation of tracheostomy patients is voiced. Less than half of nurses and physicians in this sample were able to answer correctly all three questions asked regarding emergency strategies. Recommendations address this knowledge deficit. Day et al. (2002), conducted an explorative study on nurses' knowledge and competence in acute and high dependency ward areas about tracheal suctioning. With an increasing demand for intensive care beds more nurses in acute and high dependency wards would be expected to care competently for patients with tracheostomy tubes. Aims of this study was to explore nurses' knowledge and competence in performing tracheal suctioning in acute and high dependency ward areas and to investigate discrepancies between knowledge and practice using method triangulation. Twenty-eight nurses were observed using non-participant observation and a structured observation schedule. Each subject was interviewed and questioned about their tracheal suctioning practices, and subsequently completed a knowledge-based questionnaire. Scores were allocated for knowledge and practice. The findings demonstrated a poor level of knowledge for many subjects. This was also reflected in practice, as suctioning was performed against many of the research recommendations. Many nurses were unaware of recommended practice. In addition, there was no significant

24 11 relationship. between knowledge and practice. However, during the interviews, many nurses were able to provide a rationale for specific aspects of practice that were perhaps not based on current research recommendations. The study raised concern about all aspects oftracheal suctioning and has highlighted the need for changes in practice, clinical guidelines and focused practice-based education. Ania et al. (2004) conducted an assessment of practice competence and scientific knowledge of ICU nurses in the tracheal suctioning. Objectives of this study was to evaluate practical competence of the nurses, as well as the scientific knowledge that they have on this procedures in a Polyvalent Intensive Care Unit and analyze if there were discrepancies between the practice competence and scientific knowledge. This descriptive study, performed in 34 nurses, analyzed the performance of tracheal suctioning by direct observation, using the data collection of a structured grid that included 19 aspects to evaluate, grouped into 6 categories. In the same way, knowledge on the procedure was analyzed, using a 19-item self-administered questionnaire, also grouped into 6 categories, which evaluated the same aspects observed. The total mean score obtained in the practice observation grid (P) was for a maximum score of 19, while it was in the knowledge questionnaire (Q). When analyzed by categories, discrepancies were obtained in the following aspects: in the need for hand washing prior to suctioning {P = 55.9%; Q = 97. 1% ), in cleaning of the suction catheter

25 12 after each suctioning during the procedure (P = 0%; Q = 38.2% ), in the correct performance of hyperoxygenation and hyperinsuflation, before, during and after the procedure (P = 11.8%; Q = 941% ), in the correct selection of the size suction catheter in relationship with endotracheal tubes internal lumen (P = 0%; Q = 52.9% ), in the maximum time the catheter remains in the trachea (P = 100%; Q = 23.5% ), in the maximum number of times that the catheter should be introduced in each suctioning (P = 100%; Q = 73.5%) and in the non-instillation of saline solution (P = 29.4 %; Q = 58.8% ). When the total scores obtained were compared, both in practice and knowledge, with the years of experience in ICU, no statistically significant differences were found. It is concluded that the study nurses have scientific knowledge of the suctioning procedure that are better than their practice competence. Discrepancies between practice and knowledge were also found in several ofthe aspects evaluated, which oriented towards the specific needs of training in this procedure. Donnelly et al. (2006 ), conducted a phenomenological study to investigate lived experience of a tracheostomy tube change, among patients with tracheostomy. Methods used were a phenomenological approach, guided by the insights of Martin Heidegger and Max van Manen; Participants were interviewed with their responses being transcribed into a text. This text has been subject to hermeneutic analysis using the theories of Paul Ricoeur. The findings of this study imply that the experience of a tracheostomy tube change is more

26 13 complex than that of simply a physical sensation. There was a need for participantsto prepare themselves psychologically, a process that requires not only the trust of nursing staff but also the assessment by the participant that the nursing staff member has a level of competence to perform the task. The need for maintaining communication and the ability to speak were at times more significant for participants than even the risk of other airway complications. This study had highlighted the potential for further interpretive studies into some of the more specific aspects of caring for patients that have been or are critically ill. The themes revealed would enable the nurse, required to change a tracheostomy tube, to do so with an improved level of empathy and understanding. Smith et al. (2006), conducted a study on graduate nurses' comfort and knowledge level regarding tracheostomy care. This study examined 104 new graduate nurses' ( GNs) comfort level before and after a tracheostomy in-service educational session. Results indicated no correlation between reported comfort level and knowledge in caring for patients with tracheotomies. Findings demonstrated that GNs can benefit significantly from in-service education and skills integration. This suggested that handson skills content should be a priority for inclusion into nurse residency programs, particularly with specialized, high-risk, low-incidence nursing skills, regardless of how comfortable nurses report they are with a given patient population.

27 Studies about tracheostomy suctioning. Day eta I. (2001 ), conducted an evaluation of a teaching intervention to improve the practice of endotracheal suctioning in intensive care units. This study was designed to examine to what extent intensive care nurses' knowledge and practice of endotracheal suctioning is based on research evidence, to investigate the relationships between knowledge and practice, and to evaluate the effectiveness of a research-based teaching programme. This quasi-experimental study was a randomized, controlled, single-blinded comparison of two research-based teaching programmes, with 16 intensive care nurses, using non-participant observation and a self-report questionnaire. Initial baseline data revealed a low level of knowledge for many participants, which was also reflected in practice, as suctioning was performed against many of the research recommendations. Following teaching, significant improvements were seen in both knowledge and practice. Four weeks later these differences were generally sustained, and provided evidence of the effectiveness of the educational intervention. The study raised concern about all aspects of endotracheal suctioning and highlighted the need for changes in nursing practice, with clinical guidelines and focused practice-based education.

28 15 Schwenker et al. ( 1998), conducted a study on endotracheal suctioning with instillation of normal saline. Instillation of normal saline before suctioning is a common nursing intervention although little research supports the practice. Objectives of the study were to determine when and how often saline is used during suctioning and to assess the knowledge of nurses and respiratory therapists of the advantages and dangers of using saline during endotracheal suctioning. A survey of nurses and respiratory therapists working in adult ICUs was conducted in a large university teaching hospital. The results of the survey helped determine target areas for educational programs for nurses and respiratory therapists. A protocol is being developed for use by all who do suctioning. Brooks et al. ( 1999), conducted a study on suctioning practices among physical therapists, respiratory therapists and nurses. Objectives of the study was to assess the current tracheal and oropharyngeal suctioning practice variability within and among the professionals of physical therapy, respiratory therapy and nursing. A mail survey of physical therapists, respiratory therapists and registered nurses who perform suctioning. The survey instrument consisted of questions about professional characteristics, clinical suctioning practice and sociodemographics. The survey was restricted to professionals practising within the province of Ontario. Random samples (n=448)

29 16 were drawn from membership of the regulatory boards of all three professions. The results of this study indicated a wide variation in suctioning techniques among physical therapists, respiratory therapists and registered nurses. Comparisons among professions revealed inconsistencies in some areas, such as the use of in-line catheters, gloving procedures, prelubrication and hyperinflation. Donald et al. (2000), conducted a study on setting safe and effective suction pressure, the effect of using a manometer in the suction circuit. Objectives of the study were to establish the levels of pressure used to perform tracheal suction (TS) and whether they were affected by having a manometer visible in the suction circuit. Participants of the study were sixty-four nurses and physiotherapists who regularly apply TS to patients in the intensive care units of this hospital. Conclusion of this study was all pressures in both circuits were significantly higher than those recommended as safe in the literature. In addition, pressures were unaffected by the inclusion of a visible manometer in the suction circuit. Celik etal. (2000), conducted a study on the standard of suction for patients undergoing endotracheal intubation.the purpose of this study was to determine whether using a standard method of endotracheal suctioning, to ensure consistent use of available knowledge, hao any impact on patient care. Using experimental study design, the results of two different methods of suctioning in a cardiovascular surgery intensive care unit were compared. One method

30 17 was the suctioning procedure applied by the nurses working in the intensive care unit. The other one, standard suctioning procedure developed based on the related literature and applied to the patients assigned to the experimental group by the researcher herself. Mean arterial blood pressure (MAP), heart rate (HR), and arterial blood gases (ABGs) were measured before the procedure, immediately after, 5 and 15 minutes after the procedures for both control and experimental group. The majority of the nurses suctioning the control group did not evaluate the ABGs after endotracheal suctioning, none of these patients was given oxygen both before and after the suctioning, and suctioning took longer time than recommended. To compare the results ofthe two different methods, the values of MAP, HR, P0 2 (arterial oxygenation), PC0 2 (arterial carbondioxide), and HC minutes after the procedure were used, and the differences between the two methods were statistically significant (P < 0.05). Blackwood et at. ( 1998 ) conducted a study on the practice and perception of intensive care staff using the closed suctioning system. Objectives of the study were to determine the frequency of use of closed- versus opensystem suctioning by critical care nurses and to describe the endotracheal suctioning practices of nurses who use closed-system suctioning, in particular the current practice of hyperoxygenation and hyperinflation. Results of the study was closed-system suctioning was common in the critical care setting, and current nursing practices of closed-system suctioning vary. Use of hyperoxygenation was more

31 18 common than use of hyperinflation with closed-system suctioning. Nurses had knowledge deficits about the proper performance of hyperoxygenation and hyperinflation. Further research on closed-system suctioning is warranted, especially on the practices of hyperoxygenation and hyperinflation and the effect of these interventions on the prevention of suctioning-induced hypoxemia. Akyolcu et al. ( 1994) conducted an experimental study on effects of normal saline on endotracheal suctioning. This study was designed to determine the effects of saline solution administered prior to endotracheal suctioning by nurses working in intensive care on oxygenation, heart rate and longterm pulmonary hygiene. This study concluded that saline solution administered with suctioning resulted in undesirable, although not significant, alterations in oxygen saturation and arterial blood gas levels. Collaborative, research-based policies and procedures must be developed and implemented to ensure best practices for intubated patients.(sole et al.2003). Glass ( 1996 ), conducted a study on nurses' ability to achieve hyperinflation and hyperoxygenation with a manual resuscitation bag during endotracheal suctioning. Objective of the study was to examine nurses' ability to deliver 1.5 times the ventilated tidal volume at 100% F102 with a manual resuscitation bag during endotracheal suctioning. This study concluded that nurses observed were unable to meet the standard for volume or oxygen delivery.

32 19 However this did not affect the patient's heart rate, mean arterial pressure, orsa02. Crimlisk et al. (2002) conducted a study on closed tracheal suction system: implications for critical care nursing. The Closed Tracheal Suction System (CTSS) is a multiple-use suction catheter available for suctioning the ventilator dependent patient. While research has been reported on its impact on oxygen desaturation, ventilator function, and nosocomial pneumonia, the practical issues of the technical design of the catheter and its advantage in decreasing exposure of staff to infected respiratory secretions have not been investigated. This study reported the critical care nurses' perceptions in the use of the SteriCath (Concord/Portex)_ CTSS focusing on hemodynamic stability, effectiveness of suctioning, patient safety and staff personnel exposure. Ackerman et al. ( 1996 ) conducted review of normal saline instillation: implications for practice. Nurses commonly use normal saline instillation (NSI) as a component of the suctioning procedure. The current research on NSI has not clearly identified many positive aspects of the procedure. Much of the research suggests it may actually be harmful. There has been little investigation into the reasons NSI is used. It is presumed that NSI is used to increase secretion removal when patients have thick endotracheal secretions due to inadequate humidity to the airway. Nurses need to be aware of the potential negative effects of routine NSI as well as alternative methods for maintaining adequate airway humidification.

33 20 BjArling et al. (2006 ),conducted a retrospective survey of outpatients with long-term tracheostomy. The primary aim of this retrospective study in tracheostomized patients was to compare the need for hospital care in the 2-year period before and after the tracheostomy. The authors concluded that long-term tracheostomy might not increase the need for hospital care and does not reduce life expectancy. These clinical observations were made in a setting where patients had regular access to a dedicated outpatient unit. Garner et al. (2007), conducted multidisciplinary survey on adult outpatient tracheostomy care: practices and perspectives. Objectives of the study was to determine the attitude~. opinions, and current practice of adult outpatient tracheostomy care from the surgeon and primary care physician's perspective.. This study concluded that tracheostomy care was a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. Otolaryngologists should strive to standardize tracheostomy discharge, education, and follow-up practices. Hsu et al. (2005), conducted a retrospective study on timing of tracheostomy as a determinant of weaning success in critically ill patients: The study suggested that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality.

34 21 Cobean et al. (1996), conducted a study on percutaneous dilatational tracheostomy. The researchers concluded that percutaneou~ dilatational tracheostomy was a safe, rapid, cost-effective alternative to standard open tracheostomy. It can be performed at the bedside, obviating the need to transport critically ill patients from their optimal intensive care unit environment. n t T: a bl e 2 1 K evwor d s use d~ or 1 era ure searc h Key words used Number of hits received ason Tracheotomy 724 Tracheotomy and nurses 1224 Tracheostomy and nurses knowledge 12 Tracheostomy and normal saline instillation 12

35 22 CHAPTER Ill METHODOLOGY This chapter deals with the research approach, setting, the sample and sampling techniques, development of tool, description of tool, pilot study, data collection procedure and plan of analysis. 3.1 Research approach:-adescriptive survey approach was used. The objectives of the study were To assess the knowledge of staff nurses about tracheostomy care. _To find out relationship between staff nurses_ knowledge about tracheostomy care and selected variables. 3.2 Setting:- The study was conducted in the Sree Chitra Thirunallnstitute for Medical Sciences and Technology (SCTIMST) Trivandrum, which is an Institute of National importance established by an Act of the Indian Parliament. It is an autonomous institute under the administrative Control of Department of Science and Technology, Government of India. The Institute conducts examination for selecting nursing staff. They are having written exam and interview. This ensures nurses with higher knowledge level to be selected.

36 Sample and sampling technique The sample was selected from staff nurses working in SCTIMST, Trivandrum. The sample size was thirty (30). Sampling technique used for this study was purposive samples. This includes the nurses working only in NMICU, NMW, and GMW of SCTIMST. Inclusion Criteria Nursing staff working in NMICU, NMW, and GMW. Exclusion Criteria Nursing staff working in other areas. 3.4 Development of data collection tool Data collection tool refers to an instrument which was constructed to obtain relevant data. An extensive review and study of literature and journal articles helped in preparing items for the tool. The tool used for this was self prepared questionnaire.

37 Description of tool: The tool used in the present study consisted ofthe following parts. Part I The part one consists of age, present area of working and experience in Neuro-Nursing. Part II Knowledge was assessed by using a self prepared questionnaire. It consists of ten questions. It covered knowledge on tracheostomy, tracheostomy care t~at includes the suctioning the air way to remove secretions, cleaning around the stoma and changing tracheostomy ties. Actual duration of the assessment of nursing staff was about 10 minutes. 3.6 Pilot study After obtaining prior permission from the authorities pilot study was conducted among the nursing students during September The purpose of the study was to test the feasibility. The pilot study gave more information about the research study. The pilot study samples are excluded from the main study. After making necessary correction in the tool, the main study was conducted.

38 25 samples are excluded from the main study. After making necessary correction in the tool, the main study was conducted. 3.7 Data collection For data collection formal permission was obtained from the authorities. The total period of data collection was from August to October The investigator first introduced herself and explained the need and purpose of the study. Confidentiality of their responses was assured and consent was obtained from each nursing staff. The nursing staff were interviewed with the tool. The time taken for this assessment was about 10 minutes. 3.8 Plan of analysis:- The data obtained from the nursing staff will be analyzed by using descriptive statistics and present them in the form of bar diagram and pie diagram. 3.9 Summary:- This chapter presented the research approach used for the study, setting of the study, sample and sampling techniques, development of data collection tool. Description of tool, pilot study,data collection procedure and plan for data analysis.

39 26 CHAPTER IV ANALYSIS AND INTERPREATION OF DATA This chapter presents the analysis and interpretation of data collected from 30 staff nurses working in Neuro Medical Intensive Care Unit, Neuro Medical Ward, General Medical Ward of Sree Chitra Tirunallnstitute for Medical Sciences and Technology. Analysis is a process of organizing and synthesizing data in such a way that project questions can be answered. The overall analysis is to organize structure and elicit meaning from collected data. Interpretation refers to the process of making sense of the results and examining of the implications of the findings with in a broader content. The data obtained were coded and entered in Microsoft Excel and analysed using Epi Info Version 3.2. The findings of the study were arranged and analyzed under the following sections. 4.1 Distribution of sample according to age category. 4.2 Distribution of sample according to qualification. 4.3 Distribution of sample according to experience. 4.4 Distribution of samples according to Knowledge score. 4.5 Section V- Percentage of knowledge on tracheostomy

40 4.1 Distribution of samples according to age category. The age of samples ranged from 23 to 57 years with a mean age of 36.43, standard deviation of 9.68, median of 35 and mode of 24. Table 4.1. Distribution of samples according to age category. Age Category Frequency Percentage Years Years Years 6 20 > 55 Years Total Figure 4.1 Figure 4.1 Bar diagram shows that showing distribution of sample according to age category. Age categories were made based on the age distribution of the samples so as to have a minimum number under each class. The data given in Table 4.1 shows that majority of samples belong the younger age category( years). 27

41 4.2 Distribution of date according to qualification. The qualification includes GNM, BSc and with specialty in Neuro nursing. Table 4.2 Distribution of data according to qualification. Qualification Frequency Percentage GNM B.Sc Nursing Specialty Nursing The data given in Table 4.2 shows that 19 nurses are with GNM, 7 with BSc, and only 4 of them has specialty in neuro nursing FREQUENCY GNM 63.3 BSc(N) 23.3 SPECIALITY NURSING 13.3 TOTAL 100 Figure 4.2 The same data is shown diagrammatically in Figure

42 Distribution of data according to experience. The experience ranges from below and above 10 years. Mean of 10.63, standard deviation of 8.9,median of 8.5and mode of 1. Table 4.3 Distribution of data according to experience. Experience Frequency Percentage >10 years % <10 years % TOTAL % The Table 4.3 shows that 14 numbers had below 10 years experience and 16 numbers had above 10 years of experience. <10YEARS >10YEARS Figure 4.3 The same data is shown diagramatically in figure 4.3

43 Distribution of samples according to Knowledge score. The score ranges from 7 to 10 with mean of 9.37, standard deviation of 0.72,median of 9 and mode of 9. Table 4.4 Distribution of samples according to Knowledge score. KNOWLEDGE SCORE FREQUENCY PERCENTAGE % % % % The score in the knowledge test ranged from 7 to 10. The Table 4.4 shows that 14 nurses has score of 10 and another 14 has score of 9 and 1 has 7 and 1 has 8. Figure 4.4 Figure 4.4 Pie diagram showing distribution of sample according to knowledge

44 4.5 Percentage of knowledge on tracheostomy. The data given in Table 4.5 show that the knowledge of nurses in the sub areas of tracheostomy care ranged from 96.6 to 100 percentage except in the area of saline instillation, were the samples had 46.7 percent only Table 4.5 Percentage of knowledge on tracheostomy. SINo Area of knowledge Frequency Percentage 1. Procedure % 2. Suction pressure % 3. Suctioning time % 4. Tracheostomy care(time) % 5. Cuff care % 6. Cuff management % 7. Saline instillation % 8. Tracheostomy and food intake % 9. Infection % 10. Complication % This table shows that area of knowledge ranges from 96.7 to 100%. About saline instillation the samples has 46.7% knowledge. 31

45 Table 4.6 Mean, S. D and 'P' Value of Knowledge score by age Age Category Mean S.D 'P' ::: > The data given in Table 4.6 show that the mean knowledge of nurses::: 35 years was 9.29 and the mean knowledge of nurses > 35 years was A 't' text showed that there was no significant difference in the mean knowledge score of nurses with regard to age (P 0.57). Table 4.7 Mean, S.D and 'P' Value of Knowledge score by Qualification Qualification Mean S.D 'P' Value GNM B.Sc (N) Speciality The data given in Table 4.7 show that the mean Qualification of nurses with GNM was 9.53 and the mean knowledge of nurses B.Sc (N) was 9 and Specialty was A 't' text showed that there was no significant difference in the mean knowledge score of nurses with regard to qualification. 32

46 33 This chapter deals with the analysis and interpretation of data collected from 30 staff nurses. Descriptive statistics were used for the analysis. Bar diagram is used to illustrate the findings of the study.

47 34 CHAPTER V SUMMARY, DISCUSSION,CONCLUSION, LIMITATION AND RECOMMENDATION This chapter gives a brief account of the present study including conclusions drawn from the findings and possible application of the results. 5.1 Summary The study was conducted in the Sree Chitra Tirunallnstitute for Medical Sciences and Technology (SCTIMST), Trivandrum, during August-October The sample comprised of 30 nurses both temporary and permanent. The objectives of the study was to assess the knowledge of nurses about tracheostomy care and to find out relationship between nurses knowledge about tracheostomy care and selected variables. The tools used for data collection included Self prepared questionnaire. The major findings ofthe study were -+ The Knowledge of nurses in the sub areas of Tracheostomy care ranged from 96.2 to 100% -+ About normal saline instillation duirng suctioning, the nurses were having vague knowledge. They have 46.7% knowledge only. -+ There was no significant difference in mean knowledge according to age. -+ There was no significant difference in mean knowledge according to qualification

48 Discussion The study was conducted among 30 nurses. The knowledge was assessed with a self prepared questionnaire. The questions include the tracheostomy care including tracheostomy suction, cuff care and cuff management. The area of knowledge ranges from 96.6 to 100%. But about normal saline instillation during suctioning the nurses were having vague knowledge. They have only 46.7% knowledge about saline instillation. Similar study was also conducted by Ania et al. (2004) In that study total scores obtained were compared, both in practice and knowledge, with years of experience, no stastistically significent differences were found. Schwenker et al (1998) conducted a study on endotracheal suctioning with instillation of normal saline. A protocol is being developed for use by all who do suctioning. 5.3 Conclusion Based on the findings of the study the following conclusions were drawn. The nursing staff has appreciable knowledge about tracheostomy care irrespective of age or experience. However the nursing staff hadvague knowledge about saline instillation. 5.4 Limitation The study was limited to nursing staff working in Neuro Medical Intensive Care Unit (NMICU), Neuro Medical Ward (NMW), General Medical Ward (GMW) of Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST). With these limited number of staff it is not possible to generalize findings.

49 Recommendations 0 The following recommendations are made on the basis of present study. 0 Nurses require more information about saline instillation during tracheostomy suction. 0 Similar study would be repeated by increasing the sample size.

50 37 REFERENCES 1 Ania GonzAiiz N,MartAnez-MingoA, Eseberri Sagardoy M,Margall Coscojuela M.A.,Aisian Erro.M.C.,(2004),Assessment of practices competence and scientific knowledge of ICU nurses in tracheal suctioning',journal of Enferm lntensiva, 15(3), BjArling.G., Johansson U.B.,Andersson.G., Schedin. U, MarkstrAm.A, Frostell. C.,(2006); A retrospective survey of outpatients with long-term tracheostomy Journal of ActaAnaesthesiol :50(4); Blackwood (1998),'closed Suction System';Journal of Advanced Nursing,28(5), Buglass. E.,(1999)'Tracheostomy care: tracheal suctioningand humidification", British Journal of Nursing,8(8); Blackwood (1998),'closed Suction System';Journal of Advanced Nursing, 28(5), Casserly. P., Lang.E., Fenton. J.E., Walsh. M.,(2007),"Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy", British Journal of Anaesthesia, 99(3), Celik SS,Eibas (2000),'standard of suction'; Journal of Intensive Care Nurse; 16(3), Crimlisk., (2002 ), "closed tracheal suction system: implications for critical care nursing",journal Of Advanced Nursing, 19( 1 ),

51 38 9 Cobean R, BealsM,MossC,Brendenberq CE(1996),'Percutaneous dilatation tracheostomy',archives of Surgery, 131 (3 ): Day.T., Farneii.S., Haynes.S., Wainwright. S., Wilson-Barnett. J.,(2002), "Tracheal suctioning: an exploration of nurses' knowledge and competence in acute and high dependency ward areas", Journal of Advanced Nursing,39( 1 ), Donald.K.J., Robertson.V.J., Tsebelisk. (2000), "setting safe effective suction pressure", Medical Journal of Intensive Care,26(1); Donnelly.F,Wiechula.R., (2006)," lived experience of tracheostomy tube change", Journal of Clinical Nursing, 15(9), Ely.E.W., Baker.A.M., Dunagan.DP, Burke Hl, SmithAC, Kelly PT, Johnson MM, Browder RW, Bowton Dl, Haponik EF(1996), Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously, nursing journal;335(25): Garner. JM, Shoe makermoyle.m.,.franzese.c.b.,(2007)"adultoutpatient tracheostomy care practices and perspectives",orl head Neck Journal, 136(2), Glass.,(1996), "nurses' ability to achieve hyperinflation and hyperoxygenation with a manual resuscitation bag during endotracheal suctioning",british Journal ofneuro Science Nursing,42(1),55-5.