Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and address (in block letters)

MANJU JOSEI YEAR M. Sc. NURSING ATHENA COLLEGE OF NURSINGFALNIR ROADMANGALORE – 575 001.

2. Name of the Institution ATHENA COLLEGE OF NURSINGFALNIR ROADMANGALORE – 575 001.

3. Course of Study,Subject

M. Sc. NURSINGMEDICAL SURGICAL NURSING

4. Date of Admission to the course

01.06.2012

5. Title of the Topic

EFFECTIVENESS OF VIDEO ASSISTED TEACHING

PROGRAMME ON KNOWLEDGE REGARDING

ENDOTRACHEAL TUBE SUCTIONING AMONG 4th YEAR

B. Sc. NURSING STUDENTS IN A SELECTED COLLEGE

AT MANGALORE.

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6. Brief Resume of the Intended Work

Introduction

“Tell me and I forget, teach me and I may remember, involve me and I learn”

― Benjamin Franklin

Endotracheal suctioning is performed in critically ill adults to maintain

a clear airway and optimize respiratory function. Critically ill patients often

have an increase in the production of mucous and a weakened ability to clear

secretions. If secretions are not cleared then the patient may be at risk of

infection, atelectasis and alveolar collapse. Endotracheal suctioning is carried

out when a patient with an artificial airway such as a tracheostomy or

endotracheal tube cannot cough and void pulmonary secretions. The presence

of an endotracheal tube also impedes the ability to cough, a mechanism that

requires glottic closure to generate high air flow and velocity necessary. While

some patients may be able to void secretions via a tracheostomy tube

independently, many will require assistance in the form of suction.

Complications such as hypoxia, cardiac dysarhythmias, mucosal damage and

bleeding have been associated with tracheal suctioning. Competent suctioning

technique aids in the prevention of complications associated with the

procedure1.

Endotracheal suctioning is indicated when the need to remove

accumulated pulmonary secretions, coarse breath sounds, patient’s inability to

generate an effective spontaneous cough, visible secretions in the airway,

changes in monitored flow and pressure graphics, suspected aspiration of

gastric or upper airway secretions, deterioration of arterial blood gas values,

the need to maintain the patency and integrity of the artificial airway, presence

of pulmonary atelectasis or consolidation, presumed to be associated with

secretion retention2.

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The suctioning procedure should be completed using an aseptic

technique to minimise the potential for the introduction of exogenous

organisms into the respiratory tract of the critically ill patient. Closed suction

systems offer a number of benefits including protection from bodily fluids (for

the clinician and the patient) and continuous ventilation by preventing the need

to break the circuit to introduce a suction catheter. Minimising or preventing

interruption of the ventilator circuit avoids pressure drops that may lead to

complications in the critically ill patient. Prevention of infection is an

important aspect of any clinical practice and which includes use of personal

protective equipment, hand hygiene, disposal of equipment and medical waste

and isolation of infectious patients. Additionally, personal protective

equipment including goggles, gloves and masks should be worn where there is

a risk of droplet formation during suctioning3.

Suctioning for intubated and ventilated patients is a routine nursing

procedure, yet practices vary among clinicians and hospitals1. Some suctioning

practices which have little to no evidence to support their use are still being

performed. It must be recognised that a lack of research evidence does not

necessarily mean that a practice is of no benefit. So research is sorely needed

in this field as like any other medical procedures and conditions4.

Here researcher’s personal clinical experience showed the lack of

knowledge in clinical procedures among nursing students and this made the

investigator to conduct an educational intervention to improve knowledge and

skill in endotracheal suctioning.

6.1 Need for the Study

Endotracheal suctioning 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.

Endotracheal suctioning is not a benign procedure, and operators should

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remain sensitive to possible hazards and complications and take all necessary

precautions to ensure patient safety. Secretions in peripheral airways are not

directly removed by endotracheal suctioning. Endotracheal tube suctioning

remains a routine practice in the intensive care unit, with different practices

across ICU’s. Therefore, it is important that methods of suctioning the

endotracheal tube that minimise complications are identified and implemented

into practice5

Ventilator-associated pneumonia (VAP) is a pervasive and expensive

nosocomial infection and complication that is largely related to

instrumentation of the airway with an endotracheal tube (ETT), followed by

micro aspiration of contaminated secretions. Ventilator-associated pneumonia

(VAP), one form of hospital acquired pneumonia, specifically refers to

pneumonia developing in a mechanically ventilated patient more than 48 hours

after tracheal intubation. Ventilator-associated pneumonia represents the

second most common nosocomial infection, affecting approximately in 9–27%

of all intubated patients. Ventilator-associated pneumonia prevention will

probably be most effective via a multifaceted approach, which includes

meticulous attention to basic infection-control methods during patient care,

proper patient positioning, oral hygiene, and removal of the endotracheal tube

as soon as indicated4. Only two studies found a reduction in the incidence of

ventilation- associated pneumonia with use of the closed system, and one

revealed a 3.5 times greater risk of developing this infection with the open

system7.

A descriptive study was conducted in UK, to explore the knowledge

and competence of nurses in performing tracheal suctioning. Twenty eight

nurses where observed using non-participant observation and structured

observation schedule. The study demonstrated that the majority of the subjects

(n=14) failed to perform the suctioning as accurately as they had reported. The

mean score for knowledge was 11.1 and 10.3 for practice (maximum score

20). Knowledge and practice were compared using spearman’s correlation

coefficient (r=0.338) and found that was not statistically significant (p>0.05).

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The study concluded that a poor level of knowledge for many subjects this was

reflected in practice. This study suggested that nurse require support,

education, and training relating to tracheal suctioning.8

A descriptive study was conducted to evaluate practical competence

and scientific knowledge of the nurses, on tracheal suctioning procedures in a

Polyvalent Intensive Care Unit, Spain. Study performed in 34 nurses, analyzed

the performance of tracheal suctioning by direct observation and knowledge

assessed by knowledge questionnaire (Q). Results found that, the total mean

score obtained in the practice observation grid (P) was 12.09 for a maximum

score of 19, while it was 14.24 in the knowledge questionnaire (Q). When the

total scores obtained were compared, their practice competence was lesser than

knowledge level. The study concluded that the, nurses have scientific

knowledge of the suctioning procedure that are better than their practice

competence. Based on the review of literatures and personal experience of the

investigator during practice in the field of nursing service found that staff

Nurses are not having adequate knowledge on endotracheal suctioning. This

gap of knowledge on one side and the growing risks on the other side

necessitates the need to systematically educate the staff Nurses to adopt sterile

technique during suctioning9.

Many researchers have identified that nursing students are unaware of

the current suctioning recommendations and practice is often based on ritual

and tradition as opposed to empirical evidence. In a study by Day (2002) in

UK, many nurses have failed to demonstrate an acceptable level of

competence and some of the practices observed were potentially unsafe.10 It is

essential that nurses and nursing students who perform suction must have

received appropriate training and demonstrated competence under supervision.

They should ensure that their knowledge and skills are maintained. Nurses

should also make sure that they under take role in accordance with their

original protocols policies and guidelines.11

Hence it was felt that video assisted teaching programme on

endotracheal suctioning would enable the nursing students to improve their

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knowledge and skill and also practice according to current research

recommendations. So the investigator felt to impart that the video assisted

teaching programme will facilitate 4th year B. Sc. nursing students who are on

internship in clinics as a part of their academics and as future nurse, should

know about the endotracheal tube suctioning.

6.2 Review of literature

An evidenced based self study was conducted in Japan to educate

intensive care unit staff nurses and respiratory therapists regarding ventilator

associated pneumonia prevention techniques and improve infection prevention

practices there by reducing the risk of developing ventilator associated

pneumonia. Ventilator associated pneumonia educational module with pre and

post testing was distributed to intensive care unit nurse, patient care

technicians and Respiratory Therapists. The completion rate for both pre and

post test of the module was 69% (25/36) for nursing and 86% (12/14) for

Respiratory Therapists. Nursing pre test mean score was 82% and the post test

mean score was 93%, an increase of 11% (p < .01). Pre-intervention mean

ventilator associated pneumonia rate was 7.0/1000 ventilator days (01/04-

12/04) and post-intervention mean was 0/1000 ventilator days. Educational

interventions, feedback of rates and observational data resulted in a significant

increase in the compliance and improved infection prevention practices.12

An evaluatory study was conducted in Mangalore, to assess the

effectiveness of planned teaching programme on knowledge and practice of

ET suctioning among staff nurses in different intensive unit of selected

hospitals of Mangalore. Fifty subjects were selected by purposive sampling

technique. The overall mean post-test knowledge score (27.5) was

significantly higher than the overall mean pre-test knowledge score (17.0). The

calculated ‘t’ value was 33.4 at 0.001 level13.

A quasi-experimental study was conducted in Netherlands, to evaluate

the effectiveness of an educational intervention on changing nursing practices

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and preventing suction catheter related infection in mechanically ventilated

patient. The nurse’s practice and colonization and related variables were

examined before and after an educational process. The mean score of nurses’

knowledge was 48.5 and that of practice was 33.7 before and 68.7 and 66.5

after the intervention with a computed ‘t’ value 31.7 at 0.001 level of

significance. The findings of the study showed that nurses had poor knowledge

on E T suctioning and after the intervention it improved to appropriate nursing

practice14.

A quasi-experimental study was conducted in US, to evaluate the effect

of videotape-facilitated human patient simulator(HPS) practice and guidance

on clinical performance indicators. Research participants in this project were a

convenient sample of 40 nursing students who were enrolled in a nursing

program at a university in the South eastern United States. The study was

conducted in a learning resource centre equipped with high-fidelity simulators

and video debriefing equipment. Analysis of variance (ANOVA, P= .013) )and

two-tailed t tests were used to compare control and intervention mean

differences between the two groups on behaviours (e.g., initiates

interventions), roles, scenarios, and student simulation teams. Although there

was no significant difference between the two groups on total performance

scores, the video intervention group mean score was higher (9.09) than the

control group score (8.44).15

A quasi experimental study was carried out in Bangalore, to assess the

effectiveness of a video-assisted teaching (VAT) on tracheostomy care

regarding knowledge and practice of staff nurses in 2007. The study used pre-

test and post-test control group design in which sixty staff nurses were selected

as sample by non-probability judgment sampling technique. The findings of

the study showed that in the pre-test, the experimental as well as the control

group staff nurses had on an average 42% knowledge on tracheostomy care. In

the post-test, after implementation of video-assisted teaching, experiment

group staff nurses scored up to 78% whereas in control group staff nurses

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without video assisted teaching scored only 44.5% regarding tracheostomy

care. In the pre-test, experiment group practice score was 34.5% and with

control group nurses practice score is 35.5%. In the post-test, experiment

group practice score was 80.6% and control group nurses practice score is

36.8%. In the control group out of the several demographic variables practice

gain on tracheostomy care was not associated with demographic variables. In

the experimental group out of the several demographic variables knowledge

gain on tracheostomy care was associated with gender, age, residence

frequency of tracheostomy patients in the ward, formal basic education and

experience.16

6.3 Problem Statement

Effectiveness of video assisted teaching programme on knowledge

regarding endotracheal tube suctioning among 4th year B. Sc. nursing students

in a selected college at Mangalore.

6.4 Objectives of the Study

To determine the level of knowledge regarding endotracheal tube

suctioning among 4th year B. Sc. nursing students as measured by

structured knowledge questionnaire.

To evaluate the effectiveness of video assisted teaching programme on

endotracheal tube suctioning among 4th year B. Sc. nursing students in

terms of gain in knowledge score

6.5 Operational Definitions

1. Knowledge: In this study, knowledge refers to the correct responses

obtained from 4th year B. Sc. nursing students regarding their

knowledge on endotracheal tube suctioning as measured by a

structured knowledge questionnaire.

2. Effectiveness: In this study, effectiveness refers to the changes in

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knowledge brought about by video assisted teaching programme on

endotracheal tube suctioning and is measured in terms of significant

gain in mean post test knowledge score.

3. Video-assisted teaching: Video assisted teaching programme means;

to train the educators to better supervise the Para- educators and other

classroom personnel by the use of communication through videos.

In this study video assisted teaching programme refers to the

computerized disc on endotracheal tube suctioning prepared by the

investigator, to impart knowledge to the students, which includes

indications for endotracheal tube suctioning, contraindication,

preparation of articles, and preparation of patient, techniques, duration

and frequency of endotracheal tube suctioning.

4. Endotracheal tube suctioning: Endotracheal tube suctioning is a

method of clearing pulmonary secretion by the application of negative

pressure through an appropriately sized endotracheal suction catheter

in patients who are unable to cough and clear their own secretion

effectively.

In this study endotracheal tube suctioning is a procedure to

clear the pulmonary secretion and to maintain the patency of the

endotracheal tube by an appropriately sized suction catheter.

Variables under study

1. Independent variable: In this study, it is the video-assisted teaching

programme on endotracheal tube suctioning.

2. Dependent variables: In this study, it is the knowledge regarding

endotracheal tube suctioning among 4th year B. Sc. nursing students.

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6.6 Assumptions

1. Student nurses will have some knowledge regarding endotracheal tube

suctioning.

2. Video-assisted teaching is an accepted teaching strategy.

6.7 Delimitations

This study will be delimited to:

1. The 4th year B. Sc. nursing students of a selected college of nursing at

Mangalore.

2. Generalisation is not possible due to small sample size.

6.8 Projected outcome (Hypothesis)

The hypothesis will be tested at 0.05 level of significance.

H1: The mean post-test knowledge score of 4th year B. Sc. nursing students

regarding endotracheal tube suctioning will be significantly higher than

their mean pre- test knowledge score.

7 MATERIAL AND METHODS

7.1 SOURCE OF DATA

Data will be collected from the students who are studying in a selected

college of nursing at Mangalore.

7.1.1 Research Design

Pre-experimental one group pre-test – post-test design will be used for

the study.

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O1 X O2

O1 – Pre-test

X – Video-assisted teaching on endotracheal tube suctioning.

O2 – Post- test on the 7th day.

7.1.2 Setting

The study will be conducted in Athena college of nursing, Mangalore.

It is one of the nursing institute which offers GNM, B. Sc., P. B. B. Sc. and M.

Sc. nursing courses

7.1.3 Population

Population of the present study consist of 4th year B. Sc. Nursing

students at a selected nursing institute at Mangalore.

7.2 METHOD OF DATA COLLECTION

7.2.1 Sampling Procedure

Convenience sampling technique will be used to select the sample.

7.2.2 Sample Size

The sample for the present study would consist of 60 students studying

in the selected nursing institute at Mangalore.

7.2.3 Inclusion criteria for sampling

Students who are:

Studying in the selected nursing institute at Mangalore.

Willing to participate in the study.

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Present at the time of data collection.

7.2.4 Exclusion Criteria for sampling

Students who are absent at the time of data collection.

7.2.5 Instrument Intended to be Used

The tool would consist of:

Section I: Structured knowledge questionnaire for assessing knowledge

regarding endotracheal tube suctioning

7.2.6 Data collection method

Permission will be obtained from the concerned authority. The purpose

of the study will be explained to the subjects and informed consent will be

taken from the students. Pre-test will be conducted with a structured

knowledge questionnaire on endotracheal tube suctioning. This will be

followed by a video-assisted teaching programme on same day. On the 7th day

post-test will be conducted with the same structured knowledge questionnaire

on endotracheal tube suctioning.

7.2.7 Data Analysis Plan

Descriptive and inferential statistics will be used to analyse the data.

1. Knowledge level regarding endotracheal tube suctioning before and

after video assisted teaching programme would be analysed using

percentage, mean, median, and standard deviation and would be

presented in the form of tables and figures.

2. Effectiveness of video-assisted teaching will be analysed by using

inferential statistics such as paired ‘t’ test and descriptive statistics such

as standard deviation and mean.

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7.3 Does the study require any investigations or interventions to be

conducted on patients or other humans or animals? If so, please

describe briefly.

No. The study does not involve any investigation or intervention;

however a video-assisted teaching programme will be given to the sample on

endotracheal tube suctioning.

7.4 Has ethical clearance been obtained from your institution in case

of 7.3?

Ethical clearance will be obtained from the ethical committee of the

nursing institute prior to the conduction of the study. Administrative

permission will be obtained from the concerned authorities. Written consent

will be obtained from the samples and confidentiality will be maintained.

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