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«Exploring the Competency of the Jordanian Intensive Care Nurses towards Endotracheal Tube and Oral Care Practices for Mechanically Ventilated ...»

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Global Journal of Health Science; Vol. 5, No. 1; 2013

ISSN 1916-9736 E-ISSN 1916-9744

Published by Canadian Center of Science and Education

Exploring the Competency of the Jordanian Intensive Care Nurses

towards Endotracheal Tube and Oral Care Practices for Mechanically

Ventilated Patients: An Observational Study

Abdul-Monim Batiha1, Ibrahim Bashaireh1, Mohammed AlBashtawy 2 & Sami Shennaq1


Faculty of Nursing, Philadelphia University, Jordan


Princess Salma Faculty of Nursing, AL al-Bayt University, Jordan Correspondence: Abdul-Monim Batiha, Faculty of Nursing, Philadelphia University, Jarash Road, Amman, P.O.

Box 3948, Jordan. E-mail: abatiha@philadelphia.edu.jo Received: October 22, 2012 Accepted: November 27, 2012 Online Published: December 24, 2012 doi:10.5539/gjhs.v5n1p203 URL: http://dx.doi.org/10.5539/gjhs.v5n1p203 This study was supported by Philadelphia University (Jordan) Abstract Oral care is an important feature of nursing; it is known that oropharynx is considered the main reservoir of bacterial colonization, so the removal of oral infection is a major duty of all health care providers, particularly nurses. We performed this study to explore endotracheal tube and oral care practices for mechanically ventilated patients of Jordanian intensive care nurses, and to study Jordanian intensive care nurses' practices during, prior to, and post endotracheal tube and oral care for mechanically ventilated patients. Endotracheal tube and oral care of Jordanian intensive care nurses for mechanically ventilated patients was compared with recommendations for endotracheal tube and oral care of American Association of Critical Care Nurses and guidelines of Centers for Disease Control and Prevention. Non- participant structured observational design was conducted using a 24

-item structured observational schedule. The findings show that nurses different in their oral care practices; did not follow American Association of Critical Care Nurses recommendations; and therefore delivered lower-quality oral care than predictable. Important inconsistencies were observed in the nurses’ hyperoxygenation, respiratory assessment techniques and infection control practices.

Keywords: intensive care nurse, intubated patient, Jordan, oral care practice, observational study, oropharynx

1. Introduction Oral care is an important aspect of nursing, which has an impact on the health, comfort, and well-being of mechanically ventilated patients (MVPs). A professional knowledge and skills is required to perform Oral care for MVPs (Kathleen, 2002).

Oral care has a deep influence on the overall health. Colonization of the oropharyngeal is associated with numerous systemic diseases, including chronic obstructive pulmonary disease, endocarditis, and bacteremia (Stonecypher, 2010), cardiovascular disease (Munro, 2004; Li et al., 2000; Fowler et al., 2000), In the critical care units (CCUs), interest in relationship of oral care to systemic disease has concentrated on the development of ventilator-associated pneumonia (VAP) (Graves et al., 2010; Wip & Napolitano, 2009). VAP leads to extended critical care unite (CCU) stay, costs and increased mortality (Kearns et al, 2009).

The oropharynx is usually considered the main reservoir of bacterial colonization in the upper airways because oropharyngeal colonization by aerobic pathogens occurs very rapidly in ICU patients. Nurses usually prioritize care to immediate medical problems. Moreover, critical care nurses may be hesitant to deliver oral care to MVPs because endotracheal tube (ETT) may limit entree to the oral cavity. The opportunity of removing or moving an ETT is also a concern (Stiefel et al., 2000).

Oral care is frequently considered chiefly an intervention for clients’ comfort (Yeung & Chui., 2010), a characteristic that may decrease its frequency and priority. Knowledge about the type and frequency of oral care provided to MVPs will improve nursing interventions that may increase positive outcomes in these patients (Grap et al., 2003). The removal of infection is a major duty of all health care providers, particularly nurses, as 203 www.ccsenet.org/gjhs Global Journal of Health Science Vol. 5, No. 1; 2013 they have the most frontline contact with the patient. It is essential to teach nurses the scientific care of the teeth and proper oral care to keep oral mucosa moist, clean, and free from secretions that can lead to infection. Thus, avoiding deterioration of oral health is a significant part of nursing care of acutely ill clients (Kathleen, 2002).

Furthermore, nursing practice continues to be provided based on habitual practice, tradition and individual nurses’ preferences (Kathleen, 2002).

2. Methods

2.1 Study Objectives Exploring the competency of the Jordanian intensive care nurses towards ETT and oral care practices for MVPs.

To compare ETT and oral care of Jordanian intensive care nurses for MVPs with recommendations for endotracheal tube and oral care of American Association of Critical Care Nurses (Scott & Vollman, 2011) and guidelines of Centers for Disease Control and Prevention (CDC) (CDC, 2004).

2.2 Hypothesis Jordanian intensive care nurses do not follow guidelines for ETT and oral care as recommended by Scott & Vollman (2011) and CDC recommendations (CDC, 2004).

2.3 Design To achieve the above objectives, non-participant structured observational design was used, in which the researcher is a non-participant observer who records the phenomena under examination using a framework for data collection. This framework was developed prior to commencing the study. The researchers aim is to devise a tool that will facilitate the systemic collection of data in a way that will, as far as possible, limit the subjectivity of the observer, therapy enhancing validity and reliability.

2.4 Setting This study was conducted in ten intensive care units in ten major hospitals in Jordan: 3 private hospitals, 2 university teaching hospitals, 2 military hospital and 3 public sector hospitals (Ministry of Health). This is a representative cross-section of the health sector and intensive care nurses in Jordan. This study took place between September 2010 to April 2011.

2.5 Sample The sample includes 150 intensive care nurses who perform ETT and oral care practice for MVPs. The sampling unit was the ETT and oral care event itself. Event sampling which involves the selection of integral behaviors or events was hypothetical the best suitable technique of observation for the changeable nature of the ETT and oral care procedure (Polit, 2006). Using quota sampling, a total of 150 individual ETT and oral care events were observed, whereby each nurse performed only one event. During Quota sampling the investigator can guide the selection of subjects so that the sample contains an suitable number of cases from each stratum (Laura et al., 2010), the strata in this study are ICUs nurses from 3 private hospitals, 2 university teaching hospitals, 2 military hospital and 3 public sector hospitals (Ministry of Health). In this study, event (ETT and oral care practice) sampling was used and the sequenced nature of ETT and oral care practice was followed. In addition, “event sampling requires researchers to either have knowledge about the occurrence of events or be in a position to wait for or precipitate their occurrence” (Laura et al., 2010). Exclusion and inclusion criteria were preserved.

2.5.1 Inclusion Criteria Intensive care nurses (registered or associate degree nurses) with at least one year of ICU experience were included in this study; this experience was required because if nurses have less than one year's experience it is anticipated that they do not possess the knowledge or skills required for the procedure observed.

2.6 Data Collection By 24 item structured observational schedule, data were collected which was adapted from (Scott & Vollman,

2011) and CDC guidelines (CDC, 2004) (Appendix). Pilot study was done to identify any problems that might possibly affect the research process and practically of the observational schedule. No modifications were made to the instrument based on the pilot study. The research assistants (observers) are registered nurses who received systematic training and education prior to data collection to follow the ETT and oral care according to Scott & Vollman (2011) and CDC recommendations (CDC, 2004).

To prevent Hawthorne effect, the research assistants deliberately planned the observations throughout eight months of the observational study. Observations were done during A shift (7am-3pm), B shift (3pm-11pm) and C shift (11pm-7am).

204 www.ccsenet.org/gjhs Global Journal of Health Science Vol. 5, No. 1; 2013 All days, shifts and ICU sites had equivalent chances of being selected for each time. Before access into the intensive care units (ICUs), each ICU director was knowledgeable as to why, when they would be ICU, but ICU staffs were not informed as to when the researchers would be present in the unit.

2.7 Validity and Reliability Observation check list was sent for appraisal to university doctors’ tutors in critical care nursing, arrange of experts in critical care setting and experts in nursing research to assess the validity. Following observers’ training a pilot study was carried out to test the inter-rater reliability by the use of a second observer, and no significant differences were identified.

2.8 Ethical Consideration The scientific research committee at Philadelphia University approved the methodology and provided financial support to carry out this research. Access to the field was obtained from the institution review boards in the hospitals included in this study. Written informed consent was obtained from each participant nurse before the data collection process. They were assured that confidentiality, anonymity, and the right to withdraw from the study would be honored. In addition, voluntary participation was ensured. The purpose of the study was explained and feedback about study results will be given to all participants.

2.9 Statistical Analysis Data collected were coded and tabulated according to Statistical Package for the Social Scientists (SPSS, version

17) software. Descriptive statistics included percentages for nominal-level data and frequency ratings. To exam the null hypothesis and compare ETT and oral care of Jordanian intensive care nurses for MVPs with recommendations guidelines a one-sample t-test was used.

2.10 Quality of Treatment The following assessment scale was used: a score of 22 (the highest possible score) shows that the participant practice of endotracheal and oral care matched the standards set by the Scott & Vollman (2011) variable, representing “recommended ETT and oral care practice”. Two of the original 24 scale items were not applicable to our patients because none of them were nasally intubated. Every 24 items on the schedule was weighted with 0 and 1 (zero=not done and 1=done). This was elaborated by computing the summation of the maximum possible scores for each observation, which was established as being 22. The number 22 therefore represented perfect adherence to recommended ETT and oral care (Scott & Vollman, 2011) and CDC recommendations (CDC, 2004). The higher the intensive care nurse scored based on the observation check list, the closer the participants matched the recommended practices. Likewise, the lower the intensive care nurse scored, least expected adherence to recommended practices. This score represented the “quality of treatment”. For the purposes of the data analysis, the score was divided into four parts: practices prior to oral care, during and after the oral care procedure as well as patients’ monitoring and care.

3. Results The result were divided into 5 main elements according to the observational schedule, including practices prior to oral care, oral care event, post oral care and finally patient monitoring and care.

3.1 Practices Prior to Oral Care In relation to practices prior to oral care, the results identified that only 40 nurses (27%) wash their hands (Table 1). In relation to wearing gloves before oral care, the vast majority (N=147, 98.0%) of ICU nurses wore gloves.

In addition, over three-quarters of the participants were observed to hyperoxygenate (N=122, 81.3%) before suctioning. It was noted that the vast majority of them (N=142, 94.7%) conducted endotracheal suctioning if suctioning was clinically indicated. Furthermore, participants loosened or removed tapes (N=124, 82.7%) prior to oral care. Finally, over half of the sample (N=85, 56.7%) were observed to remove bite-block or oropharyngeal airways before administering oral care, which is used to prevent biting down on the ETT and occluding airflow. (N=37, 24.6%) of patients had no oropharyngeal airway applied at all.

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3.2 The Oral Care Event Regarding toothbrush for orally intubated patients (Table 2), no participants administer tooth brushing, and over one-third of them (N=60, 40%) did oral swap with hydrogen peroxide solution (H2O2) or 2% Chlorhexidine solution to clean the mouth every 2-4 hours for their patients.

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3.3 Post-Oral Care Practices Post oral care practices results identified that the majority of participants (N=136, 90.7%) of the observed nurses complied fully with recommendations of oral care (Scott & Vollman, 2011) and CDC guidelines (CDC, 2004) in relation to frequent suction of the oral cavity/pharynx (Table 3). In addition, the oral tubes were moved to the other side by almost two- thirds of the participants (N=97, 64.7%), and the oropharyngeal airways were replaced along ETT by over half of participants (N=86, 57.3%); and reconfirming tube placement and noting position of tube at teeth or naris (N=124, 82.7%), and securing the position of the ETT was done by 86.7% (N=130). Finally, washing hands after finishing this procedure was performed by the vast majority of participants (N=144, 96.0%).

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