The practice of ETS by CCNs is one of the frequently applied procedures for the management and safety of critically ill patients in ICUs. Several studies investigated the CNNs’ practice regarding ETS [4, 13, 19]. To our knowledge, no studies have been published about the practice of ETS among CCNs in Yemen. In the present study, the adherence level of CCNs to ETS practice guidelines was either undesirable (by 55%) or moderate (by 45%) when performing the procedure for critically ill patients, with none of them showing desirable adherence to guidelines. This finding is consistent with that reported from Sudan , where fair (scored < 50%) and poor (scored 50–70%) levels of practice were observed for 76.6 and 23.4% of CCNs, respectively, while none of them showed a good level of practice (scored > 70%). Likewise, consistent findings have been reported from Finland , China , and Pakistan . Although 59.7% of Turkish CCNs have been recently found to have a very good level of knowledge of ETS guidelines, only 18.1% of them showed a good level of practice . On the other hand, undesired levels (scored < 50%) of knowledge and practice of suctioning were observed among 80.6 and 85.7% of Tanzanian CCNs, respectively . Generally, the gap between the CCNs’ knowledge can be bridged by providing them with regular courses and training based on evidence-based clinical guidelines [4, 13, 19, 21]. A national survey in Sweden showed that poor staff adherence to mechanical ventilation guidelines could be attributed to several barriers such as lack of training, lack of awareness, resistance to change, and inadequate administrators’ support . The unavailability of ETS guidelines and absence of continuous education and training may ultimately lead to differences in nursing practice . Therefore, Yemeni CCNs need regular courses and training in ETS to gain more knowledge and practice regarding the care of patients with mechanical ventilators. A recent multi-centre survey revealed low knowledge among Yemeni health care workers, including CCNs, regarding the prevention of ventilator-associated pneumonia . Because the present study only assessed CCNs’ adherence to ETS practice guidelines, further studies are recommended to investigate CNNs’ level of knowledge about ETS guidelines.
Evidence-based studies recommend the importance of performing respiratory auscultation before ETS to determine whether suctioning is needed when secretions are present, which should not be performed routinely [14, 16, 24,25,26]. However, our study showed that the majority of CCNs (70%) did not perform auscultation before ETT suctioning. This finding is consistent with that reported in other studies [4, 9, 19], where the majority or none of the CCNs performed auscultation before ETT suctioning [4, 7, 9, 19]. A possible explanation is that CCNs might depend on their experience rather than clinical evidence to assess the need for suctioning [4, 17]. Accordingly, such practices contradict the evidence that suctioning should be indicated and performed only when necessary [14, 16, 25].
Exposure of patients to ETS is often associated with anxiety and discomfort , and CCNs play a key role in alleviating this anxiety and promoting patient understanding and compliance by providing patients with clear information about the need for ETT suctioning and the consequences of not performing it when required . In the present study, the proportion of CCNs (80%) who did not explain the suctioning procedure to patients is higher than that reported for CNNs in Sudan (26.7%)  and Ethiopia (51%) . On the other hand, a lower proportion (2.8%) of Turkish CCNs explained the procedure to their patients . In the present study, approximately 30% of CCNs performed pre-hyper-oxygenation/hyperinflation, which is slightly higher than that (20%) reported for Turkish CCNs . On the contrary, it is lower than that reported in other recent studies [7, 13, 21]. It is noteworthy that pre-hyper-oxygenation (oxygen at 100% for 30 to 60 seconds prior to the suctioning event) strategy can help reduce some ETT suctioning complications, such as hypoxemia, cardiac arrhythmia, cardiac and/or respiratory arrest, and even death [14, 16]. The lack of written clinical guidelines and training programs in the surveyed ICUs could be a major reason for such practice, where CCNs may be unaware of its complications.
Approximately two-thirds of the CCNs in this study used normal saline (NS) prior to suctioning in spite of the lack of evidence about the benefit of such practice. This finding is consistent with that reported in a recent study compiling surveys from 20 countries . A recent study in Ethiopia showed that only less than one-third of CCNs were aware of the contraindication of using NS during ETS, while more than two-thirds used it during the procedure . On the other hand, another study showed that all Canadian CCNs used NS prior to suctioning . On the contrary, only one CCN was found not to use NS prior to suctioning in Turkey . It is worth mentioning that there is evidence that using NS during suctioning can lead to adverse consequences such as the increased risk of infection, reduced oxygen saturation, patient discomfort, and increased amount of secretions [15, 28, 29]. A possible explanation for this practice is the misconception of CCNs that NS humidifies and clears respiratory secretions .
The use of a small suction catheter with external diameters not exceeding one-half of the internal diameter of the ETT is recommended to allow air entry into the lungs during suctioning, consequently preventing the development of excessive negative pressure and potential atelectasis [16, 25, 30]. In the present study, the majority (57.5%) of the used catheter sizes were appropriate (less than half the internal diameter of ETT). This finding agrees with that reported for CCNs in China . In contrast to the present finding, a study in Turkey found that almost all CCNs had used catheters of the correct diameter size . However, more than half of their participants chose the catheter size based on visual recognition or color. Likewise, a study in Tanzania found that the majority of CCNs (86.4%) were unaware of determining the correct size of endotracheal catheters for suctioning, even though more than half (57.1%) of them selected the appropriate size during their practice . A possible reason for selecting large catheter sizes could be the CCNs’ perception that large sizes could facilitate the removal of thick secretions. However, large catheters can lead to hypoxemia and trauma.
ETS is an invasive procedure that requires adherence to aseptic technique and infection control measures to prevent nosocomial infections due to contamination of the lower respiratory tract . Critical steps of the aseptic technique include handwashing and wearing gloves. In the present study, handwashing and wearing gloves were practiced by 32.5 and 85% of CCNs, respectively. Similarly, a low proportion (12.5, 47%) was reported for CCNs in Turkey . In contrast, a study in China showed that two-thirds of CCNs wore gloves and washed their hands before ETS . Despite wearing gloves by all CCNs in the present study, the use of non-sterile gloves by them is inconsistent with the Clinical Practice Guidelines of the American Association for Respiratory Care (AARC) in 2022 about wearing sterile gloves before ETTs . However, the surveyed ICUs did not provide them with sterile gloves, perhaps due to their higher cost. The CCNs’ adherence to handwashing in the surveyed ICUs could be attributed to several factors such as their limited time, understaffing, and overcrowding . Regarding wearing aprons and goggles, a low proportion (12%) of CCNs wore aprons while none wore goggles, which is in line with a study in Turkey . Lack of equipment, inadequate motivation to prevent infection could be the reasons for non-adherence of CCNs to these practices.
The findings of this study showed no association between gender, age, education level, and length of experience of CCNs in the ICUs and their practice during performance ETS procedures. Similarly, recent studies in China and Tanzania found no association [13, 19]. Because more than half of CCNs (55%) in the present study held diploma degrees, the administrators of the surveyed hospitals need to exert further efforts to upgrade the education level of CCNs in the ICUs. On the other hand, training on ETS and receiving information about ETS significantly affected the CCNs’ practice. This finding highlights the importance of continuous education and training of CCNs in improving their practice during ETS of critically ill patients undergoing mechanical ventilation.
Strengths and limitations of the study
This study was the first to assess the adherence of CCNs to the guidelines of ETS in Hodeida hospitals, Yemen. Its findings can provide recommendations for improving ETS practices and raise awareness of CCNs and hospital administrators about the guidelines of ETS. However, the present study has a number of limitations. First, the study assessed CCNs’ practice of ETS, but not their knowledge. Accordingly, the gap between knowledge and practice in this issue could not be identified. Second, like many other observational studies, the Hawthorne effect may have potentially changed the CCNs’ practice due to the CCNs’ feeling of being directly observed. However, to minimize this effect, data were collected over two separate periods. Third, the sampling of CCNs from ICUs in Hodeida city may limit the generalizability of the findings of the study.