PRACTICE REGARDING CARE OF ENDOTRACHEAL TUBE AMONG NURSES WORKING IN TEACHING HOSPITAL, BHARATPUR

Methods: A descriptive, crosssectional study was conducted among 56 nurses working in critical care units of a teaching hospital, Chitwan. Sample was selected by using non probability, consecutive sampling technique. Data were collected through structured self-administered questionnaire to measure the socio-demographic and professional related information and observation checklist was used to measure the practice regarding care of endotracheal tube. Data were analyzed using descriptive and inferential statistics to find out the association between variables.


INTRODUCTION
Endotracheal tube (ETT) intubation is often an emergency procedure in critical care units. Its purpose is to maintain the airway as a life-saving measures in a patient with severe acute illness and injury associated with potential compromises to the patient's airway and ventilation. 1 Although, ETT is life saving measure, the presence of an endotracheal tube is a stressful condition and may cause significant discomfort to intensive care patients. 2 However the ETT in position, there may be various complications happened which may occur early (bleeding, pneumothorax, air embolism, aspiration, subcutaneous emphysema etc) or late (infections, dysphagia, trachea-esophageal fistula, tracheal ischemia and necrosis etc). 3 Care of endotracheal tube is necessary for mechanically ventilated patient to avoid complications associated with ETT. So, the nurses play pivotal role for caring patients with ETT in critical care unit. Daily routine care includes oral care every 2 hourly, monitoring respiratory status and placement of the endotracheal tube and repositioning the client to prevent hazards of immobility (e.g. pneumonia, pressure sore), perform oral and endotracheal suctioning of secretions, monitoring ETT cuff pressure. 4,5 Many researches show that the nurses' knowledge and practice regarding care of patients with endotracheal tube was unsatisfactory. [6][7][8] Inadequate care of endotracheal tube may lead to many complications which leads to increase morbidity, hospitalization, and mortality too. Thus, nurses should have proper knowledge and practice during caring of patients with endotracheal tube.
The objective of this study was to assess the practice regarding care of endotracheal tube among nurses working in critical area of teaching hospital.

METHODS
A descriptive cross-sectional research design was used to find out the practice regarding care of endotracheal tube among 56 nurses working in critical care unit of Chitwan Medical College of Teaching Hospital, Bharatpur, Chitwan. Non probability consecutive sampling technique was used to select the sample. Inclusion criteria of this study were nurses who had more than 3 months of work experience in critical care units and available during the data collection period.
The data collection instrument was divided into 2 sections: section1 contains socio-demographic and professional related information and section 2 contains practice regarding care of endotracheal tube. The level of practice was measured by calculating the total practice score which is further classified into two categories based on median score as satisfactory practice (≥ Median score 31) and u n s a t i s fa c to r y practice (<Median score 31).
Prior to data collection, ethical approval was obtained from Chitwan Medical College institutional review committee. Written informed consent was obtained from each respondent by clarifying the purpose of the study. Respondent's dignity was maintained by giving right to reject or discontinue from the research study at any time without any penalty.
Data were collected during the period of 2019/06/23 to 2019/07/06. First of all, researcher observed the practice regarding care of ETT in the morning shift by using the nonparticipatory observation method by using observation check list. After completing the observational checklist, researcher gave briefed to each respondent regarding observation of their practice regarding care of ETT and purpose of the study was also explained. Then distributed the selfadministered questionnaire to respondents to assess the socio-demographic and profession related variables.
The collected data were checked, reviewed, and organized daily for its accuracy, completeness and consistency. The data were entered in statistical package for social sciences (IBM SPSS) version 23.0 for further analysis. The data were analyzed in terms of descriptive statistics such as frequency, percentage, mean, median and standard deviation and inferential statistics such as Chi square test was used to measure the association between the practice regarding care of ETT and the selected variables. Table 1 shows that the mean age of the nurses was 21.93 ± 2.27 with the minimum age was 18 and maximum age was 26 years. Majority of them (66.1%) were Brahmin/Chhetri and resided in Chitwan (51.8%). Most of them (85.7%) were Hindu and 71.4% were unmarried. In regard to professional qualification, 71.4% of the nurses had completed proficiency certificate level nursing and majority (73.2%) were graduated from private institution.

RESULTS
Similarly, each fifty percent of the nurses were working in medical and surgical intensive care unit respectively and 60.7% had equal and less than 1-year total work experience in the critical care unit. All nurses said that there is available of protocol on care of ETT and had attended in-service education (not shown in table). In regard to the care of patient in each shift, 85.7% of the nurses said that the nurse patient ratio is 1:3 (Table 2).   Table 3 depicts that the nurses' had highest mean percent score (79.55%) in suctioning and lowest score (19.22%) in cuff pressure management. Table 4 shows the nurses' level of practice regarding care of ETT. The median score of overall practice was 31 with IQR (32-30). Out of 56 nurses, 57.1% had satisfactory level of practice whereas 42.9% had unsatisfactory level of practice regarding care of endotracheal tube.     Table 5 shows that the level of practice regarding care of ETT was significantly associated with nurse patient ratio (p=0.046). There was no significant association between respondents level of practice regarding care of ETT and others socio demographic and professional related variables at p value 0.05 level.

DISCUSSION
This study was designed to find out the practice regarding care of endotracheal tube among nurses of a teaching hospital, Bharatpur. The result of the present study revealed that the total mean score of nurses' practice regarding care of endotracheal tube was 30.91±2.25. Similar to our findings, Amira 7 reported that the total mean score regarding care of ETT was 36.8 ± 3.1. Similarly, 57% of the nurses had satisfactory level of practice regarding care of ETT. The reason for this finding might be due to all nurses had attended in-service education regarding care of ETT and availability of standard protocol in the ward. This finding is inconsistent with the findings of the studies conducted in Sudan by Elbokhary 9 and in Tanzania by Mwakanyanga 10 reported that 76.7% nurses had fair and 85.7% had undesirable levels of practice on care of ETT respectively.
The present study reported that the total mean score of practice regarding endotracheal suctioning among nurses was 23.07 ± 1.86 which is similar to the study 11 conducted in Ambala revealed the mean practice score on endotracheal suctioning was 22.80 ± 1.23. The total mean percentage of cuff pressure management among nurses was 19.22% which is similar to study conducted in Mexico (25.31%). 12 But this finding was inconsistent with the finding conducted in Iran 13 reported that the mean percentage of cuff pressure management was 30.97%. The lower mean percentage of nurses in cuff pressure management might be due to the reason that they don't measure the cuff pressure by manometer method.
The total mean percentage score of positioning of ETT among nurses was 68.66% which is similar with the finding conducted in Egypt (57.26%). 14 This might be due to majority of the nurses don't repositioned the ETT to the opposite side due to the threat of having dislodgement of ETT while repositioning of the tube. The Findings of the study showed that nurse patient ratio is significant association with the level of practice regarding care of ETT (p= 0.046) and no association with professional qualification, working experience and in-service education which is similar with the study conducted by Mwakanyanga 10 in Tanzania concluded that there was no association between practice score and ICU training, level of education and working experience.
This study has some limitations that need to be considered when interpreting the results. This study was conducted on only one teaching hospitals and respondents were recruited using a non-probability sampling technique. Thus, the study finding may not be generalized for other setting. However, Chitwan district is central place where nurses are enrolled for job from different districts of Nepal thus the results still had strong generalizability.

CONCLUSION
It can be concluded that more than half of the nurses have satisfactory level of practice regarding care of ET tube. The highest mean percent score on suctioning procedure and the nurse patient ratio is associated with the level of practice regarding care of endotracheal tube. So, there is need to provide continue in-service education to the nurses regarding care of ETT and should maintain appropriate nurse patient ratio.

ACKNOWLEDGEMENT
Researchers would like to express heartfelt thanks to all the respondents who participated in study.