STATEMENT OF PROBLEM

An Evaluative Study of the

Performance of Critical Care
Nurses in Selected Nursing
Procedures,Christian Medical
College & Hospital, Ludhiana,
Punjab.
OBJECTIVES:-
• To assess the performance of critical
care nurses in endotracheal
suctioning and positioning
procedures.
• To identify the deficit areas in the
performance of endotracheal
suctioning and positioning
procedures.
OBJECTIVES CONTT.
• To assess the relationship of performance
of critical care nurses with selected
variables i.e age, gender, professional
qualification, experience in present
working area, area of work and type of
training institute.
• To develop protocols for the endotracheal
suctioning and positioning procedures.
Criterion Measure for ENDOTRACHEAL SUCTIONING

A. Structure standard= Max score =24

• Expected standard met= >90 %(> 21.6)
• Need improvement < 90% (<21.6)

B. Process standard = Max score=30

• Expected standard met =100% (30)
• Need improvement < 100% (<30)

C. Outcome standard = Max score = 3

• Expected standard met =100% (3)
• Need improvement <100% (<3)
STRUCTURE PROCESS OUTCOME
S1 – The nurse exhibits P1 – Assessment
01 – Effectiveness
knowledge P1 = 2
related to endotracheal P2 – Nursing diagnosis 01 = 1
suctioning P2= 1 02 = 1
S1=9
P3 – Implementation 03 = 1
S2 – The nurse reports
P3 – 20
availability
P4– After care of articles and
of articles
patients
S2 = 13
P4 – 4
S3– Nursing/ Unit/ Practice
P5 –Documentation and
setting
Recording
S3= 2
P5 =1
P6 – Evaluation
P6 = 2

24 30 3
CRITERIA MEASURES FOR POSITIONING
A. Structure standard= Max score =12
• Expected standard met= >90 %(10.8)
• Need improvement < 90% (<10.8)

B. Process standard = Max score = 24

• Expected standard met =100% (24)
• Need improvement < 100% (<24)

C. Outcome standard = Max score = 2

• Expected standard met =100% (2)
• Need improvement <100% ( 2)
STRUCTURE PROCESS OUTCOME
S1 – The nurse exhibits P1 – Assessment
01 – Effectiveness
knowledge P1 = 2
01 = 1
related to positioning P2 – Nursing diagnosis
S1=4 O2 = 1
P2= 1
S2 – The nurse reports P3 – Interventions
availability
P3 – 14
of articles for
P4– After care
positioning for
P4 – 3
client available in the
ward/unit P5 – Recording and

S2 = 6 Reporting

S3– Nursing/ Unit/ Practice P5 =3

setting P6 – Evaluation

S3= 2 P6 = 1

12 24 2
 DATA COLLECTION PROCEDURE
• The data was collected from critical care areas
i.e. intensive care unit (1 & 2),neurosurgery ICU
,neurosciences ward.
• Prior to data collection ,a written formal
permission was obtained from the nursing
superintendent,CMC & hospital through proper
channel.
• Investigator also obtained permission from the
ward in -charges of the concerned wards.
• Sample consisted of 40 nurses.
 DATA COLLECTION PROCEDURE
• Data collection was carried out from the second
week of september,2008.
• Investigator went to concerned wards and units
after duty hours, during different duty shifts &
weekends.
• The investigator first introduced self to the
subjects and explained the purpose of gathering
information.
• They were assured that their responses would
be kept confidential and used only for research
purpose.
 DATA COLLECTION
PROCEDURE
• The investigator spent 40 minutes for
endotracheal suctioning and 35
minutes for positioning.
• A good rapport was build with the
ward incharges and staff nurses.
• PURPOSIVE SAMPLING technique
was used for data collection
 STRUCTURE STANDARD
CRITERIA
• S1 knowledge related performance related to
Endotracheal Suctioning & positioning was
filled by asking question directly to the subjects.
• S2 criteria related to availability of articles
were filled asking subjects and observing there
availability in the ward/unit.
• S3- nurses to patient ratio & in-service
education criteria were filled by asking directly
to subjects and observing the ward/unit.
 PROCESS STANDARD
CRITERIA
• P1 assessment and P3 intervention, P4 after
care of the articles, P6 evaluation were filled
by observing the subjects by observer.( 2
observations for each sample.)
• Criteria P5 recording and reporting was filled by
checking the documentation in the patient’s bed
side chart.
• Criteria related with nursing diagnosis were filled
by asking subjects and by assessing nursing
process sheet.
OUTCOME STANDARD
CRITERIA
• O.1, O2 achievement of desired
effect was filled by auditing the
bed side chart (vital signs) and
general condition of patients.
 DIFFICULTIES FACED BY THE
INVESTIGATOR

• This study consisted of evaluation of 2

procedures and moreover it was observational
study so it took lot of time. Investigator has to
collect sample during different shifts.
• As it was observatory study, investigator has to
wait for each procedure to take place. For each
procedure 2 observations were done .hence
investigator has to follow same nurse for 2nd
observation.
 Difficulties Faced by the Investigator
• Same sample was taken for both procedures,
hence investigator has to wait for time when a
nurse who has done suctioning, to do
positioning.
• . The investigator had to face lot of
inconvenience. Many times investigator had to
wait for long time in order to get information from
staff nurses related to structure standard as they
were too busy in stabilizing the condition of the
patient.
•
• The conceptual framework is based
on AMERICAN NURSES
ASSOCIATION QUALITY
IMPROVEMENT MODEL on the
standards of care & quality indicators
within the Donabedian’s framework of
structure,process,outcome (1975).
MAJOR FINDINGS

• Sample of forty nurses from selected critical

care areas comprised of – maximum number of
nurses (80%) was with GNM qualification and
majority of nurses (82.5%) were trained from
CMC & Hospital. Majority of nurses (100%) were
working in special units where as none worked
in general wards.
FINDINGS OF PERFORMANCE RELATED
TO STRUCTURE STANDARD
• Overall mean percentage score of nursing
performance during endotracheal
suctioning related to structure standard
was 66.45 which was lower than the
expected standard of 90%.
• Overall mean percentage score of nursing
performance during positioning related to
structure standard was 58.9 % which was
lower than the expected standard of 90%.
FINDINGS OF PERFORMANCE RELATED
TO STRUCTURE STANDARD
• Expected standard of knowledge related to
endotracheal suctioning was met by 48.8 % of
nurses; where as 51.2% did not meet the expected
standard of 90%. Availability of articles for
endotracheal suctioning was reported by nurses
(78.6%) and 66% nurses reported nursing unit
practice setting, 34 % did not.
• Expected standard of knowledge related to
positioning was met by 63.75 % of nurses; where as
36.25% did not meet the expected standard of 90%.
Availability of articles for endotracheal suctioning
was reported by nurses (57.8 %) and 52.5% nurses
reported nursing unit practice setting, 47.5 % did
not.
• In meeting the structured standard, during endotracheal
suctioning maximum deficits were identified structure
standard in S1 i.e. knowledge (51.2%)ranked 1, followed
by S3 related to nursing unit (34%) ranked 2 & S2
related to availability of articles (21.4 %) ranked 3.
• For positioning, the maximum deficit was found in S3
criteria i.e. related to nursing service unit (47.5%) ranked
1 followed by availability of article (42.2%) ranked 2,
followed by S1 related to knowledge (36.25 %) ranked 3.
FINDINGS OF PERFORMANCE RELATED
TO PROCESS STANDARD

• Overall mean percentage score of nursing

performance during endotracheal suctioning related
to process standard was 83 % which was lower than
the expected standard of 100%.
• Overall mean percentage score of nursing
performance during positioning related to process
standard was 75.8 % which was lower than the
expected standard of 100%.
FINDINGS OF PERFORMANCE RELATED
TO PROCESS STANDARD
• For endotracheal suctioning, maximum deficits was
found in meeting of process standard in P4 criteria i.e.
after care of articles (25%), followed by interventions
ranked 2, (20%), assessment (13.4) ranked 3, nursing
diagnosis, recording & reporting and evaluation criteria
met the expected standard showing no deficits.
• For positioning maximum deficits was found in meeting
of process standard in P2 criteria i.e. nursing diagnosis
(25%), followed by interventions ranked 2, (19.65%),
after care of articles & recording and reporting ranked 3,
(28%).assessment and evaluation criteria met the
expected standard showing no deficits.
• Maximum deficit in availability of articles during
endotracheal suctioning was in stethoscope (100%)
ranked 1,followed by pulse oximetry & EKG Monitor
(47.5% ) ranked 2, Ambu (35 %) ranked 3, sterile
Normal Saline (27.5 %) ranked 4, mask (17.5%)
ranked 5 , Sterile Water And Bowl (2.5 %) ranked
6.Orther articles meet the expected outcome.
• Maximum deficits during positioning in availability of
articles was in hand rolls (100%) ranked 1, sand bags
(87.5 %) ranked 2, water filled gloves (47.5%) ranked
3,restraints (15%) ranked 4,followed by draw
sheets/towels (7.5%) ranked 5.
FINDINGS OF PERFORMANCE RELATED
TO PROCESS STANDARD
• Maximum deficits during endotracheal suctioning in
areas of after care of articles and patient by nurses was
in providing mouth care to patient (92.5 %,) ranked 1,
followed by Clear the connecting tubes with hand (20 %)
ranked 2. Other areas of after care of articles met
expected standard.
• Maximum deficits during positioning, in areas of after
care of articles by nurses was in Lower Bed (37.5 %)
ranked 1 , followed by observe body alignment (25%)
ranked 2 & Wash Hands (2.5 %) ranked 3.
FINDINGS OF PERFORMANCE RELATED
TO PROCESS STANDARD
• 2.5 % deficit was found in P5.1 i.e.
documentation during endotracheal
suctioning.
• 50% deficit was found in P5.3 i.e. Skin
Condition rank order 1, followed by
frequency of turning & Records Procedure In
Nurses Notes ranked 2. during positioning.
• 37.5% deficits were found in evaluation
during endotracheal suctioning and 25%
deficit in positioning.
 FINDINGS OF PERFORMANCE RELATED TO
OUTCOME STANDARD

• Over all mean percentage score of performance related

to outcome standard was 65.6% which is lower than the
expected standard of 100%.
• 100% nurses’ lacks in outcome Standard during
suctioning O1 i.e. improved breathe sounds, followed by
removal of pulmonary secretions (32.5 %) rank 2,
improvement in saturation (25%) rank 3.
• 35 % Nurses lack in meeting outcome standard related
to both O 1 & O2 i.e. Comfortable Position Is Provided
To Client & Appropriate Alignment Of Patient Body
respectively
For Endotracheal suctioning
• mean % score of performance related to
structure standard was 66.45%, whereas
mean% score of performance related to process
standard was 83%. Similarly mean% score of
practices related to outcome standard was
45.8%. Mean % score of performance of nurses
related to suctioning lower than the expected
levels as per the criterion measure 90% for
structure, 100% for process standard & 100%
for outcome criterion.