Studies regarding the knowledge and practice of ETS among nurses have been conducted in several countries as ETS concerns the safety of mechanically ventilated patients (Beuret, Roux, Constan, Mercat, & Brochard, 2013; Gilder, Parke, & Jull, 2018; Leddy & Wilkinson, 2015; Negro et al., 2014). However, little is revealed from the Chinese ICUs. The results of this study show that intensive care nurses have poor to moderate awareness of evidence-based ETS practices. This result is inconsistent with studies of Negro et al. (Negro et al., 2014), Varghese and Moly (Varghese & Moly, 2016), Heidari and Shahbazi (Heidari & Shahbazi, 2017) where they revealed that nurses' knowledge of best ETS practices was in an moderate state.
In China, the poor to moderate level awareness of evidence-based ETS recommendations may be partly due to the inaccessibility of the guidelines by clinical nurses (Zhang & Yang, 2017). Even though several English ETS guidelines exit, there was no one in Chinese before the adapted guideline by Hu et al. (Hu et al., 2019). Many intensive care nurses in Chinese hospitals felt unable to access to those English guidelines due to language barriers (Zhang & Yang, 2017). In addition, insufficient training experiences may also explain this low to moderate level of awareness and adherence (Gu, Shang, Jin, Zhou, & Wang, 2011). As showed in our study, nurses received training demonstrated significantly higher awareness and adherence than those who did not. Nevertheless, one third of the participants in our study have not taken any ETS training. As such, we recommend that frequent ETS training should be in place to disseminate the up-to-date ETS recommendations to the front-line intensive care practitioners.
In agreement with previous study (Endla, Kabdal, Sahai, & Masih, 2017; Negro et al., 2014), experienced intensive nurses (5–15 years of ICU work) in our study had better knowledge of the ETS than less experienced nurses (༜5 years of ICU work) and nurses who worked for over 15 years. This may be due to reasons. First, nurses who worked in ICU for 6–15 years had enough experience to know each feature of the ETS (Negrón et al., 2014). Second, they are usually the main force of ICU and have more opportunities to receive ETS training (China Social Welfare Foundation, 2017).
Our study findings showed that the majority of the nurses lack knowledge of certain aspects of the guideline. For example, almost two-thirds of the intensive care nurses were unaware of the insignificant differences between the open and closed suctioning on clinical outcomes (i.e., oxygen saturation, cardiovascular instability, secretion removal, environmental contamination, and cost). It was an unsurprising result as there were contradictory findings in the past two decades as to the comparisons of these two suctioning methods (Afshari, Safari, Oshvandi, & Soltanian, 2014). Some researchers found that the two suctioning methods differed in affecting the heart rate (Afshari et al., 2014; Zolfaghari, Nasrabadi, Rozveh, & Haghani, 2016), while it was the other way around in other investigations (Fernández, Piacentini, Blanch, & Fernández, 2004). However, the methodological flaws of some studies made their research findings less convincing and led to the failure of generating strong recommendations (American Association of Respiratory Care, 2010). Recommendations in our study were developed by incorporating the best available evidence (Hu et al., 2019). It, therefore, has the potential to be widely applied in the clinical ETS practices in China.
Likewise, over half of the nurses did not know the pros and cons of using hyperinflation (i.e., patients may feel dyspneic when the tidal volume is over 900 cc, the hyperinflation may relate to increases in mean arterial blood pressure, using volumes of hyperinflation that are indexed to the size of the patient may assist in minimizing potential difficulties). Elbokhary et al.(Elbokhary, Osama, & Al-Khader, 2015) had similar research findings that nurses retained poor knowledge regarding the adverse effects of hyperinflation. We suggested that ETS training programs should place particular emphasis on those 'low-awareness items' to change intensive care nurses’ traditional views toward ETS and promote their acceptance of the evidence-based recommendations (Varghese & Moly, 2016).
We also found that almost one half of the participants' clinical practice differed from or contradicted the evidence-based recommendations, such as not routinely using normal saline, performing suctioning at least every 8-hour, and using 80–120 mmHg suction pressure during endotracheal suctioning. It revealed that considerable gaps exist between the evidence-based ETS practices and the current clinical practices (Graham & Logan, 2004). In order to bridge the evidence-practice gap, theoretical education or training alone may not be adequate to influence practice change (Ansari et al., 2012; Heidari & Shahbazi, 2017; Mwakanyanga et al., 2018). Routine training together with individual or group support like post-training follow-up, coaching, using of support documents like unit or hospital-level ETS regulations, web or mobile applications, checklists, reminders, user-friendly pictures, and pocket versions of the guideline could potentially elevate the knowledge level and practical ETS skills of intensive care nurses (McKillop, 2004; Mwakanyanga et al., 2018; Straus, Tetroe, & Graham, 2013). Moreover, leader support alongside the guideline implementation is recommended, as leadership has been listed as one of the most important factors influencing knowledge translation in clinical practices (Chen et al., 2020; Hu & Gifford, 2018).
Strength and Limitation
Few studies described nursing practice regarding ETS in mainland China. We disclose in the present study the intensive care nurses' knowledge and practice of ETS in Chinese ICUs and propose recommendations for the current clinical nursing practices and training. Limitations existed in this study despite our efforts to minimize the defects during the research process. First, we did not conduct a systematic psychometric testing on the questionnaire. Although it was developed based on current ETS recommendations and underwent a brief test-retest reliability and face validity test before the final version, a lack of systematic psychometric testing may limit the comparability of our findings with others. Second, we used a questionnaire survey to investigate ICU nurses' adherence to ETS recommendations rather than the onsite shadowing. There might be a discrepancy between their perceptions and the actual practices on ETS.