RELATIVE INFLUENCE OF NOTE TAKING AND GROUP DISCUSSION STUDY METHODS ON NURSING STUDENTS PERFORMANCE ON A TEST

CHAPTER ONE

INTRODUCTION

Background to the Study

The increased emphasis internationally on clinical and cost effectiveness in health policy has highlighted the need for quality health services to be built upon the use of best evidence (McKenna, Ashton & Keeney, 2010). Various governments have introduced initiatives to support the development of evidence-based healthcare systems in which decisions made by healthcare practitioners, managers, policy makers and patients are based on high quality evidence. Activity has focused on developing evidence-based guidelines for clinical interventions. For example, in the USA, the Agency for Healthcare Research and Quality leads national efforts in the use of evidence to guide healthcare decisions.

Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that started in medicine as evidence based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology, education, library, information science and other fields. (Titler, Cullen & Ardery, 2013). Polit and Beck (2011) define EBP as requiring the use of the best available research evidence and practical experience to make clinical decisions. EBP leads to cost-efficient, quality patient care and improved patient outcomes (Burns & Grove, 2010). Policy, political and professional imperatives have made EBP a clinical prerequisite for daily practice. Over the years since its formal introduction in 1992, EBP has emerged as a major policy theme in Western healthcare systems, especially, the United States of America (USA), Australia and the United Kingdom (Rycroft-Malone, 2011).

EBP is not only applying research-based evidence to assist in making decision about the healthcare of patients but rather extends to identify the knowledge gaps and finding systematically appraising and condensing the evidence to assist clinical expertise, rather than replacing it (Elshaug, 2010). In accordance with most health-related professions, there has been a growing focus on quality improvement including moving from a traditional intuition-based paradigm to evidence-based nursing practice (EBNP) (Melnyk & Fineout-Overholt, 2011).

The EBNP process consists of five stages: (1) formulating a question that will yield the most suitable answer; (2) gathering the most relevant information by systematic search of the literature or clinical guidelines; (3) performing critical evaluation of the evidence and its validity, relevance and feasibility; (4) integrating research evidence with clinical experience, patients’ values and preferences and (5) assessing treatment outcomes (Melnyk & Fineout-Overholt, 2010). Implementing EBNP is potentially beneficial for patients and healthcare systems in general, and for nurses in particular. It enhances patients’ access to information about effective treatment (Melnyk & Fineout-Overholt, 2012). EBNP can also improve the healthcare system by facilitating consistent decision making and advancing cost-effectiveness. Furthermore, EBNP can help nurses by facilitating informed and evidence-based clinical decision-making, support them to bewell informed with technologies and enable greater efficiency (Melnyk & Fineout-Overholt, 2011).

EBP in nursing has been strongly presented in the agendas of many professional organisations as an undergraduate requirement in countries, like the USA, Canada and Jordan (Baumbusch, 2010). Among the many professional organisations is the Jordanian Nursing Council (JNC), which emphasizes the implementation of EBP as one fundamental component of nursing practice and education (Jordanian Nursing Council, 2010).It is believed that the evidence-based practice in nursing education should commence in the undergraduate preparation, which provide the skills required to find, analyze and, later, synthesize best evidence for practice (Balakas & Sparks, 2010). Therefore, assessing factors influencing the implementation of EBP in nursing programs, withfuture graduate nurses, is crucial to prepare nursing graduates to adopt and implement these principles in their work.

Despite the plethora of literature on what evidence-based nursing is and is not, EBP in nursing education is still struggling and has not been addressed adequately. Many researchers identified that some problems that inhibit the implementation of EBP in nursing practice (Brown, 2009; Thompson, 2010), include insufficient educators’ skills and time to find research studies, inadequate knowledge on how to evaluate research findings, and lack of organisational support, lack of adequate understanding of technologies associated with the teaching strategies promoting EBP such as the use of human simulation in the nursing laboratories and lack of consensus on the best strategies, material, time and level of students to engage in EBP (Stichler, 2013). Other  related problem to  teaching process, especially in undergraduate education, focuses mainly on the process of deducting evidence from research rather than conducting research (Ciliska, 2010) abandoning an essential component of EBP.

By and large, the predicament of EBP is enormous. Thus, in Nigeria, EBP is still far from its realizations and under studied. It is in line with the above that the researcher seeks to find out factors that influence the implementation of evidence-based practice among nurses in selected tertiary hospitals in Enugu urban.

Statement of the Problem

Research has shown that evidence-based practice (EBP) leads to higher quality care, improved patient outcomes, reduced costs and greater nurse satisfaction than traditional approaches to care (Melnyk & Fineout-Overholt, 2011). Despite these favorable findings, many nurses remain inconsistent in their implementation of EBP (Stevens, 2011). According to Egerod and Hansen, (2012) nurses prefer to be informed by colleagues, rather than using the internet or nursing databases and most nurses rely only on what they learned during their nursing education and from experience. Even nurses with substantial knowledge about evaluating research evidence find themselves powerless and with limited authority to introduce changes in their workplaces (Banning, 2012).

In Nigeria, Ojong, Ukaegbu and Ebong ( 2012) observed that the implementation of EBP which is the bedrock of higher quality care and best patient outcomes has beenneglected and abandoned in many if not all Nigerian hospitals. In National Orthopaedic Hospital,Enugu (NOHE) and Enugu State University Teaching Hospital (ESUTH) which are the areas of study,the researcher has observed that nurses do not utilize current nursing approaches to EBP and nursing process in care of patients despite numerous workshops that have been organised in these areas.

These have raised some basic questions in the researcher’s mind thus- Are there personal/individual and organisational/institutional factors influencing the implementation of EBP? Are there potential interventions that will motivate nurses to implement EBP? This study is an attempt to answer the above questions.

Purpose of the Study

The purpose of this study is to investigate the factors that influence the implementation of evidence-based practice among nurses in selected tertiary hospitals in Enugu urban.

 

 

 

Objectives of the Study

The specific objectives are to:

• Determine personal motivating factors contributing to implementation of evidence based practice among nurses.
• Determine organisational motivating factors contributing to implementation of evidence based practice among nurses.
• Determine the perceived differences in personal factors contributing to evidence based practice among nurses in the selected hospitals.
• Determine the perceived differences in organisational factors contributing to evidence based practice to evidence based practice among nurses in the selected hospitals.

Research Questions

• What are the personal motivating factors that will influence the implementation of evidence based practice among nurses?
• What are the organisational motivating factors that will influence the implementation of evidenced based practice among nurses?
• What are the perceived differences in personal factors contributing to evidence based practice among nurses in the selected hospitals?
• What are the perceived differences in organisational factors contributing to evidence based practice to evidence based practice among nurses in the selected hospitals?

Hypothesis

• There is no significant relationship between the age of the respondents and perceived factors to implementation of EBP.
• There is no significant relationship between the educational level of the respondents and perceived factors to implementation of EBP.
• There is no significant relationship between the years of experience of the respondents and perceived factors to implementation of EBP.

Significance of the study

This study will help to stimulate discussions and research on the importance of the concept of evidence-based practice in nursingwhile the result from this study will highlight areas that may require adequate attention.The findings will provide nurses with information that will enhance the delivery of the highest quality healthcare to patients as well as ensure best patient outcome.

The results from this study will equally assist the nurses and improve their knowledge on how to operate computer, time management to improve the implementation of EBP. It will also assist the organisation and hospital management on its health policy, especially, as regards the formulation of a comprehensive evidence-based nursing practice guideline.

Scope of the study

The study is delimited to nurses in the selected tertiary hospitals in Enugu urban (National Orthopaedic Hospital, Enugu and Enugu State University Teaching Hospital, ESUTH).It is also confined to variables such as personal, organisational, perceived differences in personal and organisational factors that influence the implementation of evidence-based practice among nurses in selected tertiary hospitals.

 

 

 

Operational definition of terms

Factors influencing implementation of evidence-based practice among nurses; refer to respondents’ views, opinions on factors like personal, organisational that will positively influence nurses in implementation of evidence-based practice.

Personal/individual factors refer to certain individual constraints that influence the implementation of evidence-based practice. This may include limited knowledge, lack of interest, lack of time, lack of skills, level of education, inability to access the internet, .

Organisational/Institutional factors refer to provision/availability of internets, hospital policy, ward routine, supportive leadership, access to resources, and shortage of staff.

Evidence-Based Practice refers to application of researches that has been carried out on how to give highest quality of care that will lead to best patient outcomes.

Motivational factors refer to resources available to encourage the nurses to implement EBP like satisfactory incentives/allowances, availability of resources, and access to internet search.

 

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TABLE OF CONTENTS

Title Page                                                                                                                                i

Approval Page                                                                                                                                    ii

Certification                                                                                                                            iii

Dedication                                                                                                                              iv

Acknowledgement                                                                                                                  v

Table of Contents                                                                                                                   vi

List of Tables                                                                                                                          ix

List of Figures                                                                                                                         x

Abstract                                                                                                                                  xi

 

CHAPTER ONE: INTRODUCTION

Background to the study                                                                                                        1

Statement of the Problem                                                                                                        3

Purpose of the Study                                                                                                              4

Research Questions                                                                                                                 5

Hypotheses                                                                                                                             5

Significance of the Study                                                                                                        6

Scope of the Study                                                                                                                 6

Operational Definition of Terms                                                                                             7

 

CHAPTER TWO: REVIEW OF RELATED LITERATURE

A conceptual Review                                                                                                              8

Concept of Motivation                                                                                                           8              (a)    Types of Motivation                                                                                                      9

Intrinsic                                                                                                                          9

Extrinsic

(b)        The Motivation process                                                                                               10

(c)        General Principles of Motivation                                                                                11

Concept of Motivational variables                                                                                          12

Recognition                                                                                                                 13

Regular promotion                                                                                                       14

Enhanced remuneration                                                                                              16

Job Enrichment                                                                                                           18

Training and development                                                                                                      21

Concept of Job satisfaction                                                                                                    24

Factors affecting job satisfaction                                                                                            26

Motivational variables and job satisfaction                                                                            27

(B)       Review of Related theories                                                                                        28

Needs based theory of motivation                                                                              30

(C)       Review of Relevant Empirical Studies                                                                       32

(D)       Summary of Review Literature                                                                                  35

 

CHAPTER THREE:  RESEARCH METHODOLOGY

Research Design                                                                                                                      37

Area of Study                                                                                                                         37

Population for the Study                                                                                                        38

Sample and Sampling Technique                                                                                            39

Instrument for Data Collection                                                                                               39

Validity of Instrument                                                                                                                        39

Reliability of the instrument                                                                                                   39

Ethical Consideration                                                                                                             40

Procedure for data collection                                                                                                  40

Methods of Data Analysis                                                                                                      40

CHAPTER 4: PRESENTATION OF RESULTS

Demographic Characteristics of Respondents                                                                        41

Summary of findings                                                                                                              59

CHAPTER 5: DISCUSSION OF FINDINGS

Discussion of major findings                                                                                                  62

Implications of the findings                                                                                                    68

Conclusion                                                                                                                              69

Recommendation                                                                                                                    69

Limitations of the study                                                                                                         69

Suggestions for further studies                                                                                               70

Summary                                                                                                                                 70

REFRENCES                                                                                                                         72

APPENDIX I                                                                                                                         78

ABSTRACT

 

This study investigated the relationship between motivational variables and job satisfaction as perceived by nurse and midwife educators in Schools of Nursing and Midwifery in Akwa Ibom State. The objectives of the study were to: (i) Determine the relationship between staff recognition and job satisfaction as perceived by nurse and midwife educators in Akwa Ibom State. (ii) Determine the relationship between promotion and job satisfaction as perceived by nurse and midwife educators in Akwa Ibom State. (iii) Ascertain how salary influences job satisfaction has perceive by nurse and midwife educators in Akwa Ibom State. (iv)Ascertain how the level of job enrichment influences job satisfaction as perceived by nurse and midwife educators in Akwa Ibom State (v). Determine how training and development impact on the level job satisfaction as perceives by Nurse and midwife educators in Akwa Ibom State and (vi) Determine  if nurse and midwife educators perceived job satisfaction in their place of work. A descriptive cross sectional survey was adopted for the study. No sampling was adopted, all nurse and midwife educators in schools of Nursing and Midwifery, Akwa Ibom State consisting of one hundred and sixty (160) subjects were studied. A researcher–constructed instrument “Motivational Variables and Job Satisfaction Questionnaire (MVAJSQ)” containing 53 items in two sections was used for data collection and was pretested using split half reliability with Pearson Product Moment Correlation which yielded r = 0.75. Data was analyzed using descriptive statistical procedure: mean, standard deviation and mean of means was 2.50. Hypothesis tested with Pearson Product Moment correlation probability value less than 0.05 was considered statistically significant. The survey result revealed that nurse and midwife educators perceived recognition and promotion in their places of work, they were not enriched in their job placement and poorly perceived salary grade level, they were not satisfied with their job so the nurse and midwife educators should be made more attractive through the implementation of the special and enhanced salary structure to educators.

 

 

 

 

 

 

 

 

CHAPTER ONE

INTRODUCTION

Background to the Study

Motivation is that energizing force that induces or compels and maintains behavior Nwachukwu, (2011). Human behavior is motivated and goal directed. The success of any motivational effort depends on the extent to which the motivator meets the needs of the individual employees for whom it is intended. Motivation is a basic psychological process, and motivational factors show the competitiveness in the institution naturally along with perception, personality, attitudes and learning. Motivation is an important element of behavior (Ebrahim, &Wachtel, 2010). Shaffer and Shoben ( 2011) defined motivation as a socially learnt  behavioral pattern involving need, desire, recognitions, rewards mechanisms and end results. Motivation is very important in a workplace as it may lead to employee satisfaction.Nurse and Midwife educators are employees in nursing educational institutions, and like other employees in other work organizations, they desireto be motivated through various means.

Motivational variables and job satisfaction are very essential in the lives of employees because they constitute some of the fundamental reasons for working in life.A motivational variable is a factor that exerts a driving force on actions and work output of employers in work situations and contribute to employee’s job satisfaction.Moreover, employees are the key drivers of prosperity and success of any institution or organization. Unless and until the institutions or work organizations  recognize the effort and  contributions of their employees and reward them accordingly, they will not be able to conquer the highest level of motivation and job satisfaction of the employees(Agbaragba,2010).

Motivational variables are those factors which when put in place act like a driving force that propels an employee to work to achieve a set goal for the organization. Motivational variables include such factors as recognition, promotion, remuneration, job enrichment, staff – training and development. Reward and recognition are advantageous to the employees in a way that it injects self-confidence (Khan, 2011).  An employee looks forward to the day he will earn a promotion. Regular promotion is a reward for past performance and encouragement to help an employee to continue to excel. It is a vote of confidence and the employee who is denied promotion for a long time gets frustrated. How an employee perceives an opportunity for promotion influences job satisfaction.

Remuneration is another important motivational variable. Regular and good salary is a motivator of behavior. There are people who have to work in order to maintain a large family .If an individual works hard  but does not receive what he considers as adequate remuneration for the effort expended, he could be dissatisfied (Nwachukwu, 2011).

Job enrichment contributes a lot to job satisfaction. It is believed that the nature of job or work in the present job is one of the factors that influence job satisfaction. Management can motivate employees by designing jobs so as to satisfy motivational needs. Any job that robs employees of their needs for achievement, recognition, acceptance and self-fulfillment will tend to dissatisfy them (Nwachukwu, 2011). Management should find out if the job is fascinating, routine, satisfying, boring, pleasant, tiresome, challenging or frustrating. Whether an employee works hard or not, derives satisfaction from the job or not is influenced by the way he perceives the work he is assigned to perform (Akpan, 2011). Training and development is an important factor in fostering personal and academic development of the employee. Training is an important motivator and training of employee brings about personal and enhanced development. If employees are trained, their level of education will be updated and there will be increase in skills.  When employees are motivated through recognition, regular promotion, remuneration, job enrichment, training and development, it is likely that job dissatisfaction will be eliminated (Van-Knippenberg,2010).Motivation within an organization remains high if a worker perceives that there are opportunities for personal development or professional advancement, if he feels capable of completing tasks correctly and is involved with various organizational decision-making and goal-setting processes.

Irrespective of the relationship which may exist between motivational variables and job satisfaction different individual or groups may perceive it from different perspectives. Perception is the ability to see, hear or become aware of something through senses. It is the way in which something is regarded understood or interpreted. Nzuve and Nduta 2014 opines that perception is our sensory experience of the world around us and involves both the recognition of environmental stimuli and actions in response to these stimuli.  Motivation can be reduced if the worker perceives a lack of opportunity for growth, a lack of involvement or a lack of opportunities to demonstrate any creativity.Motivating employees to complete their work correctly and on time is one of the major tasks of management. Changing an employee’s perception of his place within a company is sometimes an effective way of improving organizational behavior constructively. Employees who perceive that they have a greater control over their work lives will likely be more motivated to excel within the organizational structure.(Kalisch, Lee &Rochman 2010).

Job satisfaction is the ability of the job to meet employee’s needs and improve their job   performance. Job satisfaction is another important variable in an employee’s expectation from work place, Mitchell and Lasan (2011) described job satisfaction as the most important and frequently studied attitude in the field of institutional behavior. It is so important that its absence often leads to poor performance and reduced institutional commitment, and lack of job satisfaction is a predictor of quitting a job (Alexander, Lichtenstein &Hallnan 2011: Jamal, 2011). Sometimes employees may quit their jobs from public to private sector and vice versa due to lack of promotion and late payment of salaries (Akpan, 20011). So job satisfaction can be motivated by the availability of recognition, promotion opportunities, pay satisfaction, job enrichment, training and development (Bolarin, 2011, Gemen, Xhenandex, Kasier, Paradisand Robinson, 2011). This study set out to investigate the relationship between motivational variables and job satisfaction as perceived by nurse and midwife educators in schools of Nursing and midwifery in Akwa Ibom State.

Statement of the Problem    

Motivation and job satisfaction are very essential to the institution/work organization and to the individual employee because they form the fundamental reason for working in life (Dweck, 2010).Job satisfaction is the whole matrix of job factor that makes a person like his work situation and be willing to head for it without distaste at the beginning of his day work (Srinivanan and Ambedkar2015).It is the extent to which employees enjoy their work, by means of satisfiable motivational variables. Job satisfaction is supposed to be an essential element for the maintenance of the workforce of any organization. Ahigh level of job satisfaction is supported to engender quality service delivery and reduce staff turnover in any organization including educational institutions.

Unfortunately, nurse and midwife educators are not in agreement in their perception of how the level of job satisfaction is influenced by motivational variables such as recognition, promotion experience, remuneration, job enrichment and training. It is important that correct relationship between motivational variables and job satisfaction be determined because research findings has showed that the job satisfaction of employees in general and more specifically nursing staff is on the decline worldwide (Rasa, Akhtar, Husnain and Akhar 2015). The researcher observed that in   Akwa Ibom State these days, many employees are changing work and many have left to other countries in search of greener pastures. This seems to mostly affect the nursing educational institutions as many educators are not performing effectively in their teaching environment, are late to classes, even sometimes absent themselves from classes. Some engage themselves in commercial activities and as such move from one office to another.

The foregoing problem stimulated the interest to investigate the relationship between motivational variables and job satisfaction as perceived by nurse and midwife Educators, in Akwa Ibom State. In addition there are few or no literature on this topic in Akwa Ibom State. This study will therefore form a baseline study and contributes to fill in the gap in knowledge. The above identified problems necessitated the desire to carry out this research on the relationship between motivational variables and job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery in Akwa Ibom State.

Purpose of the Study

The purpose of this study was to investigate the relationship between motivational variables and job satisfaction as perceived bynurse and midwife educators in Schools of Nursing and Midwifery of Akwa Ibom State.

However, the specific objectives are to;

(1)      Determine the relationship between staff recognition and job satisfaction as perceived by nurse and midwife educators in Akwa Ibom State.

(2)      Determine the relationship between promotion and job satisfaction asx perceive by nurse and midwife educators in Akwa Ibom State.

(3)      Ascertain how salary influences job satisfaction has perceived by nurse and midwife educators in Akwa Ibom State.

(4)      Ascertain how the level of job enrichment influences job satisfaction as perceived by Nurse and Midwife educators in Akwa Ibom State.

(5)      Determine how training impact on the level of job satisfaction as perceived by Nurse and Midwife educators in Akwa Ibom State.

(6)      To determine if nurse and midwife educators perceived job satisfaction in their place of work.

 

 

 

Research Questions

The following research questions were formulated in order to achieve the objectives of the study. These are:

(1)        How do nurse and midwife educators perceived the relationship between staff recognition and job satisfaction in schools of nursing and midwifery of Akwa Ibom State?

(2)   How do nurse and midwife educators perceived the relationship between staff promotion and job satisfaction in schools of nursing and midwifery of Akwa Ibom State?

(3)        To what extent does remuneration influence job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery of Akwa Ibom State?

(4)        How does nurse and midwife perceived the influence of job enrichment and job satisfaction e in schools of nursing and midwifery of Akwa Ibom State?

(5)        To what extent does training and development enhance job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery of Akwa Ibom State?

Research Hypotheses

The following research hypotheses stated in their null form were formulated to guide the objective of the study. They are

Ho1:    There will be no significant relationship between recognition and job satisfaction as perceive by nurse and midwife educators in schools of nursing and midwifery Akwa Ibom State

Ho2:    There will be no significant relationship between promotion experience and job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery in Akwa Ibom State.

Ho3:    There will be no significant relationship between remuneration and job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery in Akwa Ibom State.

Ho4:    There will be no significant relationship between job enrichment and job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery in Akwa Ibom State.

Ho5:    There will be no significant relationship between training and development and job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery in Akwa Ibom State.

Significance of Study

The findings of this study will be significant in diverse ways. Academically, it will form baseline knowledge about motivation and job satisfaction and will be a source of literature for other related studies in nursing literature.

The study, apart from providing a baseline  information through research, it will be of  help to the management of Akwa Ibom State, Ministry of Health to know how best to motivate  educators to stimulate them to action,  commitment and to achieve a desired task  as motivation   is  the process that arouses, energizes, directs, sustains behavior and performance. The study will also be useful to the Akwa Ibom State government to formulate policies relating to motivation, to achieve high level of job satisfaction among nurse and midwife educators in its schools of nursing and midwifery.

The study had the potential to show if educator’s motivation and job satisfaction will be positively affected and the likelihood of negative outcomes such as absenteeism and turnover, will be reduced. Students will stand to benefit from the outcome of this research study as the students nurses will imbibe the culture of hard work and academic discipline to become future excellent educators. To the institution it will change the performance positively.It is also expected that findings from the study will be useful in creating awareness on the types of motivational variables that are influential to job satisfaction and how they can be utilized to achieve derived results. In a nut shell, all impediments leading to motivation and job satisfaction will be brought to the fore with a view to solving them for effective teaching and learning and for the laying of a solid foundation for the future educational emancipation of the nation’s future nurse and midwife educators.

Scope of the Study

The scope of this study was limited to the relationship between motivational variables and job satisfaction as perceived by nurse and midwife educators in schools of nursing and midwifery in Akwa Ibom State and was carried out in all the schools of nursing and midwifery in Akwa Ibom State of Nigeria and it was limited to studying the various motivational variables and job satisfaction. The focus was on investigating the level of relationship between motivational variables such as recognition, promotion, remuneration, job enrichment, training and development and job satisfaction as perceived by educators. Reason for the choice of the research study was that no study has been done in this study area.

 

Operational Definitions

Motivational variables: Motivation itself is a concept which tells of an inner drive to propel an individual towards a direction – usually, goal attainment. Motivational variables in this study refer to recognition, promotion, remuneration, job enrichment, training and development as measured by the motivational variables questionnaire.

Recognition: A situation where a nurse or midwife educator is noted for an achievement and is adequately   commended

Promotion: when a nurse or midwife educator is taken from one level of the cadre to another in an upward or forward direction as and when due.

Remuneration: This is a reward, mostly money that is given to a nurse or midwife educator for the work he/she has done.

Job Enrichment: This is a situation where an educator is given much responsibilities such that the work he/she does is more than what it was before

Training and development: Training entails giving a chance  to an education to learn of something new, while development is a programme designed to advance the educator’s knowledge in a field he has already had knowledge in.

 

 

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ABSTRACT

This study was carried out to determine endotracheal suctioning knowledge and practice among critical care practitioners in intensive care units of University of Calabar Teaching Hospital. The objectives of the study were to identify critical care practitioners’ knowledge of endotracheal suctioning, evaluate adherence to  procedure in endotracheal suctioning, assess their competence in performing endotracheal suctioning, determine if there is an association between knowledge and competence in performing endotracheal suctioning and determine if there are differences in knowledge and practice between the critical care practitioners. A descriptive survey and observational designs were adopted for the study .A total population study of 96 respondents was used for the study. The instrument for data collection was a structured questionnaire and observational checklist. The face and content validity were determined by the supervisor, and two consultant Anaesthetists in UCTH. The results were presented in tables as percentages. Pearson Chi-square test was used to determine the association between the knowledge distribution for doctors and nurses, a Chi-Square Test of Association revealed no significant difference between them, p = .803 at 0.05 level of significance. Majority of practitioners Age between 31-35 years (85.2%) had low knowledge while few (14.8%) had high knowledge. Likewise, practitioners between 36-40 years, (85.2%) had low knowledge while few (14.8%) had high knowledge and those above 40 years, (48.8%), had low knowledge while (51.2%) had high knowledge. However, findings from the study revealed that few physicians, (21.7%) had inadequate adherence to practice of endotracheal suctioning procedure while majority (78.3%) had moderately adequate adherence. Likewise, nurses, (40.7%) had inadequate adherence while (59.3%) had moderately adequate adherence. Out of the 50 critical care practitioners that were assessed using the check-list, all had poor competence in endotracheal suctioning procedure. In conclusion, the overall knowledge of practitioner was low and there was no difference between knowledge and practice among practitioners. However, knowledge did not significantly influence practice of critical care practitioners. It was recommended that a fully equipped modern laboratory be put in place for continuous practice and simulation.

 

CHAPTER ONE

INTRODUCTION

Background to the Study

Endotracheal suctioning is a clinical procedure that helps to clear airways in the respiratory system by mechanically removing accumulated pulmonary secretions  in patients with artificial airways (Sharma, Sarin & Bala, 2014). Critically ill patients with artificial airways require endotracheal suctioning to remove secretions and prevent airway obstruction, without which the patient may experience inadequate oxygenation and ventilation. Endotracheal intubation is an artificial airway that inhibits cough reflex and interferes with normal muco-ciliary function, therefore increasing airway secretion production and decreasing the ability to clear such secretions (The Royal Children’s Hospital Melbourne, 2012). Although   endotracheal suctioning is an essential way of maintaining ventilation and oxygenation  in patients with such artificial airways, it can result in adverse effects and serious complications when performed inappropriately or incorrectly (Kelleher & Andrews, 2008).

 

Patients on mechanical ventilation are vulnerable to disease complications such as alveolar hypoventilation, alveolar hyperventilation, fluid and electrolyte imbalance, pneumothorax and ventilator associated pneumonia, a most common infectious complication accounting for about 47% of all infections among critical care patients (Sharma, Sarin & Bala, 2014). In spite of the fact that most of the technical aspects of managing mechanical ventilator is the responsibility of respiratory care practitioners (physiotherapist who specialized in respiratory care), nurses provide holistic care to patients, including the management of clinical symptoms and responses to mechanical ventilator support (Chlan, 2011).

Critical care practitioners (anesthetists and nurses) are professionals that provide evidence-based assistance in critical care units of healthcare facilities in order to pro­mote quality healthcare services to clients. Such practitioners monitor client’s responses to ventilation intervene to maintain oxygenation and ventilation and ensure that the complex needs of critically ill patients are met. It is very important that critical care practitioners are aware of endotracheal suctioning procedure and are able to practice according to current evidence based recommendations. Knowledge and experience can determine a critical care practitioner’s ability to adequately perform endotracheal tube suctioning. However, some researchers have documented that some critical care practitioners do not have sufficient knowledge about the current recommendations for endotracheal suctioning and, their practice is often based on rituals and traditions (Frota, Loureiro & Ferreira, 2013). Others observed that the critical care practitioners do not often adhere to the recommended procedures by the World Health Organisation and their level of competence in endotracheal suctioning practices is below expectation (Akram, Negin, Mohsen & Mohammadreza, 2012; Bighamian, Zarkeshan & Rafieeano, 2010; George & Sequiera, 2010).

 

Also, it was reported in a multisite survey of suctioning techniques and airway management practices by Sole, Byers and Ludy (2009) that the management practices were inadequate; compliance with hand washing guidelines was 82%, wearing gloves was 75%, elevating head of bed was 50%, and proper oral care protocol was 50%. Day, Farrell and Hayes (2012) observed that the mean score for knowledge was 11.1 and 10.3 for practice among critical care practitioner; and majority of the subjects failed to perform suctioning as accurately as they had claimed.

 

Similarly, in Cairo, a study by Nahla (2013), revealed that less than half of the nurses recognized closed system suctioning as recommended, while the rest were unfamiliar with closed system suctioning. Heyland, Cook and Dodek (2012) also reported on prevention of ventilator associated pneumonia practice in Canadian critical care units that nurses were familiar with closed suctioning practices because such practices were common in 88% of the ICUs. Sierra (2010) reported that in Spain open tracheal suctioning was reported in 96% of the ICUs and added that closed suction systems are not commonly used, and thus nurses were unfamiliar with those systems. More than half of the nurses in the study knew that frequent change in suction systems, and kinetic beds decrease the risk and occurrence of pneumonia. While only 48% of nurses knew that semi-recumbent positioning help in prevention of pneumonia.

 

Despite the recognition that endotracheal suctioning is an effective technique that clears the airways  by mechanically removing accumulated pulmonary secretions  in critically ill  patients with artificial airways, the adherence to established guidelines on endotracheal suctioning by critical care practitioners is not impressive. Studies by Day, Farnell, Haynes, Wainwright and Wilson-Barnett (2012); Negro, Ranzani  and Manara (2014) have shown that critical care practitioners’ lack of adequate knowledge about endotracheal suctioning may be a barrier to adhere to evidenced based guidelines.

 

The researcher is unaware of any empirical evidence of endotracheal suctioning knowledge and practices of critical care practitioners and has not come across any study on endotracheal tube suctioning in Nigeria. Hence, this research was undertaken to evaluate the effectiveness of endotracheal suctioning in terms of knowledge and practices of critical care practitioners in University of Calabar Teaching Hospital, Calabar.

 

Statement of the Problem

Hospital acquired infections such as Ventilator Assisted Pneumonia (VAP) among critical care patients is a major healthcare challenge. Incidence of hospital acquired infections has continued to rise, especially in the developing countries, despite advancements in health technology (Ulu-Kilic & Ahmed, 2013). Although they account for fewer than 10% of total beds in most hospitals, more than 20% of all nosocomial infections are acquired in ICUs (Ulu-Kilic & Ahmed, 2013).

 

In clinical practice in the critical care unit of the University of Calabar Teaching Hospital, the researcher has observed that some critical care practitioners do not adhere strictly to endotracheal suctioning procedure, according to recommendations and guidelines. Among the poor practices observed were: poor insertion of catheter, poor positioning of the patient and poor infection control practices during and after suctioning. These observations made the researcher to ponder and ask: why is there lack of adherence to best-practices and lack of competence in performing endotracheal suctioning among critical care practitioners? Could it be related to lack of knowledge? Does it cut across all critical care practitioners? This study will therefore assess endotracheal suctioning knowledge and practices among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.

 

Purpose of the Study

The purpose of this study is to assess endotracheal suctioning knowledge and practice among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.

 

Specific Objectives            

The specific objectives of the study are to:

1. Identify knowledge of endotracheal suctioning procedure among critical care practitioners’ in University of Calabar Teaching Hospital (UCTH), Calabar.
2. Evaluate adherence to step by step (practice) procedure in endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
3. Assess level of competence in performing endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
4. Determine association between knowledge and competence in performing endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
5. Determine differences in practice between the critical care practitioners.

 

Hypotheses

The following hypotheses were formulated to guide the study:

1. There is no significant relationship between socio-demographic characteristics and knowledge of endotracheal suctioning among critical care practitioners.
2. There is no significant relationship between socio-demographic characteristics of respondents and competence in performing endotracheal suctioning among critical care practitioners.
3. There is no significant differences in practice of endotracheal suctioning between critical care practitioners

 

 

Significance of the Study

This study would be of immense benefit to health personnel/workers (physicians and nurses), researchers and the entire society.

Physicians and nurses working in ICU in conjunction with hospital management would through the findings of this study prepare protocol for endotracheal suctioning in UCTH, Calabar. This will enable them adhere to recommended suctioning techniques.

 

Stakeholders in health and policy makers such as the WHO would understand the level of knowledge and practice of endotracheal suctioning among critical care practitioners, thereby formulating policies that will bring about efficiency in the practice by critical care practitioners. They will strategize towards ensuring that factors militating against good suctioning are overcome; and this will promote quality healthcare delivery in critical care units through efficient utilization of endotracheal suctioning in critical care units.

 

Researchers would benefit from this study because it will serve as a reference material and it will add to existing literature on knowledge, practice and competence of endotracheal suctioning in the management of patients in critical care units.

 

Scope of the Study

The focus of this study is to evaluate endotracheal suctioning knowledge and  practices among critical care practitioners in Intensive Care Unit of University of Calabar Teaching Hospital (UCTH), Calabar. It will involve both nurses and physicians that work in the critical care unit of UCTH, Calabar. As well as assess their adherence to best practices in endotracheal suctioning and competence in performing endotracheal suctioning.

 

Operational Definition of Terms

Critical Care Practitioners: Physicians (doctor anaesthetists) and nurses working in the critical care units of UCTH, Calabar. They are referred to in this work interchangeably with dependent nurse/physician care agent.

Endotracheal Suctioning: A procedure to clear the airways by mechanically removing accumulated pulmonary secretions in patients with endotracheal tube.

Intensive Care Units (ICU): Are unit in the hospital where patients with life threatening conditions are cared for by specially trained staff. Here it includes ICU and recovery rooms

Endotracheal Intubation:  A procedure in which endotracheal tube is placed into the trachea in order to maintain an open airway in patients who are unable to breathe on their own.

Competence: Ability to perform endotracheal suctioning according to recommended guidelines.

Knowledge of endotracheal suctioning: The ability of critical care practitioners to identify information concerning clinical procedures employed to clear the airways by mechanically removing accumulated pulmonary secretions in patients with artificial airways The responses to questions on knowledge of endotracheal suctioning will be rated as high for scores above 50%, 49% and below as poor/ low. The questionnaire has 22 items. To calculate the % score thus; Total score obtain divided by numbers of item multiply by 100. High Knowledge: Are those who scored above 50% on answering questions on knowledge of endotracheal suctioning. Low/poor Knowledge: Are those who scored between 0- 49% on answering questions on knowledge of endotracheal suctioning.

Practice: The act of removing accumulated pulmonary secretions in patients with artificial airways by doctor anaesthetists and nurses that work in the critical care unit according to recommended guidelines. Observational checklist on practice was scored over 23 and rated as follows: scores less than 13 will be inadequate practice, scores from 14 -18 as moderately adequate while scores from 19- 23 will be rated as adequate.

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