Final Res Pres Jas

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 S1 – The nurse exhibits knowledge related to endotracheal suctioning S1=9 S2 – The nurse reports availability of articles S2 = 13 S3– Nursing/ Unit/ Practice setting S3= 2

P1 – Assessment P1 = 2

OUTCOME 01 – Effectiveness

P2 – Nursing diagnosis

01 = 1

P2= 1

02 = 1

P3 – Implementation

03 = 1

P3 – 20 P4– After care of articles and patients P4 – 4 P5 –Documentation and Recording 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 S1 – The nurse exhibits knowledge related to positioning

PROCESS P1 – Assessment P1 = 2 P2 – Nursing diagnosis

S1=4

P2= 1

S2 – The nurse reports

P3 – Interventions

availability of articles for positioning for client available in the ward/unit

setting S3= 2

12

01 – Effectiveness 01 = 1 O2 = 1

P3 – 14 P4– After care P4 – 3 P5 – Recording and Reporting

S2 = 6 S3– Nursing/ Unit/ Practice

OUTCOME

P5 =3 P6 – Evaluation

P6 = 1

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.