Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 2642
  • Home
  • Print this page
  • Email this page

   Table of Contents      
Year : 2018  |  Volume : 23  |  Issue : 3  |  Page : 178-182

Performance of ICU nurses in providing respiratory care

1 Department of Critical Care Nursing, School of Nursing and Midwifery, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication2-May-2018

Correspondence Address:
Somayeh Ghafari
Department of Critical Care Nursing, School of Nursing and Midwifery, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnmr.IJNMR_205_16

Rights and Permissions

Background: Failure to provide proper respiratory care leads to incidence of certain complications such as ventilator-associated pneumonia. Nurses have a crucial role in providing this care. The aim of this study is to assess the performance of ICU (Intensive Care Unit) nurses in providing respiratory care. Materials and Methods: The present descriptive cross-sectional study recruited 120 nurses working in selected hospitals affiliated to Isfahan University of Medical Sciences from March to August 2016. The questionnaire used included demographic and employment details and performance observation checklist (containing 39 items in four care domains) based on recommendations in clinical guidelines. The performance of each nurse during a working shift was observed. Data were analyzed by SPSS 18, using tables of frequency, mean, and standard deviation. Results: According to the results obtained, mean (SD) total performance score of nurses in providing respiratory care was 15.46 (2.16). The highest score was obtained in preventing contamination of respiratory equipment 5 (0), and the lowest score was in oral care 0.68 (0.73). Conclusions: Considering that respiratory care is one of the main pillars of patient care in ICU and that nurses scored poorly in this area, it is imperative to pay greater attention to this area. It is essential to provide necessary training to nurses and adequate facilities for improving the quality of clinical care.

Keywords: Intensive care unit, nursing, respiratory care

How to cite this article:
Yazdannik A, Atashi V, Ghafari S. Performance of ICU nurses in providing respiratory care. Iranian J Nursing Midwifery Res 2018;23:178-82

How to cite this URL:
Yazdannik A, Atashi V, Ghafari S. Performance of ICU nurses in providing respiratory care. Iranian J Nursing Midwifery Res [serial online] 2018 [cited 2023 Mar 25];23:178-82. Available from: https://www.ijnmrjournal.net/text.asp?2018/23/3/178/231485

  Introduction Top

Because of their lethargy, weakened defense mechanisms and prolonged hospitalization, and especially endotracheal intubation and ventilator-assisted breathing, patients in intensive care units are exposed to the risk of infection.[1] The respiratory system has a determining role in maintaining vital human processes; thus, the respiratory system management is the first factor in successful care of Intensive Care Unit patients.[2],[3] Respiratory care is one of the most important nursing care in ICU.[4] Respiratory care include suctioning airways, oral care, oxygen therapy, respiratory monitoring, and care related to the prevention of ventilator-associated pneumonia (VAP).[5] Many studies have indicated complications caused by improper respiratory care in ICU,[6] for instance, VAP.[7] Statistics published in Iran suggest that 10% of patients undergoing general surgery, 20% of patients with endotracheal intubation, and 70% of those with acute respiratory distress suffer pneumonia during their stay in ICU.[7] The results of a study on suctioning revealed nurses' poor knowledge and performance and also non-compliance of suctioning procedure with the standard method.[8] Several studies have shown that nurses frequently fail to perform such care for various reasons such as not knowing positive results of using the standard method, absence of standard instructions, low nurse/patient ratio, and lack of supervision although they are well aware of respiratory care.[9–11] Besides, improper respiratory care spreads a variety of infections and complications, and also prolongs hospital stay and costs incurred.[12],[13] Studies conducted in Europe and America estimate VAP-associated costs between 30 and 40 thousand dollars per patient. Another report indicates that only in America, these infections lead to more than 1.75 million extra days of hospitalization and 1.5 billion dollars of additional costs.[14],[15] Moreover, prolonged use of mechanical ventilation may cause complications such as respiratory infection, and thus makes it hard to wean the patients from mechanical ventilation.[16],[17] Nurses are more in touch with the patient and patient monitoring systems than other members of the medical team, and because of the sensitive and critical nature of ICU, precise respiratory care of patients is one of the main pillars of nursing care in these units.[18],[19] Nursing is one of the biggest sources of workforce in the national healthcare. Nurses directly influence patient care and its outcomes,[20] and because of their direct contact with patients, they are expected to have a key role in respiratory care and the prevention of nosocomial infections.[21] Given the importance of saving patients' lives, the enormous sensitivity of ICU, and the importance of performing nursing care according to standard principles, and considering that no comprehensive study has been conducted to assess performance of ICU nurses in relation to respiratory care, the present study was conducted with the aim to assess performance of ICU nurses in teaching hospitals in Isfahan. The present study results can be used by nursing authorities and managers in educational planning and enhancing the quality of nursing care according to current standards.

  Materials and Methods Top

In the present descriptive cross-sectional study, performance of 120 ICU nurses of selected hospitals affiliated to Isfahan University of Medical Sciences was observed in 2016. It is worth noting that the studied hospitals matched in terms of employment status and performance of nurses. Sample size was determined according to a similar study,[7] and using sample size equation based on mean and standard deviation at significance level of α = 5% and power of 80% and effect size of d = 0.33. Samples were selected by convenient sampling.

Study inclusion criteria included nurses with bachelor's degree and higher qualifications, and exclusion criteria included unwillingness to take part and transfer to other departments. The researcher-made questionnaire of the performance of nurses in respiratory care comprised a demographic details form and a performance observation checklist with 39 items, including airway care (21 items), the prevention from contamination of respiratory equipment (5 items), oral care (5 items), and pneumonia prevention (8 items). The questionnaire used in the present study was developed after considering recommendations in the field of nursing and careful review of clinical guidelines from accredited centers concerning respiratory care such as: the Center for Control and Prevention of Diseases in America,[22] Institute of Health Promotion.[23] Hong Kong Center for Protection of Health,[24] the Canadian Association of Medical Microbiology and Infectious Diseases,[25] and the Center for Monitoring Preservation of Health in Ireland.[26] The items in observational checklist were scored one for Yes and zero for No, such that correct performance scored one and incorrect one scored zero.

Criterion and construct validities of the tool assessed by ten faculty members from Nursing and Midwifery School and three ICU experts. Reliability of the tool was assessed by intraobserver reliability, such that performance of 10 nurses was concurrently observed by researcher and an assistant (a nursing student) using the observation checklist, and an acceptable Intra-class Correlation Coefficient of 92% was found. Performance of each nurse during a working shift was assessed once using observation checklist, and one point was given to a correct performance and zero to an incorrect performance. Each nurse scored between 0 and 390 points. SPSS software (version 16, SPSS Inc., Chicago, IL, USA) was used for data analysis. Since the presence of the researcher could affect nurses' performance, the observer continually attended the ward for long periods of time in different working shifts to make her presence normal and to observe nurses' actual performance.

Ethical considerations

Approval to conduct the study was granted by the ethics committee of Isfahan University of Medical Sciences (ethics code: 295013), and written informed consents were obtained from samples at the beginning of the study.

  Results Top

In the present study, 120 nurses aged between 22 years and 48 years, with mean (SD) age of 30.42 (5.84) years took part, of whom, the majority were female (89.25%), and 93.34% had bachelor's degree education. The majority (93.30%) worked rotational shifts, 45.87% had between 1 and 5 years of work experience, and the majority (36.49%) were passing their obliged service period [Table 1].
Table 1: Frequency and percentage of participating nurses according to demographic variables

Click here to view

According to the results obtained, mean (SD) total score of respiratory care was 15.46 (2.16). The highest score (100%) was related to the prevention from contamination of respiratory equipment, and the lowest (13.66%) to oral care [Table 2].
Table 2: Performance of respiratory care in ICUs of selected hospitals

Click here to view

  Discussion Top

In the present study, nurses' performance was observed and assessed in five domains, including (hand hygiene, suctioning, taking care of endotracheal tube cuff, and position change), oral care, prevention from contamination of respiratory equipment and prevention from VAP, and the highest mean score related to the prevention from contamination of respiratory equipment. In a study conducted in Shiraz by Yazdani et al., performance of nurses in preventing VAP was assessed using a questionnaire whose items had been extracted from the clinical guidelines for control and prevention of diseases, and prevention from contamination of respiratory equipment had a high score of 82%,[27] which agreed with the present study results. In the present study, patient's respiratory equipment was changed when it was clearly contaminated. Oral care is another component of respiratory care.[6] Thus, patients' oral hygiene is essential, and brushing teeth and use of chlorhexidine mouthwash can help.[28] According to the results obtained, the poorest performance was in oral hygiene (13.66%), and although oral care of patients under mechanical ventilation is among duties of trained nurses, it was found to have lower care priority in the hospitals studied, and nurses had inappropriate oral hygiene protocol and often delegated this task to patient care technicians. In a study conducted by Adib Haj Bagheri and Ansari, oral care was also found to have a low priority in view of nurses, and most nurses revealed that they had not received adequate training in this area.[29] Behesht Aeen et al. conducted a study on the prevention of pneumonia, and found the weakest performance in oral care, which agrees with the present study results.[7] In a qualitative study conducted in Hong Kong by Chui and Yeung, nurses believed the fear of performing oral hygiene, its low priority, and lack of adequate support for performing this task were the barriers to performing oral hygiene.[30] Next to oral hygiene, the weakest performance was in the prevention of VAP (33.62%). The present study results agree with those obtained by Behesht Aeen et al., who stated that the majority of nurses (66.40%) performed poorly in the prevention of VAP.[8] The present study results showed that ICU nurses had a poor performance and did not completely follow the clinical guidelines for the prevention of VAP. A study by Jordan and colleagues also showed that nurses' performance in the prevention of VAP is poor.[10] This problem appears to be affected by issues such as lack of time and facilities, shortage of workforce, absence of a plan and knowledge of nurses about proper care of patients under mechanical ventilation.[31] In the present study, airway care was also assessed as part of respiratory care, in which nurses also performed poorly (33.76%). This domain included suctioning, cuff care, and contact precautions. In a study conducted by Behesht Aeen et al., nurses had poor performance regarding cuff care, which agrees with the present study results.[8] Mol et al. showed that 84% of nurses in public hospitals and 57% in private hospitals had inadequate knowledge about endotracheal tube cuff care.[32] In the present study, nurses performed poorly in measuring cuff pressure using a manometer and minimum air leakage method. This may be attributed to nurses' lack of knowledge about proper cuff care, and also to lack of facilities such as manometer. The results of this study indicate that nurses' performance of suctioning is not in accordance with the standards.

In a study conducted on suctioning by Johnson et al., nurses performed poorly in this area, which agrees with the present study results.[3] Also, in consistence with the results of the present study, we can mention the results of Kelleher et al. and Ansari et al. that indicated poor performance of nurses in relation to suction.[33],[34] A study by Thompson et al. in China found that 65% of nurses had a satisfactory performance, which differs from the present study, due to the fact that in this study open courses on airway care were performed as planned for nurses.[35]

The results of this study showed that suction is performed routinely in ICU, which may be due to the lack of knowledge of nurses about the procedures of lung auscultation, how to assess the patient's need for suction, and the benefits of this care. The results of Sole's study in the United States showed that patients who had suctioned after assess of the need for suction had a better result and fewer side effects than routine suctioning patients.[36]

The lack of special endotracheal tubes for suctioning subglottic secretions due to their high costs, also, the effect of using direct observation on the behavior of nurses, were the limitations of this study but the second item was beyond the researcher's control.

  Conclusion Top

According to the present study results, nurses performed poorly in respiratory care, which can be attributed to non-compliance with clinical guidelines, not involving nurses in the development and implementation of protocols, lack of necessary resources, high costs, and lack of time, skills, and knowledge. The present study results are indicative of the fact that the nursing team requires training courses and educational protocols in relation to respiratory care. It is therefore recommended that evidence-based clinical guidelines about respiratory care be placed in ICUs, and hospital managers provide facilities needed for providing optimal services in hospitals.


We thank all personnel and authorities of selected hospitals of Isfahan University of Medical Sciences for their help in this project (No: 295013).

Financial support and sponsorship

Isfahan University of Medical Sciences.

Conflicts of interest

Nothing to declare.

  References Top

Sole ML, Klein DG, Moseley MJ. Introduction to critical care nursing6: Introduction to Critical Care Nursing: Elsevier Health Sciences; 2013.  Back to cited text no. 1
Khorasgan I. A survey on nursing process barriers from the nurses' view of intensive care units. Iran J Crit Care Nurs 2011;4:181-6.  Back to cited text no. 2
Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, et al. Guidelines for the management of adult lower respiratory tract infections-Full version. Clin Microbiol Infect 2011;17:E1-59.  Back to cited text no. 3
Hov R, Hedelin B, Athlin E. Good nursing care to ICU patients on the edge of life. Intensive Crit Care Nurs 2007;23:331-41.  Back to cited text no. 4
Melsen WG, Rovers MM, Groenwold RH, Bergmans DC, Camus C, Bauer TT, et al. Attributable mortality of ventilator-associated pneumonia: A meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis 2013;13:665-71.  Back to cited text no. 5
Goutier JM, Holzmueller CG, Edwards KC, Klompas M, Speck K, Berenholtz SM. Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: A systematic literature review. Infect Control Hosp Epidemiol 2014;35:998-1005.  Back to cited text no. 6
Behesht Aeen F, Zolfaghari M, Asadi Noghabi AA, Mehran A. Nurses' performance in prevention of ventilator associated pneumonia. Journal of Hayat 2013;19:17-27.  Back to cited text no. 7
Dehghani K, Nasiriani K, Mousavi T. Investigating intensive care unit nurses' performance and its adjusting with standard. SSU Journals 2014;21:808-15.  Back to cited text no. 8
Zolfaghari M, Behesht-Aeen F, Asadi-Noghabi A, Mehran A. Effects of active and passive implementation of ventilator associated pneumonia guideline on nurses' performance in critical care units: A controlled clinical trial. Nursing Practice Today 2015;1:126-34.  Back to cited text no. 9
Jordan A, Badovinac A, Špalj S, Par M, Šlaj M, Plančak D. Factors influencing intensive care nurses' knowledge and attitudes regarding ventilator-associated pneumonia and oral care practice in intubated patients in Croatia. Am J Infect Control 2014;42:1115-7.  Back to cited text no. 10
Lim KP, Kuo SW, Ko WJ, Sheng WH, Chang YY, Hong MC, et al. Efficacy of ventilator-associated pneumonia care bundle for prevention of ventilator-associated pneumonia in the surgical intensive care units of a medical center. J Microbiol Immunol Infect 2015;48:316-21.  Back to cited text no. 11
Aysha ZM, El-Din SM, Attia NR, Ibrahim M. Efficacy of implementing nursing care protocol on the incidence of ventilator associated pneumonia in Intensive Care Unit at Tanta emergency hospital. Journal of American Science 2016;12.  Back to cited text no. 12
Sinuff T, Muscedere J, Cook DJ, Dodek PM, Anderson W, Keenan SP, et al. Implementation of clinical practice guidelines for ventilator-associated pneumonia: A multicenter prospective study. Crit Care Med 2013;41:15-23.  Back to cited text no. 13
Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 2012;33:250-6.  Back to cited text no. 14
Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:2039-46.  Back to cited text no. 15
Koulenti D, Tsigou E, Rello J. Nosocomial pneumonia in 27 ICUs in Europe: Prespective from the EU-VAP/CAP study. Eur J Clin Microbiol Infect Dis 2016.  Back to cited text no. 16
Dessap AM, Katsahian S, Roche-Campo F, Varet H, Kouatchet A, Tomicic V, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: Role of fluid management. Chest 2014;146:58-65.  Back to cited text no. 17
Gallagher JA. Implementation of ventilator-associated pneumonia clinical guideline (Bundle). The Journal for Nurse Practitioners 2012;8:377-82.  Back to cited text no. 18
Ban KO. The effectiveness of an evidence-based nursing care program to reduce ventilator-associated pneumonia in a Korean ICU. Intensive Crit Care Nurs 2011;27:226-32.  Back to cited text no. 19
Ruffell A, Adamcova L. Ventilator-associated pneumonia: Prevention is better than cure. Nurs Crit Care 2008;13:44-53.  Back to cited text no. 20
Akın Korhan E, Hakverdioǧlu Yönt G, Parlar Kılıç S, Uzelli D. Knowledge levels of intensive care nurses on prevention of ventilator-associated pneumonia. Nurs Crit Care 2014;19:26-33.  Back to cited text no. 21
Hughes JM, Cardo DM, Cohen ML. Guidelines for preventing health-care-associated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Respir Care 2004;49:926-39.  Back to cited text no. 22
Campaign ML. Getting started kit: Prevent ventilator-associated pneumonia how-to guide. Cambridge: Institute for Healthcare Improvement, 2008.  Back to cited text no. 23
Hong SW, Yin P, Leung HP, Cho J, Man R. Recommendations on prevention of ventilator-associated pneumonia. Hong Kong Centre for Health Protection; June 2010, 2010.  Back to cited text no. 24
Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol 2008;19:19-53.  Back to cited text no. 25
Group SW. Guidelines for the prevention of ventilator-associated pneumonia in adults in Ireland: HSE Health Protection Surveillance Centre (HPSC); 2011.  Back to cited text no. 26
Yazdani M. Comparison of Clinical Training Guide prevention of ventilator-associated pneumonia in two ways: Face-to-face workshop, the knowledge and practice of nurses working in intensive care in: Lorestan; 2013.  Back to cited text no. 27
Turkestani F, Dietz J, Kim Y, Vines D, Dubosky M. Oral care kits used during mechanical ventilation in the intensive care unit (ICU): A retrospective comparison of outcomes. Age (yr) 2016;60:61-15.  Back to cited text no. 28
Adib-Hajbaghery M, Ansari A, Azizi-Fini E. Oral care in ICU patients: A review of research evidence. KAUMS Journal (FEYZ) 2011;15:280-93.  Back to cited text no. 29
Yeung KY, Chui YY. An exploration of factors affecting Hong Kong ICU nurses in providing oral care. J Clin Nurs 2010;19:3063-72.  Back to cited text no. 30
Jansson M, Ala-Kokko T, Ylipalosaari P, Syrjälä H, Kyngäs H. Critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia-A survey study. Intensive Crit Care Nurs 2013;29:216-27.  Back to cited text no. 31
Mol D, De Villiers G, Claassen A, Joubert G. Use and care of an endotracheal/tracheostomy tube cuff-are intensive care unit staff adequately informed? S Afr J Surg 2004;42:14-6.  Back to cited text no. 32
Kelleher S, Andrews T. An observational study on the open-system endotracheal suctioning practices of critical care nurses. J Clin Nurs 2008;17:360-9.  Back to cited text no. 33
Ansari A, Masoudi Alavi N, Adib-Hajbagheri M, Afazel M. The gap between knowledge and practice in standard endo-tracheal suctioning of ICU nurses, Shahid Beheshti Hospital. Journal of Critical Care Nursing 2012;5:71-6.  Back to cited text no. 34
Thompson DR, Chan D, Chung L, Au WL, Tam S, Fung G, et al. An evaluation of the implementation of a best practice guideline on tracheal suctioning in intensive care units. Int J Evid Based Healthc 2007;5:354-9.  Back to cited text no. 35
Sole ML, Bennett M, Ashworth S. Clinical indicators for endotracheal suctioning in adult patients receiving mechanical ventilation. Am J Crit Care 2015;24:318-24.  Back to cited text no. 36


  [Table 1], [Table 2]

This article has been cited by
1 Competence in caring for patients with respiratory insufficiency: A cross-sectional study
Ann-Chatrin Leonardsen,Vivian Nystrøm,Inger-Johanne Sælid Grimsrud,Linn-Maria Hauge,Brita F. Olsen
Intensive and Critical Care Nursing. 2020; : 102952
[Pubmed] | [DOI]
2 Nursing interventions in intensive care unit patients with breathing difficulties: A scoping review of the evidence
Renate Slang,Lene T. Finsrud,Brita F. Olsen
Nordic Journal of Nursing Research. 2020; 40(4): 176
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Article Tables

 Article Access Statistics
    PDF Downloaded486    
    Comments [Add]    
    Cited by others 2    

Recommend this journal