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A Nursing Professor's Perspective: Transitioning From Nursing Student to Staff Nurse

 |  By HealthLeaders Media Staff  
   November 03, 2009

I am writing this from the perspective of a college professor who teaches mental health nursing, transcultural nursing, and pharmacology math. I also continue to practice as a nurse in the clinical setting, most recently in acute care on pulmonary step-down, adult psychiatry, and geropsychiatry units. It truly is a marvelous existence because I am fortunate enough to work with my former students while refreshing and maintaining the clinical skills I worked so hard to obtain all those years ago. My clinical practice often permits me to easily assess the effectiveness or, at least, retention of my teaching efforts and those of my peers as I observe our students' transitions from academia into beginning clinical practice.

We faculty consciously endeavor to instill a strong sense of professional pride and accountability along with the nursing knowledge. I'd even go so far as to admit nursing educators do indeed try to cultivate students who feel guilt or shame when their nursing performance fails to meet the quality thresholds fixed by our professional standards and practice guidelines.

My clinical role allows me to witness the interminable challenges my new professional peers daily confront. And I see a long-recognized disconnect arise: the one between what is taught and "real-world" pragmatism.

That incongruity, it seems to me, is even more conspicuous in these days due to an increased reconsideration of care delivery methods. Providers are reshaping delivery methods to be congruent with the Institute of Medicine's Six Aims of High-Quality Health Care (IOM, 2006). The Aims assert care should be:

  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

I would like to focus our present discussion on effective care. The IOM describes effectiveness in part as being evidence-based, meaning interventions for which there is objective empirical support. Effectiveness also includes avoiding continued use, or at least questioning the use, of interventions lacking scientific confirmation. Let's consider a clinical example.

For many years, nurses and respiratory therapists have instilled small amounts of sterile normal saline into tracheostomy or endotracheal tubes prior to suctioning. The purpose was to loosen thick secretions and aid airway clearance. It seemed a good idea at the time but research hadn't been done. The practice continues. In one descriptive comparative study (Sole, Byers, Ludy & Ostrow, 2002), 95 nurses and 37 respiratory therapists working in adult critical care units at four different sites were surveyed regarding their suctioning techniques. Thirty percent of all nurses and 78% of respiratory therapists reported routinely instilling saline prior to suctioning.

Is this practice supported by evidence? One very recent randomized clinical trial (Caruso, Denari, Ruiz, Demarzo, & Deheninzelin, 2009) using 264 subjects in a single surgical intensive care unit of an oncologic hospital found instilling saline before tracheal suctioning decreased the microbiology proven incidence of ventilator-associated pneumonia (VAP). In the results discussion, the investigators do wonder if the effect was in any way due to shallow sedation levels that permitted the saline to produce sputum clearing coughs (think "water-boarding" here). Also, the authors agree that there was no difference in suspected VAP rates between the intervention group patients who received saline instillation and the control patients who didn't. The researchers urge further studies before recommending saline instillation as a regular step in the suctioning procedure.

The preponderance of the evidence, however, suggests routine saline instillation can be harmful and ought to be avoided. Pedersen, Rosendahl-Nielson, Hjermind, and Egerod (2008) reviewed the available literature regarding endotracheal suctioning. The authors searched literature from 1962 through the present. A total of 77 papers were included in the final review, four studies describing patient personal experiences, 19 literature reviews, two meta-analyses, and 52 clinical trials. Their analysis findings include recommending nurses should suction only when necessary, use a catheter occluding less than half of the lumen of the endotracheal tube, use the lowest possible suction pressure, and avoid saline instillation.

At this point, envision one of my graduates being directed by a nurse mentor during orientation to squirt 5 or 10 mL of sterile normal saline into the tracheostomy tube before suctioning. The student recalls being taught differently and remembers the evidence, but often abjectly yields to confident assertions of the mentor: "I've been doing this for 26 years and it works." The outmoded, unsupported, and potentially harmful practices continue.

Saline instillation is merely an illustration of a more pervasive problem. There are similar current nursing practice versus evidence-based practice conflicts. So, here are some questions for us all. How can nursing educators in colleges and healthcare systems create an environment that fosters the introduction of evidence-based practice? How can we empower new graduates to feel confident and assertive about what they've learned while being respectful of their professional 'elders'? How can we convince, co-opt, or even coerce long-time nurses to quit unsafe and ineffective interventions? Any suggestions?

References
Caruso, P., Denari, S., Ruiz, S., Demarzo, S., & Deheinzelin, D. (2009). "Saline instillation before tracheal suctioning decreases incidence of ventilator-associated pneumonia." Critical Care Medicine 37(1): 32-38.

Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

Pedersen, C., Rosendahl-Nielsen, M., Hjermind, J. & Egerod, I. (2008). "Endotracheal suctioning of the adult intubated patient—What is the evidence?" Intensive and Critical Care Nursing 25(1): 21-30.

Sole, M., Byers, J., Ludy, J. & Ostrow, L. (2002). "Suctioning techniques and airway management practices: Pilot study and instrument evaluation." American Journal of Critical Care 11(4): 363-368.


Richard Freedberg, RN, MSN, MPA, is professor of mental health nursing at Lansing Community College in Lansing, MI. He continues to practice in a clinical setting, and has experience that includes staff nursing and management roles in medical-surgical and mental health acute-care settings, home-care nursing, and medical intermediate care.


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