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

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.