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:
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.