Abstract
Background
Endotracheal tube (ETT) suctioning is a critical nursing procedure essential for airway management in mechanically ventilated patients admitted to intensive care units (ICUs). Proper suctioning practices help reduce complications, including ventilator-associated pneumonia (VAP). However, evidence suggests that ICU nurses’ knowledge and practices regarding ETT suctioning remain suboptimal. This study aimed to assess the effectiveness of an educational intervention on ICU nurses’ knowledge and practices regarding ETT suctioning.
Methodology
A quasi-experimental single-group pretest–posttest study was conducted in the intensive care units (ICUs) of three public sector tertiary care hospitals in Peshawar, Pakistan. Eligible ICU nurses who met the inclusion criteria and consented to participate were recruited using convenience sampling (n = 60). Knowledge and practice were assessed before and after the educational intervention using a structured knowledge questionnaire and an observational practice checklist.
Results
Nurses’ knowledge scores improved significantly following the intervention (pre-intervention: 6.57 ± 1.79 vs. post-intervention: 10.23 ± 1.68; mean difference = 3.66; p < 0.001), with a very large effect size (Cohen’s d = 2.12). Practice scores also increased significantly from 12.65 ± 1.83 to 16.38 ± 1.43 (mean difference = 3.73; p < 0.001), corresponding to a very large effect size (Cohen’s d = 2.27).
Conclusion
The educational intervention was associated with substantial improvements in ICU nurses’ knowledge and practices regarding endotracheal suctioning. However, because this study employed a single-group pretest-posttest design without a control group, the findings should be interpreted with caution, as causal relationships cannot be established. Regular in-service education is recommended to maintain competency and promote adherence to evidence-based endotracheal suctioning practices.
Clinical trial registration
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12912-026-05049-1.
Keywords: Endotracheal suctioning, Intensive care units, Critical care nursing, Mechanical ventilation, Nursing education, Ventilator-associated pneumonia
Introduction
Endotracheal tube (ETT) suctioning is a fundamental nursing procedure in intensive care units (ICUs) and is essential for maintaining airway patency in mechanically ventilated patients who are unable to clear respiratory secretions independently [1]. The procedure plays a critical role in preventing airway obstruction and reducing complications such as ventilator-associated pneumonia (VAP), which remains one of the most common and serious hospital-acquired infections in ICU settings, contributing to increased morbidity, mortality, prolonged hospital stays, and higher healthcare costs [1].
Despite its clinical importance, adherence to evidence-based ETT suctioning guidelines remains inconsistent in both high-income countries and low- and middle-income countries (LMICs). In LMIC settings such as Pakistan, this gap is often more pronounced due to limited access to updated training, high patient-to-nurse ratios, workload constraints, and variability in institutional protocols [2].
Studies from Pakistan and similar regional contexts have reported inadequate knowledge and suboptimal endotracheal suctioning practices among ICU nurses, indicating a persistent theory-practice gap in critical care nursing [3–5]. This gap highlights the need for structured, context-specific educational interventions that facilitate the translation of evidence-based guidelines into routine clinical practice. Consistent with the Knowledge-to-Action (KTA) Framework, educational interventions can support the implementation of evidence by improving healthcare professionals’ knowledge, skills, and adherence to recommended practices, thereby enhancing competency in airway management [6].
Evidence-based guidelines recommend key suctioning practices, including appropriate pre-oxygenation, limiting suction duration, maintaining aseptic technique, and avoiding the routine instillation of normal saline [7] However, adherence to these recommendations remains inconsistent in clinical practice. In addition, variation exists in the use of open and closed suction systems, with closed systems being more common in high-resource settings, whereas open suctioning remains prevalent in resource-limited environments because of cost and equipment constraints [7].
Existing literature from LMICs, including South Asia and the Middle East, consistently highlights deficits in ICU nurses’ knowledge and procedural adherence related to suctioning techniques, reinforcing the need for continuous professional development and competency-based training programs [7, 8]. These gaps underline the importance of educational strategies that are practical, standardized, and feasible within resource-constrained ICU environments.
Given this context, strengthening ICU nurses’ knowledge and practice through structured educational interventions is essential to promote evidence-based practice, improve the quality of patient care, and enhance patient safety [9]. Therefore, this study aimed to evaluate the effect of an educational intervention on ICU nurses’ knowledge and practices regarding endotracheal suctioning in selected tertiary care hospitals in Pakistan.
Research hypotheses (Operationalized)
H1
ICU nurses will demonstrate a statistically significant improvement in knowledge scores regarding ETT suctioning following the educational intervention.
H2
ICU nurses will demonstrate a statistically significant improvement in practice scores regarding ETT suctioning following the educational intervention.
Methodology
Study design
A quasi-experimental study design with a pre- and post-test approach was used to achieve the objectives of this study.
Study settings
The study was conducted in the medical and surgical intensive care units (ICUs) of three public sector tertiary care teaching hospitals located in Peshawar, Khyber Pakhtunkhwa, Pakistan. These hospitals were selected because they are major referral centres providing critical care services to a large patient population and have established ICUs with mechanically ventilated patients requiring endotracheal tube suctioning. The selected hospitals also employ a substantial number of registered ICU nurses involved in direct patient care, making them appropriate settings for assessing and improving nurses’ knowledge and practices regarding ETT suctioning.
Inclusion criteria
Registered nurses holding at least a diploma or degree in nursing and working in the ICUs of the selected hospitals were eligible to participate.
Exclusion criteria
Nurses who were on relieving duty from other wards/units, working in administrative positions, and not involved in bedside care were excluded from the study.
Data collection tools
A questionnaire was developed by the researchers and consisted of three sections.
Demographic Information
Knowledge Assessment
Practice Skills Assessment
The knowledge tool included 20 items, scored as 1 for a correct response and 0 for an incorrect response, with a maximum possible score of 20. The practice checklist included 15 items, each scored as performed (1) or not performed (0), with a maximum possible score of 15.
The questionnaire was evaluated for content validity by a panel of subject experts, including senior nursing faculty members, nurse educators, and critical care nursing specialists with expertise in intensive care practices and nursing research methodology. Each item was reviewed for relevance, clarity, simplicity, and representativeness of the construct using a structured rating scale. The overall Content Validity Index (CVI) was calculated at 0.81, indicating good content validity and acceptable agreement among experts regarding the adequacy of the tool. The internal consistency of the questionnaire was assessed using Cronbach’s alpha, which demonstrated strong reliability (α = 0.89), indicating high internal consistency among the items measuring nurses’ knowledge and practice of endotracheal tube suctioning. Additionally, the tool was pilot tested on a small group of ICU nurses to assess clarity, feasibility, and practicality. Minor refinements were made based on feedback prior to final data collection.
Sample and sampling
The sample size was calculated a priori using OpenEpi and G*Power software for a paired pre–post quasi-experimental design. The previously reported value “alpha = 0.95” was incorrect and has been revised to a confidence level of 95% (α = 0.05), with a power of 80%. An assumed proportion of 0.50 was used to ensure maximum variability, and a moderate standardized effect size (Cohen’s d = 0.50) was selected based on prior educational intervention studies where local estimates were unavailable. The final sample size of 60 participants was considered sufficient to detect statistically and clinically meaningful pre-post differences.
A control group was not included due to logistical and ethical considerations within the ICU setting, including staffing constraints, risk of contamination between intervention and control units, and institutional limitations in allocating nurses to separate study arms without affecting patient care continuity. Therefore, a single-group pretest-posttest design was adopted as a feasible and pragmatic approach for evaluating the educational intervention in a real-world clinical environment.
The intervention content was developed based on current evidence-based guidelines for endotracheal suctioning and was reviewed for content validity by three experts in critical care nursing and clinical education. Inter-rater reliability for the observational practice checklist was assessed during pilot testing, yielding a Cohen’s kappa of 0.82, indicating strong agreement among observers. Internal consistency of the knowledge questionnaire demonstrated acceptable reliability with a Cronbach’s alpha of 0.84.
The study was conducted in the intensive care units (ICUs) of three public-sector tertiary care hospitals. ICU nurses who met the predefined inclusion criteria were recruited using a convenience sampling technique as shown in Fig. 1.
Fig. 1.
Flow diagram of the study participants
Scoring system
The questionnaire and observation checklist were scored based on the number of correct responses. For knowledge and practice assessment, Bloom’s cut-off points were adapted to categorize individuals as having poor (≤ 59%), average (60%-79%), or good (80%-100%) knowledge and practice [9].
Data analysis plan
The normality of the data was assessed using the Shapiro-Wilk test. The results indicated that the data were normally distributed p > 0.05. Descriptive statistics, including mean, standard deviation, and frequency distributions, were used to summarize the data. A paired sample t-test was applied to assess differences between pre- and post-intervention scores for knowledge and practice. One-way ANOVA was used to compare mean scores across different demographic variables. A p-value of ≤ 0.05 was considered statistically significant.
Research intervention protocols
Pre-intervention phase
Prior to the intervention, all ICU nurses involved in the study were screened and informed consent was obtained from the participants with the help of two qualified data collectors. Data collection began with a structured questionnaire that covered demographic information, knowledge of endotracheal tube (ETT) suctioning, and an observational checklist assessing current practice.
Intervention phase
Participants were recruited during duty hours by the principal investigator and two trained data collectors in coordination with ICU nurse managers. Administrative approval was obtained from hospital administrations and unit heads prior to recruitment. Eligible nurses were informed about the study objectives, procedures, duration, potential benefits, and voluntary nature of participation, and written informed consent was obtained before enrollment. Participation was voluntary, with assurance of the right to refuse or withdraw at any stage without any impact on employment or professional evaluation, and confidentiality was strictly maintained.
Following baseline assessment, participants were organized into small groups (8–12 nurses per session) to maintain ICU workflow and minimize disruption of patient care. The educational intervention was delivered face-to-face by the principal investigator, who holds a BSN and MPH degree and has clinical and academic experience in critical care nursing education.
The intervention consisted of a structured 45–60 min session, including a 25–30 min theoretical component (indications for suctioning, infection prevention, equipment preparation, complications, and evidence-based guidelines) and a 20–30 min practical demonstration of standardized ETT suctioning using stepwise clinical protocols. Sessions were supported with audiovisual materials, procedural checklists, and demonstration aids.
Intervention fidelity was ensured through standardized content, consistent sequencing, and uniform delivery across all sessions, all conducted by the same trainer without modification. A structured checklist was used during demonstrations to reinforce adherence to each procedural step.
Post-intervention phase
The post-intervention assessment was conducted two weeks after completion of the educational intervention using the same knowledge questionnaire and observational checklist. A two-week follow-up was selected to evaluate the short-term effectiveness of the educational intervention and is consistent with previous educational intervention studies involving ICU nurses that assessed changes in knowledge and clinical practice within a similar timeframe. [10] The practice checklist was completed through direct observation and evaluated adherence to evidence-based procedures, including patient assessment before suctioning, infection prevention measures, proper equipment handling, and post-suctioning care. The follow-up assessment aimed to evaluate the retention of knowledge and the translation of learned practices into routine ICU patient care.
Ethical considerations
Approval for this study was obtained from the Khyber Medical University Peshawar (Ref no: KMU-INS/14 − 2/3322), and relevant hospital authorities. Prospective participants were fully briefed on the study’s purpose, the voluntary nature of their involvement, and their right to withdraw at any time without penalty. Written informed consent to participate was obtained from all participants. To protect participant anonymity, strict confidentiality of all data was maintained throughout the study.
Results
The study included 60 participants, with the majority being female (60%) and aged between 22 and 28 years (66.7%). Regarding nursing qualifications, 51.7% held a diploma in nursing, while smaller proportions had a Bachelor of science in Nursing (BSN) (21.7%) or a Post RN BS (23.3%). Only 1.7% had attained Master in Nursing (MSN) or another advanced qualification. In terms of total nursing experience, 41.7% had 3–5 years of experience, while 28.3% had more than five years of experience. Critical care experience varied, with 36.7% having less than a year and only 13.3% possessing more than five years. Notably, more than half (55%) had never received training in critical care, 25% had attended training once, and even fewer had participated multiple times, as shown in Table 1.
Table 1.
Socio-demographic variables of participants (n = 60)
| Variables | Categories | Frequency (n = 60) | Percentage (%) |
|---|---|---|---|
| Gender | Male | 24 | 40 |
| Female | 36 | 60 | |
| Age | 22–28 years | 40 | 66.7 |
| 29–35 years | 15 | 25 | |
| 36 + years | 5 | 8.3 | |
| Nursing Qualification | Diploma in nursing | 31 | 51.7 |
| BS Nursing | 13 | 21.7 | |
| Post RN BSN | 14 | 23.3 | |
| MS Nursing | 1 | 1.7 | |
| Other | 1 | 1.7 | |
| Total Experience in Nursing Practice* | less than 1 year | 7 | 11.7 |
| 1–3 years | 11 | 18.3 | |
| 3–5 years | 25 | 41.7 | |
| 5 years and above | 17 | 28.3 | |
| Experience in critical Care areas† | less than 1 year | 22 | 36.7 |
| 1–3 years | 19 | 31.7 | |
| 3–5 years | 11 | 18.3 | |
| 5 years and above | 8 | 13.3 | |
| Training/Specialty Courses in Critical Care areas | Never | 33 | 55 |
| Once | 15 | 25 | |
| Twice | 8 | 13.3 | |
| Three times or more | 4 | 6.7 |
* Total experience in nursing practice includes overall clinical nursing experience in all healthcare settings
† Critical care experience specifically refers to work experience in ICU/critical care units only
Figure 2 illustrates the distribution of participants’ knowledge and practice levels before and after the intervention. Prior to the intervention, 93% of participants had poor knowledge, 7% had average knowledge, and none achieved a high knowledge level.
Fig. 2.
Pre- and post-knowledge and practice scores
The results indicated a significant improvement in both knowledge and practice after the intervention. The mean knowledge score increased from 6.57 to 10.23, while the mean practice score rose from 12.65 to 16.38, demonstrating substantial gains. Additionally, the slight reduction in standard deviation for both knowledge (1.789 to 1.681) and practice (1.830 to 1.427) suggest greater consistency in post-intervention scores, as illustrated in Table 2.
Table 2.
Total Knowledge and practice score of the participants paired t-test
| Pair | Total score | Mean | Std. Deviation |
|---|---|---|---|
| 1 | Pre knowledge | 6.57 | 1.789 |
| Post knowledge | 10.23 | 1.681 | |
| 2 | Pre–Practice | 12.65 | 1.830 |
| Post Practice | 16.38 | 1.427 |
A paired-samples t-test was performed to compare ICU nurses’ knowledge and practice scores before and after the educational intervention. The findings demonstrated statistically significant improvements in both outcomes. The mean knowledge score increased by 3.667 points (SD = 1.410; 95% CI: 3.302–4.031; p < 0.001), indicating a significant enhancement in nurses’ knowledge following the intervention. Similarly, the mean practice score increased by 3.733 points (SD = 2.231; 95% CI: 3.157–4.310; p < 0.001), demonstrating a significant improvement in nurses’ clinical practice as shown in Table 3.
Table 3.
Paired t-test knowledge and practices scores (Paired Differences)
| S.No | Variable | Mean | Std. Deviation | 95% Confidence Interval of the Difference | Sig. (2-tailed) | |
|---|---|---|---|---|---|---|
| Lower | Upper | |||||
| 1 | Total Knowledge Score | 3.667 | 1.410 | 3.302 | 4.031 | < 0.001 |
| 2 | Total Practice Score | 3.733 | 2.231 | 3.157 | 4.310 | < 0.001 |
Table 4 presents the one-way ANOVA results for post-intervention practice scores across different experience groups, where the overall difference was not statistically significant (F-test, p = 0.088). In contrast, Table 5 reports the Tukey HSD post-hoc analysis for post-intervention practice scores, not knowledge scores. Therefore, the significant pairwise differences identified in Table 5 relate specifically to practice performance among experience groups. The Tukey HSD analysis demonstrated significant differences in post-intervention practice scores between the less than one year experience group and both the 3–5 years group (mean difference = 2.034, p = 0.026) and the 5 + years group (mean difference = 3.067, p = 0.001), with nurses having greater experience achieving higher practice scores. No statistically significant differences were observed among the 1–3 years, 3–5 years, and 5 + years groups. These findings indicate that the major variation in practice scores occurred between nurses with less than one year of experience and those with more clinical experience.
Table 4.
Shows the pre-intervention mean practice scores compared across categories (qualifications, years of experience, and training courses)
| ANOVA | |||||
|---|---|---|---|---|---|
| Total Knowledge Score | |||||
| Sum of Squares | Df | Mean Square | F | Sig. | |
| Between Groups | 20.672 | 3 | 6.891 | 2.296 | 0.088 |
| Within Groups | 168.061 | 56 | 3.001 | ||
| Total | 188.733 | 59 | |||
Table 5.
Tukey total practice score HSD of demographics
| Multiple Comparisons | ||||||
|---|---|---|---|---|---|---|
| (I) Total Experience in Nursing Practice | (J) Total Experience in Nursing Practice | Mean Difference (I-J) | Std. Error | Sig. | 95% Confidence Interval | |
| Lower Bound | Upper Bound | |||||
| less than 1 year | 1–3 years | 1.896 | 0.792 | 0.090 | − 0.20 | 3.99 |
| 3–5 years | 2.034* | 0.701 | 0.026 | 0.18 | 3.89 | |
| 5 years and above | 3.067* | 0.736 | 0.001 | 1.12 | 5.02 | |
| 1–3 years | less than 1 year | -1.896 | 0.792 | 0.090 | -3.99 | 0.20 |
| 3–5 years | 0.138 | 0.593 | 0.995 | -1.43 | 1.71 | |
| 5 years and above | 1.171 | 0.634 | 0.263 | − 0.51 | 2.85 | |
| 3–5 years | less than 1 year | -2.034* | 0.701 | 0.026 | -3.89 | − 0.18 |
| 1–3 years | − 0.138 | 0.593 | 0.995 | -1.71 | 1.43 | |
| 5 years and above | 1.033 | 0.515 | 0.198 | − 0.33 | 2.40 | |
| 5 years and above | less than 1 year | -3.067* | 0.736 | 0.001 | -5.02 | -1.12 |
| 1–3 years | -1.171 | 0.634 | 0.263 | -2.85 | 0.51 | |
| 3–5 years | -1.033 | 0.515 | 0.198 | -2.40 | 0.33 | |
*. The mean difference is significant at the 0.05 level
The Pearson correlation analysis examined the relationship between participants’ pre-intervention and post-intervention knowledge scores. A two-tailed Pearson correlation demonstrated a statistically significant positive linear relationship between the two measurements (r = 0.671, p < 0.001), indicating that participants with higher baseline knowledge scores generally achieved higher post-intervention knowledge scores.
In contrast, the correlation between total knowledge scores and total practice scores was weak and not statistically significant (r = 0.078, p = 0.553), indicating that higher knowledge scores were not associated with better practice performance in this sample. Therefore, although both knowledge and practice improved following the educational intervention, the findings do not support a direct relationship between the two outcomes as illustrated in Table 6.
Table 6.
Correlation between pre- and post-knowledge and practice scores
| Variable | Total Knowledge Score | Total practice Score | |
|---|---|---|---|
| Total Knowledge Score | Pearson Correlation | 0.671** | |
| Sig. (2-tailed) | 0.000 | ||
| Total Practice Score | Pearson Correlation | 1 | 0.078 |
| Sig. (2-tailed) | 0.553 |
**. Correlation is significant at the 0.01 level (2-tailed)
Figure 3 illustrates the percentage compliance of nurses with different practice categories before and after the educational intervention. The findings demonstrate an overall improvement in compliance following the intervention. Compliance related to infection control practices increased from 70% in the pre-intervention phase to 82% in the post-intervention phase. Similarly, compliance with other clinical practices improved from 75% before the intervention to 86% after the intervention.
Fig. 3.
Shows the compliance of pre and post interventional groups in percentage
Discussion
The present study evaluated the effectiveness of an educational intervention on nurses’ knowledge and practice regarding evidence-based clinical procedures in critical care settings. The findings demonstrated statistically significant improvements in both knowledge and practice scores following the intervention, indicating that structured educational programs are effective in enhancing nursing competencies in intensive care environments.
The demographic profile showed that most participants were young female nurses, primarily aged 22–28 years, reflecting the typical composition of the critical care nursing workforce in many low- and middle-income countries, including Pakistan. More than half held diploma-level qualifications, while fewer possessed higher nursing degrees. This workforce pattern is consistent with the nursing structure in Pakistan, where diploma-prepared nurses continue to form the majority of bedside ICU staff due to shortages of bachelor -qualified nurses and limited access to specialization pathways [11, 12].
A notable finding was that more than half of the nurses had not received formal critical care training. This reflects a persistent gap in Pakistan’s healthcare system, where structured ICU competency-based training programs and continuing professional development opportunities remain inconsistent across institutions. Previous studies conducted in Pakistan have similarly identified inadequate access to specialized ICU training, contributing to variability in clinical competence and patient safety practices [11, 13].
The educational intervention produced a significant improvement in nurses’ knowledge scores, supporting the effectiveness of structured educational programs in enhancing theoretical understanding and clinical decision-making. These findings are consistent with international literature demonstrating that targeted educational interventions improve cognitive competencies and knowledge retention among ICU nurses [14, 15]. The improvement may be attributed to the structured, evidence-based and practice-oriented nature of the intervention.
Similarly, nurses’ practice scores improved significantly following the intervention, indicating better adherence to evidence-based clinical procedures. This aligns with studies reporting that educational interventions significantly improve compliance with infection prevention protocols and procedural safety standards in ICU settings [16, 17]. In Pakistan, similar interventions have demonstrated improvements in nursing practice and patient safety compliance in critical care environments.
A reduction in standard deviation in post-intervention scores suggests improved uniformity in both knowledge and practice among participants. This indicates that the intervention not only improved overall competency but also reduced variability in clinical performance. Such standardization is essential in ICU settings where inconsistency in care may affect patient outcomes.
The paired t-test confirmed statistically significant improvements in both knowledge and practice scores, and the narrow confidence intervals further support the reliability of these findings. These results are consistent with quasi-experimental studies demonstrating significant improvements in ICU nursing competencies following structured training programs [18, 19].
Interestingly, no statistically significant association was found between years of experience and knowledge scores. This suggests that clinical experience alone does not guarantee updated theoretical knowledge or adherence to evidence-based guidelines. Similar findings have been reported in Pakistani and international studies where knowledge was more strongly associated with recent training than with years of experience [20, 21].
In contrast, practice scores showed significant differences between nurses with less than one year of experience and those with more than three years of experience, with more experienced nurses demonstrating better performance. This may be due to repeated exposure to clinical procedures and greater familiarity with ICU workflows. However, the absence of differences among higher experience groups suggests a plateau effect in clinical skill development.
A key finding of this study was the weak, non-significant correlation between knowledge and practice scores, indicating that improved theoretical knowledge did not immediately translate into better clinical performance. This knowledge-practice gap is well documented in critical care nursing and reflects the complex nature of behaviour change, which is influenced by factors beyond knowledge acquisition, including clinical experience, workload, staffing constraints, organizational support, resource availability, and opportunities for repeated skills practice and feedback [22, 23]. While structured educational interventions can produce rapid and consistent improvements in knowledge, sustained changes in clinical practice typically require multifaceted implementation strategies such as simulation-based training, bedside mentoring, audit and feedback, and ongoing competency assessment [22, 23]. Furthermore, the two-week follow-up period was likely sufficient to detect cognitive gains but insufficient to capture the consolidation of behavioural changes in routine ICU practice [24].
The strong positive correlation between pre- and post-intervention knowledge scores suggests that participants with higher baseline knowledge achieved better post-intervention outcomes, indicating that prior cognitive foundation enhances learning uptake.
Finally, the improvement in infection control practices observed after the intervention is particularly significant, as healthcare-associated infections remain a major challenge in ICUs globally and in Pakistan. Studies consistently show that structured educational interventions improve adherence to infection prevention protocols and contribute to better patient safety outcomes [25, 26].
This study was conducted in three hospitals in Peshawar, which limits the generalizability of the findings. Future studies should include both public and private hospitals with a larger sample size to improve external validity. In addition, factors influencing the implementation of evidence-based endotracheal tube (ETT) suctioning practices were not explored and should be investigated in future research. The present study employed a single-group pre-post intervention design, which allowed assessment of changes in nurses’ knowledge following the educational intervention. However, the absence of a control group limits internal validity and precludes definitive causal attribution, as the observed improvements may have been influenced by uncontrolled factors such as testing effects, maturation, or external events. In addition, the use of convenience sampling may have introduced selection bias, limiting the representativeness of the sample and the generalizability of the findings. Although the intervention demonstrated significant improvements in knowledge scores, these findings should be interpreted with caution. Future studies should employ randomized controlled or quasi-experimental designs with appropriate control groups, probability sampling, and blinding procedures where feasible to strengthen methodological rigor, minimize bias, and provide more robust evidence regarding the effectiveness of educational interventions.
Recommendation
Educational interventions on endotracheal suctioning should be integrated into continuing professional development programs and delivered at regular intervals (e.g., every six months), with additional training incorporated into the orientation of newly appointed ICU nurses to promote sustained competency. While the present findings demonstrate an association between structured education and improved knowledge and practice, causal inferences should be interpreted cautiously due to the single-group pre-post design.
To enhance adherence to evidence-based practice, ICUs should implement standardized endotracheal suctioning protocols supported by concise bedside reference materials. Competency should be evaluated periodically using validated knowledge assessments, standardized observational checklists, and clinical audit indicators, with structured feedback provided to reinforce best practices and identify areas requiring further training.
Future research should investigate the long-term retention of knowledge and skills through follow-up assessments at clinically meaningful intervals (e.g., 6–12 months) and examine organizational and contextual factors influencing implementation. More rigorous study designs, including randomized controlled trials and implementation research, are recommended to establish the effectiveness, scalability, and sustainability of educational interventions.
Conclusion
The educational intervention was associated with significant improvements in nurses’ knowledge and practice regarding endotracheal tube suctioning. These findings indicate that structured, competency-based educational programs can effectively enhance ICU nursing performance and adherence to evidence-based guidelines.
The results support the implementation of regular in-service training programs (e.g., every 3–6 months) that combine theoretical instruction with hands-on simulation and bedside skill reinforcement, delivered by ICU educators or trained clinical supervisors. Such focused, practical training components are likely to be most effective in improving clinical competence and patient safety.
Although this study was conducted in three public-sector tertiary care hospitals, the findings may be relevant to similar ICU settings with comparable organizational and educational characteristics. However, the convenience sampling approach, relatively small sample size, and single-group pre-post design limits the broader transferability of the findings. Therefore, the results should be interpreted with caution, and larger multicentre studies across diverse healthcare settings are needed to confirm their applicability and strengthen causal inference.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors extend sincere appreciation to the nursing managers and staff nurses from the participating hospitals for their time, cooperation, and valuable participation in this study.
Abbreviations
- ICU
Intensive care unit
- ETT
Endotracheal Tube
- ETS
Endotracheal suctioning
- VAP
Ventilator-associated pneumonia
- CVI
Content Validity Index
Author contributions
All authors contributed equally to the conception, design, data collection, analysis, and writing of this manuscript.
Funding
This study received no external funding.
Data availability
Raw data will be provided for evidence purpose on reasonable request.
Declarations
Ethics approval and consent to participate
To ensure the rights of all participants, we strictly adhered to the Declaration of Helsinki in designing and conducting the research. This study was approved by the Ethics Committee of Khyber Medical University Peshawar, Pakistan (Ref no: KMU-INS/14 − 2/3322). All participants were informed about the aim of the study and the voluntary nature of their involvement. Written informed consent to participate was obtained from all participants. Moreover, the participants were informed about the confidentiality of the data and their right to withdraw from the study at any time. All methods were carried out in accordance with relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
Raw data will be provided for evidence purpose on reasonable request.