Nurses' knowledge of care of chest drain: A survey in a Nigerian semiurban university hospital.

BACKGROUND/
OBJECTIVE: Inefficient nursing care of chest drains may associated with unacceptable and sometimes life-threatening complications. This report aims to ascertain the level of knowledge of care of chest drains among nurses working in wards in a teaching hospital in Nigeria.
METHODS: A cross-sectional study among nurses at teaching hospital using pretested self-administered questionnaires.
RESULTS: The majority were respondents aged between 31 and 40 years (45.4%) and those who have nursing experience between 6 and 10 years. Only 37 respondents (26.2%) had a good knowledge of nursing care of chest drains. Knowledge was relatively higher among nurses who cared for chest drains daily, nurses who have a work experience of <10 years, low-rank nurses and those working in the female medical ward; however, the relationship were not statistically significant (P > 0.05). Performance was poor on the questions on position of drainage system were not statistically significant with relationship to waist level while mobilizing the patient, application of suction to chest drains, daily changing of dressing over chest drain insertion site, milking of tubes and drainage system with dependent loop.
CONCLUSION: The knowledge of care of chest drains among nurses is poor, especially in the key post procedural care. There is an urgent need to train them so as to improve the nursing care of patients managed with chest drains.

Introduction

Chest drains have remained a common, simple and effective tool for managing chest trauma[1] and pleural pathologies. They are largely used in patients admitted with these pathologies in accident and emergency units, Intensive Care Units, adult and pediatric medical and surgical wards.

Nursing care of chest drains can either be preprocedural or postprocedural. Preprocedural care involves ensuring that an informed consent is obtained and giving additional relevant information to the patient, gathering the correct materials for tube thoracostomy and assisting the procedure. Postprocedural care entails monitoring vital signs, maintaining a closed system, assessing and charting drainage, protecting the water seal drainage system, assisting patients during change of position and assisting in removing tube after it has served its function.

Inefficient nursing care and poor surgical techniques during insertion are associated with unacceptable and sometimes life-threatening complications that can be classified as technical or infective.[2] Recently, recommendations and guidelines on the care of chest tubes that are largely evidenced based have been published.[3]

We aimed to determine the knowledge gaps in the care of chest drains among our nurses.

To the best of our knowledge, there have been no studies that have examined the nurses’ knowledge of care of chest drains in our sub-region.

Methods

We used closed-ended questions to draw up a 25-item questionnaire. The questions were distributed over four sections: Demographic data, need for education on care of chest drain, 15 statements based on anatomy, function of chest drain and basic postprocedural nursing care of chest drain. The response to the statements in the questionnaire is either “true,” “false” or “do not know.” The respondents were asked to select one of the above responses for each of the statement. A pilot study was carried out among 22 nurses in a nearby university hospital to improve the reliability of the instrument. The questionnaire was modified after the pilot study.

A total of 15 marks were allocated to 15 statements in the questionnaire, each statement having one mark. Participants who scored 0–9 were graded as poor knowledge while those who scored 10–15 were graded as good knowledge of care of chest drain. The weight of the score awarded to each statement and the grading were determined independently by two nurse tutors and a thoracic surgeon who were not part of the study.

The survey involved a total population study of all eligible respondents and they were all cadres of nursing staffs working in the adult and pediatric medical and surgical wards, gynecological wards, Intensive Care Unit, accident and emergency units and pediatric emergency units of Irrua Specialist Teaching Hospital, Irrua. It is a 375-bedded university hospital located in Irrua Specialist Teaching Hospital, Irrua. They filled the questionnaires during their shift duty, and the questionnaire was retrieved immediately after the shift.

Ethical approval was obtained from the Ethics and Research Committee of the institution.

We obtained permission from the head and director of nursing service, and verbal consent was obtained from each respondent before administering the questionnaire. The questionnaire was anonymous, and it was not possible to detect nonresponders. The participants were informed that their response would be analyzed and published.

The data from all the returned questionnaires were entered into Statistical Package for Social Science (SPSS, Version 16.0. Chicago, SPSS In.) and analyzed. Both descriptive and inferential statistics were computed. The level of significance was set at P < 0.05.

Results

A total of 141 nurses returned the questionnaire. The response rate was 76.6%. The majority of respondents (45.4%) were aged between 31 and 40 years. This was followed by those aged 41–50 who accounted for 31.2% of respondents. Nursing Officer I and II accounted for 29.1% and 37.6% respectively. Registered staff nurses with basic nursing qualification accounted for 87.9% of respondents while those with bachelor degree in nursing accounted for 12.1% of respondents. The majority of our respondents were nurses who have been practicing nursing profession for 6–10 years [Table 1]. The number of respondents and the ward they were working is also shown in Table 1.

Table 1

Demographic data

	Number (%)
Sex
Male	20 (14.2)
Female	121 (85.5)
Total	141 (100)
Age
21-30	19 (13.5)
31-40	64 (45.4)
41-50	44 (31.2)
51-60	14 (9.9)
Total	141 (100)
Rank
NO 1	41 (29.1)
NO 2	53 (37.6)
SNO	7 (5.0)
PNO	1 (0.7)
ACNO	14 (9.9)
CNO and above	25 (17.7)
Total	141 (100)
Academic qualification
RSN	124 (87.9)
BSc. Nursing	17 (12.1)
Total	141 (100.0)
Years of experience
1-5	41 (29.1)
6-10	43 (30.5)
11-15	15 (10.6)
16-20	14 (9.9)
>20	28 (19.9)
Total	141 (100.0)
Ward
Female medical ward	20 (14.2)
Male medical ward	17 (12.1)
Female surgical ward	14 (9.9)
Male surgical ward	16 (11.3)
ICU	11 (7.8)
A/E	22 (15.6)
Pediatric emergency unit	14 (9.9)
Pediatric ward	11 (7.8)
Gynecology ward	16 (11.3)
Total	141 (100.0)

ICU=Intensive Care Unit, A/E=Accident and emergency, SNO=Senior Nursing Officer, PNO=Principal Nursing Officer, ACNO=Assistant Chief Nursing Officer, CNO=Chief Nursing Officer, RSN=Registered nurse

Only a few nurses (33.3%) have attended seminars on care of chest tubes. In most cases, the seminars were organized by the Nursing School. All the respondents believe that it is important for the institution to organize updates and seminars on care of chest drains. Less than half of the nurses (46.8%) cared for chest drains daily while 36.9% of respondents cared for chest drains about once monthly. The remaining 7.1% and 9.2% of nurses cared for chest drains weekly and twice monthly respectively.

Only 37 respondents (26.2%) had a good knowledge of nursing care of chest drains. Of these respondents, the majority were nursing officers I and II, and nurses with nursing experience between 1–5 years (29.73%) and 6–10 years (29.73%). Most of the respondents manage chest drains in the female medical ward (24.32%), the male medical ward (16.22%) and the male surgical ward (16.22%); 19 (51.35%) of those who possess good knowledge of chest drain care for chest drain daily. The relationship between knowledge about care of chest drains and the ward in which the nurse was working, the years of experience of the nurse, how regularly the nurse cared for chest drains, the rank and whether the nurse had attended a course or symposium on care of chest drains were not statistically significant [Table 2].

Table 2

Variables and score

Variable	Performance			P
	Good (%) (n) 26.2% (37)	Comparative performance (%)	Poor (%) (n) 73.8 (104)
Rank
NO 2	20.8 (11)	29.73	79.2 (42)	0.606
NO 1	34.1 (14)	37.84	65.9 (27)
SNO	14.3 (1)	2.7	85.7 (6)
PNO	0 (0)	0	100 (1)
ACNO	21.4 (3)	8.11	78.6 (11)
CNO and above	32 (8)	21.62	68 (17)
Academic qualification
RSN	28.2 (35)	94.6	73 (89)	0.057
BSc. Nursing	11.8 (2)	5.5	88.2 (15)
Years of experience
1-5	26.8 (11)	29.73	73.2 (30)	0.379
6-10	25.6 (11)	29.73	74.4 (32)
11-15	40 (6)	16.22	60 (9)
16-20	7.1 (1)	2.7	92.9 (13)
>20	28.6 (8)	21.62	71.4 (20)
Ward
Female medical ward	45 (9)	24.32	55 (11)	0.126
Male medical ward	35.5 (6)	16.22	64.7 (11)
Female surgical ward	0 (0)	0	100 (14)
Male surgical ward	37.5 (6)	16.22	62.5 (10)
ICU	27.3 (3)	8.11	72.7 (8)
A/E	13.6 (3)	8.11	86.4 (19)
Pediatric emergency unit	28.6 (4)	10.81	71.4 (10)
Pediatric ward	18.2 (2)	5.5	81.8 (9)
Gynecology ward	25 (4)	10.81	75 (12)
Care of tubes
Daily	28.8 (19)	51.35	71.2 (47)	0.747
Weekly	20 (2)	5.4	80 (8)
Twice monthly	15.4 (2)	5.4	84.6 (11)
Once monthly or fewer	26.4 (14)	37.84	73.1 (38)
Attending seminars
Attended seminars	36.2 (17)	45.95	63.8 (30)	0.058
Has not attended seminars	21.3 (20)	54.05	78.7 (74)

ACNO=Assistant Chief Nursing Officer, CNO=Chief Nursing Officer, PNO=Principal Nursing Officer, SNO=Senior Nursing Officer, NO=Nursing Officer, RN=Registered nurse, ICU=Intensive Care Unit, A/E=Accident and emergency

Respondents performed unsatisfactorily on questions about the position of drainage system with relationship to waist level while mobilizing the patient, application of suction to chest drains, daily changing of chest drains, milking of tubes and drainage in a system with a dependent loop [Table 3].

Table 3

The performance for the statements in the questionnaire

Statements	Appropriate response	True (%)	False (%)	Do not know (%)	Missing value (%)
Chest drains are inserted to allow the withdrawal of air, blood or fluids from the chest cavity	True	139 (99.3)	1 (0.7)	0 (0)
It is performed most of the time under general anesthesia	False	51 (36.2)	82 (58.2)	5 (3.5)	3 (2.1)
Fluctuation of the fluid level in the drainage tubing (“swinging”) and/or bubbling during normal respiration is not a true way of knowing if the tube is patent	False	48 (34)	69 (48.9)	16 (11.3)	8 (5.3)
Additional pain medication should be administered during the insertion of a chest drain	True	113 (80.1)	9 (6.4)	15 (10.6)	4 (2.8)
The chest drainage system must be kept below the drain insertion site	True	121 (85.5)	4 (2.8)	4 (2.8)	12 (8.5)
A bubbling chest drain should never be clamped	True	82 (58.2)	34 (24.1)	18 (12.8)	7 (5.0)
Dependent loops is excellent for drainage	False	57 (40.4)	16 (11.3)	42 (29.8)	26 (18.4)
Regular milking of tubes help to maintain patency	False	58 (41.1)	58 (41.1)	10 (7.1)	15 (10.6)
Both the amount and color of any fluid draining at least daily must be charted	True	129 (91.5)	2 (1.4)	2 (1.4)	8 (5.7)
It is important to drain large effusion faster to enable patient have a quick recovery	False	45 (31.9)	83 (58.9)	7 (5.0)	6 (4.3)
When mobilizing, ensure the drainage system is kept above the waist level	False	70 (49.6)	52 (36.9)	11 (7.8)	8 (5.7)
Suction should never be applied to a chest drain	False	109 (77.3)	19 (13.5)	8 (5.7)	5 (3.5)
Change the dressing only when they are soaked	False	102 (72.3)	34 (24.1)	1 (0.7)	4 (2.8)
It is important for the patient to perform valsalva maneuver on removal of tube	True	57 (40.4)	23 (16.3)	47 (33.3)	14 (9.9)

Discussion

The importance of a sound knowledge of the care of chest drains cannot be overemphasized as mismanagement can have devastating consequences. Previous surveys on the knowledge of care of chest drains in both adult and pediatric patients have identified significant gaps in knowledge.[45]

Only 33.3% of our respondents have received some form of lectures or symposium about nursing care of chest drains. This low figure agrees with other studies. Fremlin et al. showed that only 12% of respondents had received formal education, and only 34% felt confident in managing chest drains.[6] Another study revealed that only 11.9% had attended any educational lecture or workshop on chest drain management.[7]

Most respondents (99.3%) correctly answered that chest drains are inserted into the pleural cavity and serve to drain air, blood or fluids from the chest cavity. This indicates that the respondents have a good knowledge of basic anatomy and function of a chest drain.

Significant pain has been associated with tube thoracostomy. In a study by Fremlin et al., 25% of patients reported pain during or following chest tube insertion.[6] Most of our respondents believe that there is need for additional pain medication during insertion of chest drains. The need for additional analgesia is also supported by other studies.[5] Pain arising from tube thoracostomy results in shallow breathing, atelectasis and increased pulmonary complications.

A significant percentage of our nurses either do not know or were not sure that fluctuation of the fluid level in the drainage tubing (“swinging”) is a true way of knowing if the tube is patent. Swinging is as a result of changes in intrapleural pressure between inspiration and expiration. Loss of swinging indicates blockage while excessive swinging can result from pneumothorax or a bronchopleural fistula.

The standard practice is to always ensure that the underwater seal drain remains below the site of tube thoracostomy while on bed or during transportation.[8] This is to ensure that there is no backflow of the contents of the drain into the pleural space. The majority of our respondents (85.5%) got it correctly; however, many believed it should be above the waist level during transportation.

Unfortunately, most of our respondents (88.6%) are ignorant of the fact that a fluid-filled dependent loop is particularly dangerous. It can change pleural pressures from −18 cmH2O to 8 cmH2O and completely block drainage of pleural content within 30 min. This clearly shows how important it is to avoid a dependent loop or more importantly to empty the collection in a dependent loop every 15 min.[3]

Clogging of chest drain necessitating tube manipulation is a common practice. Shalli et al. demonstrated in his study that all the surgeons (100%) had observed chest tube clogging and 87% reported adverse patient outcome from clogged tubes. It may also increase nursing duties.[9] The majority of nurses (75%) agreed that nursing patients on clogged drain took them away from important tasks. Tube manipulations can be in the form of milking, stripping, tapping and squeezing of tubes.[10] In our study, 41.1% of respondents still believe in milking of chest tubes to improve drainage. However, previous studies have revealed that nurses have correctly indicated that tube manipulation as stripping or milking chest tubes does not keep tubes patent.[49] Increased drainage observed in a study where tubes were milked was attributed to pleural stimulation.[11] Lung damage can also result from milking either by hand or with mechanical roller.[12]

Suction is indicated in some patients that are on chest drainage; however, the majority of our respondents wrongly answered that suction drainage is never indicated. The level of suction has traditionally been −20 cmH2O; however, no work has suggested an optimal level of suction.[3] Sanni et al. investigated the usefulness of suction in reducing the incidence of prolonged air leak in patients undergoing lobectomy. They found six relevant studies. None of the studies favored the use of suction over gravity water seal drainage in reducing prolonged air leak. Two studies found no differences between the two while four favored gravity over suction.[13] Suction may also be indicated when a greater force is required to expand a stiff and noncompliant lung, in patients with large air leak and those who may require positive end-expiratory pressure.[14]

There is need for daily assessment of the amount and nature of drainage preferably in a chest drain chart. Bubbling and the presence of respiratory swing should also be documented.[15]

A good number of our respondents (58.8%) knew that it is important not to drain more than 1 L at a time to avoid reexpansion pulmonary edema.[2] Other prophylactic measures against reexpansion pulmonary edema include recognizing patients at high risk of the complication, leaving thoracostomy tubes initially off suction and preferring underwater seal drainage rather than negative pressure apparatus.[2]

Dry gauze dressing of tube thoracostomy site without heavy strapping has been encouraged by Roskelly.[8] Although it has been the traditional way of dressing drain sites, a case has been made for the use of transparent adhesive dressing.[16] With this kind of dressing, the insertion site can easily be observed, and superficial surgical site infection easily detected.[16] It is advisable to change dressing every day, with care not to tamper with the security of the drain.

There is a controversy whether to remove chest drains either in end-inspiration or end-expiration. Bell et al. demonstrated no difference in incidence of recurrent pneumothorax when tube is removed either on end-inspiration or end-expiration.[17] Valsalva maneuver holds the breath at end-expiration. The same physiological process can be achieved by asking the patient to hold his/her breath out.

Overall our study has demonstrated that 73.8% of respondents have a poor knowledge in the care of chest drains. This is consistent with the other studies.[4567] Nurses in the female surgical ward exhibited the poorest level of knowledge of care of chest drains. Previous studies have shown that nurses in respiratory wards appeared to have limited knowledge of chest drains.[6] Nurses in the female medical ward had the best performance in our study. Other variables that performed relatively better were those that cared for chest drain daily, those who have practiced nursing for <10 years, and low-rank nurses (nursing officers I and II). This is easily explained by the statement that practice makes perfect. The low-rank nurses and those with nursing experience <10 years were likely to be the ones delegated to care for chest drains. All the nurses that have attended seminar or symposium on care of chest drain did so more than 5 years ago. Apparently the knowledge acquired may be outdated, hence they were found not to be better than those who never attended such seminar/symposium

Maggie et al. demonstrated poor knowledge in milking chest drain, aspects of suction level, clamping of chest drains and types of chest drain system;[7] however, our study revealed poor knowledge on position of drainage system with relationship to waist level while mobilizing the patient, application of suction to chest drains, daily changing of dressing over chest drain insertion site, milking of tubes and drainage in a system with a dependent loop. These are the most important postprocedural care.

The introduction of digital thoracic drainage has solved most of the problems encountered nursing patients on chest drains. Thopaz, a digital portable drainage system has been found to be more scientific and the drainage accurately recordable. Patients on this system are easily mobilized, and its characteristic weightlessness, silence, and compact design have endeared the system to patients.[18]

Conclusion

This study has revealed that the knowledge of care of chest drain among nurses is poor. The worst performance was noted in the postprocedural care of chest drains. There is a need to train our nurses and reevaluate them after training to ensure that our patients on chest drains receive the best nursing care.