Introduction

Tracheostomy is one of the most common surgical techniques performed in intensive care unit (ICU) patients to facilitate weaning and to speed up the recovery process. It used to be reserved for severely ill patients with acute respiratory obstruction. It improved patient comfort and reduced the need for sedation1,2,3.

Tracheostomy may be associated with numerous acute, perioperative complications, some of which continue to be relevant well after the placement of the tracheostomy4. Tracheostomy tubes can be placed either surgically or percutaneously for the therapeutic purpose purposes when upper airway obstructions, failure to liberate from the ventilator, and debilitating neurological conditions are only a few indications5.

Care of Patients with a tracheostomy is a true emergency and an essential aspect of effective airway management. Nurses practice the function and limitations of endotracheal and tracheostomy care in mechanically ventilated patients and appropriate management is very important, to providing high-quality care6,7. A study using a descriptive cross-sectional study design at the Sahang University Hospital in Egypt showed that nurses had nearly 70% unsatisfactory levels of practice in providing tracheostomy care8. So, nurses must provide proper care to tracheostomy patients to prevent complications. A study to assess the knowledge regarding tracheostomy care among staff nurses and nurse students at Narayana Medical College and Hospital, Nellore showed that nurses had a moderate level of knowledge (53%)9. Another study conducted among critical care nurses showed that, the level of knowledge was moderate, which was lower than the expectations10.

Appropriate tracheostomy care requires that nurses maintain specific knowledge and a particular skillset, to ensure safe, competent care. Prompt recognition of problem and action by the nurse may resolve acute respiratory distress, dyspnea, and increased work of breathing and prevent adverse events. One of the most important considerations is effective mobilization of secretions, and a suction catheter is the most important tool7,11,12.

The first tracheostomy tube change, performed 1–2 weeks after placement, carries some risk and should be performed by a skilled operator in a safe environment13.Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions14.

Tracheostomy care is a major health concern and patients die as a result of nurses’ lack of awareness on tracheostomy care, even though, nurses are responsible for management of common symptoms and responses to mechanical ventilator support15,16.

To care for patients effectively, nurses must be competent in their knowledge of basic principles of tracheostomy care and must implement appropriate interventions to manage patients’ many responses to this common treatment effectively, which can be particularly challenging in nonverbal patients.

After a surgical procedure is performed to create an anterior opening or communication between the trachea and its overlying skin, it is necessary to give care to the opening of the trachea; hence the responsibility of the nurse is very important to provide appropriate care. So, as we have repeatedly stated above, nurses should have sufficient knowledge and skills in tracheostomy care.

Inadequate knowledge and poor practice of tracheostomy care among nurses can lead to severe consequences for patients, including an increased risk of infection, tube blockage, accidental decannulation, and other complications that compromise patient safety and recovery3,10,17.

While existing studies indicate varying levels of knowledge and practice among nurses regarding tracheostomy care, there is a significant gap in research specific to Ethiopia. This study aims to assess the knowledge, practice, and associated factors related to tracheostomy care among nurses working at Northwest Amhara Comprehensive Specialized Referral Hospitals, addressing this crucial gap in the literature.

Methods and material

Study design, area, and period

An institutional-based quantitative cross-sectional study design was done from December 4 - to February 20, 2024, at Northwest Amhara Comprehensive Specialized Referral Hospitals, Northwest Ethiopia. There are a total of five hospitals including in BaharDar, the capital city of the region, Tibebegion Comprehensive Specialized Hospital (TGCSRH), Felegehiwot Comprehensive Specialized Referral Hospital (FHCSRH), University of Gondar Comprehensive Specialized Referral Hospital (UoGCSRH)), Debre Tabor Comprehensive Specialized Hospital (DTCSH), Debre Markos Comprehensive Specialized Hospital (DMCSH) are available. These hospitals serve about 22,000,000 individuals in inpatient and outpatient services. There are now 1682 nurses employed by those institutions, and around 286 nurses working in the surgical ward, surgical ICU, and recovery ward18.

Source population and study population

Study population

All nurses who had been working in selected units or wards (Recovery ward, surgical and surgical ICU ward) at UoGCSRH, DTRH, DMRH, TGRH, and FHRH during the data collection period, 2024.

Inclusion and exclusion criteria

Inclusion criteria

All nurses who were working in the Recovery ward, surgical ICU & Surgical ward of Northwest Amhara Comprehensive Referral Hospitals, Northwest Ethiopia during the time of data collection.

Exclusion criteria

Nurse Managers who were working in the selected area were excluded.

Sample size determination and sampling technique

Sample size determination

The Sample size was calculated by using a single population proportion formula with Epi Info-7 software to obtain the required sample size with the following assumption. So, considering a 95% confidence interval (CI) 5% margin of error, and 50% proportion. Based on this the final sample size was 384.

Even though the total number of source population is less than the computed sample size; so, data was collected from all nurses in the selected hospital that fulfills the inclusion criteria in a total sample size of 281.

Sampling technique

A census was employed to recruit the participants for the study since the number of the source population is lesser than the calculated sample size. The total number of nurses who were working in the surgical ward, surgical ICU ward, and Recovery ward was 286.

Operational definition

Tracheostomy care: Tracheostomy care is a critical aspect of nursing responsibilities, requiring specialized skills to ensure optimal patient outcomes19.

Good knowledge: if participant’s response on knowledge questions is above or equal to the computed mean8.

Good practice: if participant’s response on practice questions is above or equal to the computed mean14.

Data collection tool and procedure

Data was collected by using a self-administered questionnaire, which involves 5 questions for Socio-demographic and other factors, 13 questions for knowledge and 22 questions for practice. The tool that was used to collect the data was an adopted questionnaire20. The participant filled out the questions at their place of employment. Nurses who are working other than in the study areas are recruited for data collection and Master of Science -holder nurses are recruited as supervisors. Overall, the data collection process was coordinated and supervised by the principal investigator.

Data quality assurance

To ensure the quality of data one-day training was given to data collectors and supervisors regarding the structured questionnaire (on the objective of the study and how to collect the data). Face validity was checked by the experts before starting the actual data collection. Pretesting on the instrument was carried out on 14 nurses who worked in the same hospital setting to evaluate the tool and there were no changes on the instruments since it was understandable by the respondents and did not contain ambiguities. Regular supervision was done to check the consistency and completeness of the filled-out questionnaires, by the supervisors and principal investigator. By using SPSS version 20, Cronbach’s alpha was calculated to test the internal consistency of items. The tests showed 0.765 and 0.857 for knowledge and practice. After the actual data collection process, the collected data were cross-checked for questionnaires’ consistency and completeness.

Data processing and analyzing

After being checked visually and coded the data were entered into Epi Info version 7 and exported into SPSS version 20 for analysis. A frequency table described the participant’s characteristics, knowledge, and practice scores. Multicollinearity among the dependent variables was assessed using the variance inflation factor, and its values were between 1 and 10. Model adequacy was checked using the Hosmer-Lemeshow goodness of fit test, and the model was fitted well, indicating 0.22 and 0.26 for knowledge and practice, respectively. Frequencies, percentages, and mean were computed to describe the key variables of the study. Binary logistic regression was performed to determine significant associations between independent variables and the dependent variable, and all independent variables that were less than 0.2 in bivariable analysis were entered into multivariable logistic regressions. A P-value of < 0.05 was considered significant for all analyses.

Results

Socio-demographic and work-related factors of knowledge

A total of 281, with a response rate of 98.25% of study participants were involved in this study. Among respondents 142 (50.5%) were males. In this study, 107 (38.1%) of the age group was between20-30. Out of 281 nurses, most of the respondents (73.3%) had a bachelor’s degree, and 113 (40.2%) of the respondents had 11–15 years of work experience (Table 1)

Table 1 Socio-demographic characteristics and work-related factors of the study participants on knowledge and practice of tracheostomy care in Northwest Amhara comprehensive specialized referral Hospitals, Northwest Ethiopia, 2024 (N = 281).
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Knowledge of nurses on tracheostomy care

The overall mean knowledge score of the study participants on tracheostomy care was eight. In this study, 143 (50.9%) with 95% CI: (43.23%, 54.99%) of the participants had good knowledge. Among a total of knowledge assessment questions, 225(80.1%) of participants correctly answered the statement that the trachea extends downward to the level of the 6th thoracic. Of 281 respondents almost more than half of the respondents (59.1%) correctly answered that the normal measurements of tracheostomy tube cuff pressure are 20–25 mm of Hg. Whereas 55.9% wrongly answered the statement that Length and inner diameter in millimeters are the criteria you base on while choosing a tracheostomy tube (Table 2)

Table 2 Nurse’s responses on knowledge of tracheostomy care in Northwest Amhara comprehensive specialized referral Hospitals, Northwest Ethiopia 2024 (N = 281).
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Practice of nurses on tracheostomy care

In this study nurses’ level of practice on tracheostomy care was good (49.8%) with a 95% of CI: (43.94–55.70). About 84.4% of the respondents correctly answered a statement during the first days of tracheostomy; the trachea should be suctioned every two hours. On the other hand, the nurse’s response on preventing complications of Tracheostomy by monitoring signs and symptoms was correctly answered by only 111 respondents (39.5%) (Table 3)

Table 3 Nurse’s responses on the practice of tracheostomy care in Northwest Amhara comprehensive specialized referral Hospitals, Northwest Ethiopia 2024 (N = 281).
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Factors associated with the level of knowledge on tracheostomy care

In the binary logistic regression, three of five variables were found to have a significant association with participants’ level of knowledge on tracheostomy care at a p-value of < 0.2. However, after controlling for the effects of potentially confounding variables using multivariable logistic regression participants’ educational status, their working unit, and working experience were found to be significant predictors for knowledge of tracheostomy care.

The study result showed that nurses with master’s degrees had 2.271 times more knowledge than those with bachelor’s degrees [AOR = 2.271, 95% CI (1.243–4.149)]. Nurses who had ≥ 15 working experience and those nurses working at the surgical ICU had [AOR = 4.168, 95% CI (1.725–10.073)] and [AOR = 2.114, 95% CI (1.122–3.982)] times knowledge than the counterparts respectively (Table 4)

Table 4 Factors associated with nurses’ knowledge regarding tracheostomy care in Northwest Amhara comprehensive specialized Hospitals, Northwest Ethiopia 2024 (N = 281), were analyzed in both bivariable and multivariable.
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Factors associated with the level of practice

In the binary logistic regression, five variables were found to have a significant association with participants’ level of knowledge on tracheostomy care at a p-value of < 0.2. Then sex of the participants, age, working experience, working unit, and their knowledge of tracheostomy care were found to be significant predictors for knowledge of tracheostomy care after controlling for the effects of potentially confounding variables using multivariable logistic regression. Here the variable sex, age, work experience, working unit, and knowledge of the participant about tracheostomy care had 2.345 [AOR = 2.345, 95% CI (1.270–4.330)], [AOR = 276, 95% CI (0.109–0.702)], [2.892 = 95% CI (1.173–7.34)], [2.702 = 95% CI (1.237–5.904)] and 6.971[AOR = 95% CI (3.708–13.107)] had good practice respectively (Table 5)

Table 5 Bivariable and multivariable analysis of factors associated with the practice of nurses on tracheostomy care in Northwest Amhara comprehensive specialized Hospitals, Northwest Ethiopia 2024 (N = 281).
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Discussion

To care for a patient with a tracheostomy requires a clear understanding of each patient’s need for the tracheostomy and the type of tube that is required21. This requires good knowledge and practice of nurses towards tracheostomy care. The result of this study showed that the overall good knowledge of nurses on tracheostomy care was 50.9% with 95% CI: (43.23, 54.99). This result is in line with the result of a study conducted in Pakistan 52%22. Furthermore, studies in Iran and Saudi Arabia also support these findings, showing a knowledge level of 55%10. Possible similarities between the studies might include the use of nurses as the research population, a similar research design, and similar working units for participant recruitment.

This study’s findings are lower than those of a study conducted in Rwanda, which reported a knowledge level of 71%20. This discrepancy may stem from several factors, including differences in socio-demographic characteristics such as education level, age, and work experience among the participants. Additionally, variations in healthcare infrastructure, available training programs, and institutional support for continuous education could influence knowledge levels. Local healthcare practices may also play a role in shaping nurses’ Knowledge and competencies in tracheostomy care. Similarly, this result is lower than those of study conducted in Egypt, 86.7% of the study participant had possess good knowledge23. In contrast in the previous study, their level of knowledge was measured after educational programs, because nurses’ knowledge is improved significantly by continuous educational and knowledge-building training programs. Even though there was improvement knowledge after the program, the study showed that improvement lowered slightly post 3 months at follow-up 73, 3%. It suggests that education, training, and follow-ups are essential in mainting the knowledge level.

In this study nurses level of practice on tracheostomy care was good (49.8%) with a 95% of CI: (43.94–55.70). This result is higher than the study conducted in Rwanda, which was 97.5% of participant exhibited low level of practice20. The findings of both studies showed that, despite their significant differences, the practice level of nurses was below expectations.

The current study showed that nurses with master’s degrees were 2.271 times more knowledgeable about tracheostomy care than nurses with BSC degrees. This underscores the importance of education as a key determinant of knowledge. For nurses to improve the quality of patient care by improving their scientific knowledge, educational interventions are essential. This observation aligns with literature suggesting that nurses with advanced education typically receive training on preventing respiratory problems.

Nurses with at least 15 years of working experience had 4.168 times more good knowledge than their counterparts. This finding is similar to the study conducted in Iraq, where working experience is significantly associated with knowledge of tracheostomy care. The fact that nurses are more likely to be exposed to patient care repeatedly and get more experience from working with senior healthcare providers might be the reason for the advantageous relationship observed in this study.

Those nurses working at the surgical ICU had also 2.114 times better knowledge than those nurses who are working in other departments. This is due to the fact that Intensive Care Units (ICUs) specialize in providing treatment and monitoring for critically ill patients, including those with tracheostomies. Nurses who are working in the ICU become more exposed because tracheostomy care is often provided in the ICU.

In this study being female had 2.345 times good practice than males. This might be because women are more likely than males to be kind and able to improve patient thoughts, making them more suited for jobs in nursing.

On the other hand, nurses in the age group between 41 and 50 had 0.276 negatively associated with the practice of nurses. This might be individual willingness and knowledge levels, all have an impact on recommendations24, This implies that experienced nurses might be less likely to alter their standard procedures unless they perceive a definite advantage or become convinced by newly acquired information. And nurses working for 6–10 years had 2.89 times good practice. This might mean working in nursing for 6–10 years is enough time to understand and perform the duties of the nursing profession properly. Although working for many years gives us a lot and have skills, doing the same job for a long time brings boredom. However, as we can see in this study, we think that the reason for the performance of nurses who have worked for 6–10 years is good because 6–10 years are when they understand things well and gain enough knowledge. So, their motivation to work is high.

Nurses who worked in the ICU had 2.702 times better practice than nurses who worked in other units. This is because the working environment has a positive influence on improving practice. That is why ICU nurses have good practice because they frequently give care to patients with tracheostomies. The UK Resuscitation Guidelines (2010) provide strong support for this idea, saying that staff working in emergency medicine and critical care may possess more advanced resuscitation knowledge and skills than non-resuscitation specialists in their regular clinical roles25.

Based on the current study findings, it can be concluded that there exists a positive and direct relationship between knowledge and practice. Nurses with good knowledge of tracheostomy care had 6.971 times more good practice than nurses with poor knowledge. The possible explanation might be explained by several research studies that have proven the indisputable value of training in individual psychomotor skills.

Strength and limitation

One of the limitations of this study is it may not show a temporal relationship because of the cross-sectional study design since exposure and outcome are simultaneously assessed. Besides that, observational data collection was not conducted; we would appreciate it if we use the observational data collection method because it allows us directly to see what people do rather than relying on what people say they did. Despite the limitation, this study covers a large setting (multicenter) area and clearly shows the knowledge, practice, and associated factors of nurses towards tracheostomy care.

Conclusion

The study concluded that nurses’ knowledge and practice regarding the tracheostomy care was inadequate. A positive and substantial correlation was found between knowledge and factors such as being masters, ≥ 15 years, working at surgical ICUs and it was found that a positive and substantial correlation between practice and factors such as being female, nurses working experience, nurses who are working in ICUs and nurses possessing good knowledge of tracheostomy care. A negative association was found with nurses on 41–50 age groups.