1 医工学治療 Therapeutics and Engineering Title: DIFFERENCES IN VISUAL ATTENTION BETWEEN NOVICE AND EXPERT NURSES PERFORMING ENDOTRACHEAL SUCTIONING (ES) : A SIMULATION STUDY 論文様式:原著 著者名: 1) Noriyo Colley, Faculty of Health Sciences, Division of Nursing, Hokkaido University 2) Tadayoshi Asaka, Faculty of Health Sciences, Division of Rehabilitation Science, Hokkaido University 3) Shinya Sakai, Faculty of Health Sciences, Division of Functioning and Disability, Hokkaido University 4) Yasuko Nagata, Hokkaido University Hospital, Paediatric Surgery, Ward Manager 5) Hiromi Shimizu, Sapporo Ayumi no Sono, Registered Nurse 6) Chiseki Honda, Kirin beer park chitose, Occupational health nurse 7)Tomoyuki Sasaki, Sapporo Ayumi no Sono, Physiotherapist 8) Takeshi Nishioka, Faculty of Health Sciences, Department of Medicine Keywords: endotracheal suctioning; expertise; eye movement; tacit knowledge; multitasking risk 2 連絡先: 〒060-0812 札幌市北区北 12条西 5丁目 北海道大学大学院保健科学研究院 TEL: 011-706-2320 FAX:ありません E-MAIL:noriyo@med.hokudai.ac.jp 利益相反について: 本論文発表に関連して、開示すべきCOI関係にある企業等はございません。 3 Title: DIFFERENCES IN VISUAL ATTENTION BETWEEN NOVICE AND EXPERT NURSES PERFORMING ENDTRACHEAL SUCTIONING (ES) : A SIMULATION STUDY Abstract Background: Endotracheal suctioning was authorized to be performed by individuals after attending a training course even though they do not possess a medical/nursing qualification in 2012 in Japan, though it is still considered as an evasive medical procedure. Objectives: This paper aims to discover experienced nurses’ proficiency of endotracheal suctioning in order to discuss future solution of nursing delegation. Methods: EMR-9○R (NAC Image technology Inc.) was used for eye tracking. EMR-dFactory○R version 2.7.0 was used for data analysis. ES was separated into six phases. Performance time, visual pathways, and movement speed of each participant were then analysed. Participants: Participants were recruited by snowball method and bulletin board. Inclusion criteria for nurses were experience of endotracheal suctioning in real work at any institution, and for students no experience of endotracheal suctioning in real settings. Results: Nurses' average time for ES was significantly shorter than students’; however, there was no significant correlation between years of 4 experience and the time (p= -0.006). Bimodality of eye movement velocity at 0-40 and 180-220 deg./s was also observed in the nurses’ group, in contrast to the unimodal distribution of the students’ velocity. Conclusion: Nurses achieved both time-efficiency and risk-avoidance by quickly gathering adequate visual information. Preparations before procedure to avoid task multiplicity are also important. 5 Introduction Rapid developments in medical technology have contributed to quality of life in patients with ventilators. In 2012 in Japan, home based endotracheal suctioning was authorised to be performed by non-qualified persons, but still categorized as a medical procedure due to its multiplicity and complexity. Numerous research papers warn about the risks, such as bleeding and pain 1) , anxiety 2) , cardiac dysrhythmia by stimulation of the vagus nerve 3) , infection 4,5) , mucosal damage, tracheal stenosis or unwanted increase of tissue in the airway, and hypoxia 6,7) , loss of end-expiratory lung volume (EELV), tidal volume (VT) and lung derecruitment 8-12) , and atelectasis 13,14) . Endo tracheal Suctioning (ES) restricts ventilator users to participate in society 15,16) , which could increase the risk of social isolation. Frequent suctioning increases the risk of alveolar derecruitment 17) , whereas lack of suctioning causes ventilator-associated pneumonia (VAP) 18 ), partial endotracheal tube (ETT) occlusion 19) , or suffocation 20,21) . Recent researchers have found that the selection of catheter size plays a more important role in protecting against derecruitment than open or closed suctioning system 22) . Hepponstall et al. (2012) concluded that “the change of lung volume is uniform 23) ”. ES is, therefore, a procedure that is unavoidable and involves a certain level of risk. However, ES is still under the debate whether it is “medical procedure” or not, for family caregivers at home 6 settings in Japan. Moreover, little is known about the relationship between ES-related complications and expertise, as well as how experts avoid those complications. Özden and Görgülü (2012) made a guideline for the enhancement of patient safety and the quality of nursing care 24) . Maggiore et al. (2013) conducted a prospective study before and after improving and implementing guidelines of ES to decrease adverse events 25) . Beuret et al. (2013) warned that there are discrepancies between ES guidelines and practice, with respect to adequate suction size (5.3%) and suction pressure monitoring (57.6%) 26) . The difficulty of describing expert nurses’ “tacit knowledge 27) ” might be a cause of those findings. This study was conducted to discover the differences in visual attention between novices and experts performing ES, and to describe nurses’ risk avoiding technique, in order to discuss future solution in delegation of suctioning as a process of demedicalization 28) . A simulation-based study was conducted, comparing nursing students to experienced nurses with respect to transitions in eye movements during ES to describe nurses’ visual attention to improve suctioning techniques and training methods for safe social task shifting. 7 2 Method 2.1. Participants Participants were recruited by snowball method and bulletin board at a division of nursing in a university from July 1 st to August 2 nd . Inclusion criteria for nurses were experience of endotracheal suctioning in real work at any institution, and for students no experience of endotracheal suctioning in real settings. Two participants who have low vision and could not put research apparatus were excluded. Overall, eleven female nurses from three institutions (with three to 17 years of experience, mean 8.67 years) and nine nursing students from one university (third-year students, 8 female and 1 male students, no work experience related to nursing) participated in this research. Sample size was determined according to previous researches 29-31) . Nine of the 11 nurses have been using the open suctioning system (OSS) single-use catheter method at their work, whereas two nurses had experience with the OSS dry method and the soak method. Only one nurse had experience with a closed suctioning system (CSS). All the nursing students had learned the OSS single-use catheter method before this research as a part of their curriculum. Single university students were chosen to uniform their background knowledge about suctioning. Simple lecture was provided individually from one of our research member. After collecting data, we showed one of researcher’s eye movement 8 video to every nursing student for their future interest. All participant received rewards for cooperation after this research. 2.2 Ethical consideration The protocol was approved by the Ethical Committee of Faculty of Health Sciences, Hokkaido University (no. 13-2). Written permissions from all participants were obtained in advance of the research. 2.3 Variation of Suctioning Procedure Suctioning technique is important in maintaining the patency of an artificial airway to avoid pneumonia and suffocation. There are two types of ES: OSS and CSS. OSS can be subdivided into three: dry method, soak method, and single-use method. These depend on whether the tracheal catheter is dried in a clean container, or soaked in disinfectant, those exchanged every 24 hours to maintain hygiene, or disposed after every suctioning. CSS is considered to decrease the transient loss of EELV and VT, however, it is still expensive for long-term consumption. Fernández et al. (2004) found that decreased lung volume in patients without severe lung disease was transient and rapidly reversible 32) . After a meta-analysis, Jongerden et al. (2006) concluded that there 9 is no evidence to prefer CSS to OSS 33) . Jongerden et al. (2012) stated that both systems can be considered equally safe with respect to heart rate, mean arterial pressure, and oxygen saturation 34) . More recently, Corley et al. (2012) said that EELV recovers more slowly after CSS than after OSS 35) . Therefore, the OSS dry method was selected in this research, and it is a common and financially reasonable technique for both hospital and home settings in Japan. Each participant performed a suctioning procedure twice, and the better of the two was selected for analysis. Before analysis, the process of OSS was separated into six phases from Phase one to six. Phase one (P1) is from touching the disposable gloves to first touching the catheter. P2 is till just before insertion of the catheter into the tracheal tube. P3 is till pulling out the catheter. P4 is from reattachment of the connection onto the tracheal tube to closing of the lid of the catheter container. P5 is until the turning off of the suctioning machine. P6 is the time for the participant removes the disposable gloves. 2.4 Apparatus EMR-9○R (NAC Image Technology Inc.) version 2.61 model ST-725 was used for eye tracking. Participants wore a cap with two lenses and carried a shoulder bag while suctioning. The 60°lens field and gravity mode for the fixation algorithm were chosen. 10 The sampling frequency was 60Hz. Retention of eye movement was defined as more than 100ms and less than 2.00 degrees 36) . EMR-dFactory○R version 2.7.0 and Microsoft Excel 2010 was used for data analysis. Figure1 shows a snapshot of this research procedure. 3 Results Data was collected from July 23 rd to August 15 th in 2013. Firstly, performance time, visual pathways, and movement speed of each participant were analysed. The nurses' average performance time was significantly shorter than that of the students (Figure 2). Most of students were still inserting catheter when nurses finished ES. However, no significant correlation was observed between years of experience and performance time by Pearson product-moment correlation coefficient (p=-0.006). Secondly, the performance times of the six phases were compared between the nurses and the nursing students. The overall data was calculated by Fisher's exact test and Welch t-test, as its small sample size and equal variances were not assumed (Table 1). Significant differences were found in five of the six phases other than P3, which is the time for inserting the catheter into the tracheal tube. Therefore, the “less than 15 seconds rule 37) ” seems to be kept by both groups. The majority of time spent by the 11 student group was based on the time spent for steps before and after catheter insertion and tidying up of the suctioning machine equipment. We also found that some students took 4-5 seconds of hesitation between disconnecting the tracheal tube connector and inserting the catheter. Bimodality of eye movement velocity at 0-40 and 180-220 deg/s was also observed in the nurses’ group, in contrast to the unimodal distribution of the students’ velocity (Figure 3). From the result, the students’ eye movement were slower than the nurses’. They consciously or unconsciously controlled their oculomotor speed to obtain visual information. Compared to the students’ eyesight and focal point, which were fixed on the ETT (Figure 4(a)), the nurses observed a wider area, such as the patient model’s face around the nose, the pulse oximetry, and the tip of the catheter (Figure 4(b)). Expert nurses were not just quickly collected visual information; their focus of their eyes was proper. The nurses’ focal point shifted to the face of the human model as shown in Figure 1 or to pulse oximetry while the nurse was putting on gloves or wiping catheter by alcohol cotton. This multi-layered observational skill seemed to be part of the nurses’ tacit knowledge. Expert nurses’ were able to move their hands and simultaneously they could pay attention to different things. 12 In contrast, the majority of nursing students did not move their attention from ETT; after the procedure a student stated that she attempted to look at the patients’ faces but she was unable to do so. The nurses consciously or unconsciously obtained observation skills for suctioning as necessitated by the situation. This accuracy of observing point could be another evaluation criterion for expertise in ES. Moreover, the distance between the simulator and each participant’s eyes was greater for the nurses than for the students, which might involve the ability of information acquisition in multitasks like ES. 4 Discussion From the analysis of oculomotor between the two groups, the nurses’ group was found to demonstrate quicker and safer suctioning than the students’ group demonstrated. The expert nurses’ distribution of eye movement velocity was bimodal; nurses observed effectively to prevent adverse events, controlling their visual search in terms of speed and accuracy. Learners were slower in body and eye movement, concentrating their attention only on ETT during P3, and they were unable even to glance at the patient’s face. Reductions in the time to disconnect from the ventilator could be the most effective means of preventing diminution of EELV and VT seems to 13 require repeated practices. One reason for the longer performance time among the nursing students’ was hesitation or indecisiveness about the correctness of the next task. After watching the nurses on video, several students stated that they thought it had been played in fast forward. Performance time can be a criterion for evaluating suctioning technique; because a shorter performance time reduces the patient’s waiting time from when they call the nurse until when the nurse inserts the catheter. The visual information accumulation methods differ between novices and experts; the differences appear in eye movement in the shape of anticipation and the useful field of view 38,39) . The activeness and predictability of the expert's visual information intake is due to the formation of cognitive schema and matrix by experience. During suctioning, the field of view, including that in peripheral vision, became wider for the nurses. They are capable to handle multiple visual information that allow them to assess the risk of adverse events. According to Maggiore et al. (2013), the most frequent incidents in ES were oxygen desaturation (6.5% of 4506 suctioning procedures), haemorrhagic secretion (4.0%), blood pressure changes (1.6%), and heart rate fluctuations (1.1%) 40) . Our previous research mentioned that there were more than ten observation points during catheter insertion 41) ; whereas the results showed that the 14 nurses were only observing the patient model’s face, the tip of the suctioning catheter, and the oximetry. These three observation points, however, cover the majority of the side effects from the provision of ES. For instance, in the case of haemorrhage, the sputum changes colour; the tip of suctioning catheter is the most important observation point. In the case of cyanosis, facial colour and oxygen saturation are the information that is necessary to assess. Perhaps nurses also use suctioning sound and touch to evaluate the amount or softness of secretion and to assess the patient’s lung function impairment. In the case of bradycardia, facial expression and sound of pulse rate from oximetry will assist nurses’ decision-making regarding whether to continue the suctioning. Although may need more in-depth research, these three observation points seem effective minimum elements for maintaining speed and safety. The nurses’ observation spots in the video seemed effective at preventing such incidents for beginners. There are two types of attention: bottom-up attention, and top-down attention 42) . In the usual optic environment, multiple objects are simultaneously projected onto the retina. The former attention is for highlighted objects that are noticeable and that automatically trigger a person’s attention. The latter attention is defined as that when objects are evenly distinctive but the person is able to pay attention to an object out of 15 his/her own interest or from direction by others. From these findings, at least cyanosis, haemorrhage, and bradycardia must be detected by the top-down attention before the actual provision of ES for the quality of care. Once new knowledge is acquired and repeatedly put into practice, it gradually becomes automatic and non-conscious 43) . Experts cannot explain what they are doing if they cannot realize and verbalise it. Automated expertise results in significant but unintended omissions when experts attempt to communicate their skills to others 44) . Therefore, there might be a large discrepancy between learners and experts in terms of skill inheritance. What kind of information is where was already embedded in their body through experience. The skills of ES, therefore, have to be recognized as tacit knowledge that requires experience, and not merely as knowledge of a technique. As for infection risk, several students inadvertently contaminated the suctioning catheter. They touched the tip of catheter with gloved fingers or they swung the tip of catheter. Hunt and Joslyn (2000) pointed out that “Errors most likely increase in number and severity under time-pressure and anxiety-producing situations 45) ”. Preparation to manage danger and unwanted situations before provision of ES is also important for quality of nursing. Some procedures, such as selecting adequate suction size or setting suction pressure, can be prepared before ES, and multiplication of tasks can be avoided. 16 Especially in relation to risk, the causes and effects of ES need to be elucidated by future research. 5 Conclusion Our results show that the nurses’ group performed ES significantly quicker than the students did; however, there was no significant correlation between years of experience and performing time. The nurses’ observation point was reasonable to avoid main adverse events of ES and more accurate and speedy than the nursing students. These results imply that expertise is a key factor for providing safe ES. Further research is needed to reveal the skill acquisition process and the decision-making process of expert ES providers. Preparations before ES to avoid task multiplicity are also important. 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Eye movement speed distribution in nursing students and nurses 27