Published in PLOS One on 2026-06-16, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Loema Moshi Buyi, Rashid Heri, Menti Lastone Ndile
Source: PLOS One • DOI 10.1371/journal.pone.0347186
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Endotracheal tube suctioning (ETS) is a critical procedure for mechanically ventilated patients. Evidence-based guidelines exist to ensure its safe performance; however, adherence remains suboptimal, especially in resource-limited settings. This study aimed to explore the barriers to ETS guideline adherence among ICU nurses at Muhimbili National Hospital (MNH), Tanzania.
An exploratory qualitative study was conducted in the medical and surgical ICUs of MNH. Seventeen ICU nurses with ≥1 year of experience were purposively sampled. Semi-structured interviews were performed, audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis following Braun and Clarke’s framework.
Three key barriers emerged: (1) Resource scarcity, including critical shortages of staff, equipment, and supplies; (2) Human and behavioral challenges, such as knowledge deficits and resistance to change away from routine practice; and (3) Guideline accessibility and usability, concerning poor accessibility and a perception that guidelines were not tailored to the local context.
Non-adherence to ETS guidelines primarily reflects systemic constraints rather than individual neglect. Strengthening adherence requires multi-level interventions: improving staffing and resources, providing continuous training, and adapting international guidelines to the local context.
Background
Endotracheal tube suctioning (ETS) is a frequently performed invasive nursing procedure in intensive care units (ICUs) and plays a critical role in maintaining airway patency, optimizing gas exchange, and preventing complications such as atelectasis and ventilator-associated pneumonia (VAP) [1]. As a core ICU nursing competency, ETS requires consistent adherence to evidence-based practices supported by ongoing training and access to clinical guidelines.
When ETS is performed incorrectly, it can result in significant adverse outcomes, including hypoxemia, cardiovascular instability, airway trauma, mucosal bleeding, and an increased risk of nosocomial infections [2]. To mitigate these risks, evidence-based ETS guidelines have been developed, emphasizing appropriate patient assessment, correct catheter selection, strict aseptic technique, and continuous patient monitoring throughout the procedure [3–5].
Despite the availability of these guidelines, adherence to recommended ETS practices remains suboptimal, particularly in low-resource settings. Multiple interacting barriers, including systemic constraints such as high nurse-to-patient ratios, shortages of equipment and consumables, and irregular access to clinical guidelines and in-service training influence nurses’ adherence. Behavioural factors, including reliance on habitual practices and risk perception, as well as contextual influences such as unit culture and limited supervisory support, further contribute to suboptimal adherence to ETS recommendations [6–12]. In contrast, non-adherence in well-resourced settings is more commonly attributed to time pressure or individual clinical judgment rather than resource limitations [10,13].
Evidence from Tanzania highlights these systemic challenges. A survey mapping emergency and critical care services conducted in ten districts and tertiary hospitals reported that only 20% of surveyed hospitals had staff trained in critical care, 40% had mechanical ventilators, and 44% had access to critical care practice guidelines [14]. These findings underscore significant gaps in both resources and training. Similarly, a study conducted in a tertiary hospital in Tanzania found that approximately 103 (80%) nurses had inadequate knowledge of evidence-based ETS practices, resulting in frequent deviations from standard care [15].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider hospital systems desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Loema Moshi Buyi, Rashid Heri, Menti Lastone Ndile. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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