Abstract: Endotracheal tube (ETT) suctioning is a vital procedure that requires competence and confidence. , traditional method become not effective in education and student was not competent or satisfied when they thought with it. Peyton's teaching methodology is a recent approach that is designed to improve the performance, self-efficacy, and satisfaction of Critical Nursing students. Aim: to determine the influence of Peyton's four-step approach on the performance, self-efficacy, and self-satisfaction of critical care nursing students in relation to endotracheal tube suctioning. Methods: A quasi-experimental employs a research design, The clinical critical skills laboratory at the Faculty of Nursing, Beni-Suief University, was the site of the study . Four tools were utilized to collect data: Critical care nursing students' personal and academic characteristics, Endotracheal tube (ETT) suctioning Observational Checklist, learning self-efficacy scale and Student Satisfaction In addition, Self-Confidence in Learning scale. Results: There were statistical significant differences between the performance, self-efficacy, satisfaction, and self-confidence of students  in study and control group (P < 0.001).   Conclusion: Appling Peyton's four-step strategy helps critical nursing students to improve their performance, self-efficacy and satisfaction. Regarding Endotracheal Tube Suctioning Recommendations: Incorporating the using of Peyton's four-step approach as a teaching strategy for all practical skills in clinical critical skills lab for undergraduate students.