Poster Submission
Jen1321
PICOTW5.pdf
IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 9, Issue 1 Ser. IV. (Jan - Feb. 2020), PP 19-23
www.iosrjournals.org
DOI: 10.9790/1959-0901041923 www.iosrjournals.org 19 | Page
Nurse's Perception about Nurse's Independent Actions in
Preventing Ventilator Associated Pneumonia (VAP)
Agus Surya Bakti 1,
Setiawan 2,
Asrizal 3
123 Faculty of Nursing, Universitas Sumatera Utara, Indonesia
Abstract: Ventilator associated pneumonia (VAP) is a nosocimial infection that results in pneumonia after 48
hours and more after mechanical ventilation. Nurses in terms of performing nursing care are responsible for
the prevention of VAP. In this case the nurse's role is very important in taking independent measures of VAP
prevention so that VAP risk can be minimized. This study aims to explore nurses 'perceptions about nurses'
independent actions in VAP prevention at Mitra Medika General Hospital, Medan. The design of this study is a
qualitative research with a phenomenological approach conducted from January 2019 to May 2019. The
method of data collection is by conducting focus group discussions (FGD). Participants involved in this study
were 28 participants taken through purposive sampling. Analysis of data using qualitative methods. The results
showed that there were six themes: 1) nurses' knowledge of VAP in general was still lacking, 2) there were
barriers to the implementation of nurses' independent actions in VAP prevention, 3) lack of experience of
nurses in taking independent actions of VAP prevention, 4) the importance of establishing self-action protocols
nurses in VAP prevention, 5) nurse independent actions of nurses needed in VAP prevention, 6) implementation
strategies needed in developing nurses' independent actions in VAP prevention. This research has produced
nurses' perceptions about nurses' independent actions in VAP prevention. Nurse independent action is needed
to prevent VAP as well as increase nurses' knowledge and compliance as well as to make a decrease in the
incidence of VAP in patients with ventilators.
Keywords: Ventilator Associated Pneumonia (VAP), Knowledge, Compliance
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Date of Submission: 31-12-2019 Date of Acceptance: 15-01-2020
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I. Introduction Ventilator associated pneumonia (VAP) is a problem that occurs when patients receive treatment in
intensive care units (ICU) where 8-28% occur in patients who are mechanically ventilated (Chastre, 2002).
Ventilator associated pneumonia (VAP) is also known as a nosocimial infection that results in pneumonia after
48 hours and more after installation of mechanical ventilation (Magnuson, 2013).
Patients who are installed with mechanical ventilation are at 28% risk of VAP, and also account for
86% of cases of nosocimial infections and VAP about 3 to 10 times (Augustyn, 2007). The indicated time of
VAP also varies based on the length of mechanical ventilation installed, where 3,387 patients in 45 days of
treatment with mechanical ventilation will be exposed to the VAP within the first 9 days, and predicted the total
number of VAP events on the first and second days is 5.3 and 8.3 events (Marine Giard, 2008 ). The incidence
of VAP also increased by 41 cases from 1000 mechanical ventilation use (Porhomayon, 2017).
Nurses in terms of performing nursing care are responsible for the prevention of VAP. In this case the
nurse's role is very important in taking independent measures of VAP prevention. Assessment and intervention
by nurses are seen from risk factors for aspiration during intubation, frequent intubation, abnormal body
temperature, large amounts of sputum, high or low leukocytes and other markers of infection such as C-reactive
protein (CRP) and procalcitonin.
Nurses as providing 24-hour care to patients must understand in the implementation of the nurse's
independent actions in the prevention of VAP, so what is needed is nurses' knowledge so that the prevention of
VAP properly implemented fiber compliance levels can be maximized.
Nurses' knowledge in VAP prevention is influenced by the level of education, experience of nurses and
training (Korhan, 2013). However, other opinions mention the knowledge of nurses in the prevention of VAP is
not absolutely caused by factors of education, tenure and training (Rifai, 2016). Knowledge in implementing
VAP prevention will be a barrier to compliance in VAP prevention so efforts should be made to increase
knowledge (El Khatib, 2010). qualitative research.
Nurse's Perception about Nurse's Independent Actions in Preventing Ventilator Associated ..
DOI: 10.9790/1959-0901041923 www.iosrjournals.org 20 | Page
II. Methods This type of research is a qualitative study using focus groups discussion (FGD) to collect data related
to research objectives. The sampling technique used in this study was purposive sampling used to identify
nurses about independent actions in VAP prevention. The number of participants in this study were 28
participants which consisted of 1 room head, 8 team leaders, 19 implementing nurses. Then the researchers also
took participants 1 head of nursing sub-division, 1 infection prevention and control committee, 1 nursing
committee and 1 clinical instructor.
Data collection tools used in this study were researchers, in addition to FGD guidance and voice
recorders. Researchers as an important data collection tool to have the ability to conduct interviews to obtain
data that is real and real. Another data collection tool is the FGD guide on nurses' perceptions about
independent actions in the prevention of VAP in the ICU room of Mitra Medika General Hospital, Medan. FGD
Guidelines have been tested for content validity by conducting discussions with supervisors and three experts in
their fields before being used for data collection.
The FGD was carried out for 60 minutes in a group of 28 participants. Before conducting the FGD, the
researcher first gave an informed concern to the participants. Before the FGD was conducted, the researcher had
carried out many interactions with the participants involved in this research so that the researcher had known
the characters of the participants.
In this study data triangulation was also carried out. Data triangulation techniques enable researchers to
obtain different but complementary data on the same topic. The triangulation technique used in this study was
carried out by collecting data from several data sources in the study such as data from nurses and leaders of the
Medan Medika General Hospital.
Data analysis begins immediately after the FGD is conducted All audio recordings are transcribed
verbatim using anonymous participant identification. Data are analyzed in the form of themes by finding
similarities and differences in data, then grouping them into broader, more abstract, and comprehensive
categories of meaning (Lobiondo Food & Haber, 2014).
III. Results and Discussion 3.1 Results
Participant Characteristics
There were 28 participants involved in this study. Participants consisted of ICU room nurses and
nursing management. The age of participants is mostly early adulthood, 19 people. Partispan gender is mostly
female as many as 18 people. Nurse education varies consisting of nurses with D3 nursing as many as 11
people, nursing education as many as 4 people and nurse education as many as 13 people. The most dominant
work experience of participants 1 to 2 years is 9 people. More detailed participant data can be seen in Table 1.
Table 1. Frequency Distribution of Participant Demographic Data (n=28) Characteristics f %
Age
Late teens 8 28.6
Early adulthood 19 67.9 Late adulthood 1 3.6
Amount 28 100,0
Gender Male 9 32.1
Girl 18 64.3
Amount 28 100,0
Last education D3 Nursing 11 39.3
Bachelor of Nursing 4 14.3
Ners 13 46.4 Amount 28 100,0
Work experience
1 to 3 months 1 3.6 4 to 12 months 2 7.1
1 to 2 years 9 32.1
2 to 3 years 7 25 3 to 4 years 4 14.3
4 to 5 years 5 17.9
Amount 28 100,0
Job status
Head of the room 1 3.6
Team leader 5 64.3 Managing nurse 18 17.9
Head of nursing 1 3.6
Nursing Committee 1 3.6
Nurse's Perception about Nurse's Independent Actions in Preventing Ventilator Associated ..
DOI: 10.9790/1959-0901041923 www.iosrjournals.org 21 | Page
IPCN 1 3.6 CI 1 3.6
Amount 28 100,0
Theme 1: Nurse knowledge about VAP in general is still lacking
The nurse's knowledge in implementing VAP prevention measures that still lacks consists of A) nurses'
knowledge about the VAP concept which is lacking where 1) general concept of VAP's knowledge is still
lacking, 2) new nurse's knowledge which is still minimal about VAP. B) nurses' knowledge about VAP
prevention independent measures where 1) new nurses do not understand the actions taken in VAP prevention.
Nurses' knowledge of VAP prevention in general is still lacking expressed by some participants such as the
following expression:
'... VAP may be caused by bacteria when we treat patients with ventilators. (Participant 10)
‘’ ...... don't really understand about the concept of VAP, because indeed this has to be studied intensively and
requires resource persons to teach it ... (Participant 4)
.... ’.... because you don't really understand the rationale, such as the position of the head, the administration of
medicine, and what else is forgotten ...‘ ’(Participant 3)
Theme 2: There are obstacles to the implementation of the nurse's independent actions in VAP prevention
Obstacles to the implementation of independent nurse actions in VAP prevention consist of A) unclear VAP
precautionary information for nurses, where 1) limited junior nurse knowledge, 2) limited educational
information flow in VAP prevention, 3) VAP prevention action information for junior nurses limited. B) the
tools used for VAP prevention have not been maximized, where 1) the tools not available in VAP prevention, 2)
the lack of training in the use of tools used for VAP prevention, 3) the nurses' skills that are still lacking in the
use of tools. C) the structure and process of the nurse's independent action in preventing VAP is not optimal,
where 1) the workload is still high, 2) the absence of guidelines for independent action taken, 3) the limited
SPO of the independent action taken, 4) the nurse's compliance is still lacking in VAP prevention, 5) nurse
skills are still lacking in VAP prevention measures.
Nurses' knowledge of VAP prevention in general is still lacking expressed by some participants such as the
following expression:
'... VAP may be caused by bacteria when we treat patients with ventilators. (Participant 10)
‘’ ...... don't really understand about the concept of VAP, because indeed this has to be studied intensively and
requires resource persons to teach it ... (Participant 4)
.... ’.... because you don't really understand the rationale, such as the position of the head, the administration of
medicine, and what else is forgotten ...‘ ’(Participant 3)
Theme 3: The nurses' lack of experience in taking independent measures of VAP prevention
The experience of nurses in conducting independent VAP prevention measures consists of: A) the experience of
junior nurses is lacking, where 1) junior nurses who only have experience of senior actions, 2) the experience of
actions taken is not in accordance with knowledge. B) nurses' experience in using VAP prevention tools is not
yet maximal, where 1) the tools used are rarely replaced, 2) the use of tools that are not in accordance with
knowledge.
The lack of experience of nurses in taking independent measures of VAP prevention can be seen from the
following expressions:
‘’ ... yes, take care as usual, but don't know yet what action can be taken to prevent VAP, just limited to
knowledge ... ‘’ (Participant 3)
‘’. if the rheuse should be changed every 6 months' (Participant 5)
‘’ .... is only limited to maintenance, considering that it requires complex care including VAP prevention ... ‘’
(Participant 14)
Theme 4: The importance of a nurse's independent action protocol in VAP prevention.
The importance of a nurse's independent action protocol in VAP prevention consists of A) Nurse's independent
action in VAP prevention is more maximal, where 1) Nurses are more directed in taking VAP prevention
independent action, 2) Senior nurses are more confident in teaching junior nurses in VAP prevention, 3)
Improving nursing care, 4) Maximizing nurse work, 5) All actions can be accounted for, 6) Junior nurses are
more focused with the guidance in preventing VAP, 7) Junior nurses more easily take action. B) improving the
quality of hospital services, where 1) increasing Hospital promotion, 2) Reducing mortality, 3) Reducing
hospital costs, 4) Patients not affected by nosocimial infections, 5) Families and patients happy, 6) Using
ventilators to shorter.
The importance of establishing a nurse's independent action protocol in VAP prevention can be seen from the
following expression:
Nurse's Perception about Nurse's Independent Actions in Preventing Ventilator Associated ..
DOI: 10.9790/1959-0901041923 www.iosrjournals.org 22 | Page
‘’ …… These nurses need guidelines that really aim to prevent pneumonia like that ... ’’ (Participant 6)
‘’ .... important and important, especially for this new child right, we just learned a lot, now while we don't have
a guide, we only participate in with the seniors, it still floats ... ‘’ (Participant 11)
‘’ ..... there are protocols that are sure to be easier and more directed, new and senior are easy to teach ...
(Participant 7)
Theme 5: Nurse independent actions required for VAP Prevention
Nurse's self-action needed in VAP Prevention consists of A) Nurse taking care in VAP Prevention through
respiratory care, where 1) Nurse's independent action in monitoring the Cuff used by the patient, 2) Independent
action in weaning, 3) Nurse's self-action in performing oral care . B) Independent measures of VAP prevention
through the process of intubation, where nurses independently act in intubating. C) Independent measures of
prevention through patient nutrition, where the nurse's independent actions in feeding through NGT. D) The act
of taking precautions through the equipment used by the patient attached to the ventilator, where 1) The nurse's
independent actions in the storage of tools, 2) The nurse's independent actions in controlling the devices that are
already installed, 3) The nurse's independent actions in the use of tools and materials during the treatment
process.
The nurse's independent actions required in VAP Prevention can be seen from the following expressions:
‘’ .... a guide to cuff pressure as well but there is no courage yet, because it is risky to re-intubate ... ’’
(Participant 5)
'.... how is the respiratory care for the nurse so that the patient is safe from pneumonia ...' '(Participant 2)
... ’... when the patient has a ventilator attached, what is done as a guide to nursing action so that the patient
does not VAP ...’ ’(Participant 3)
Theme 6: Implementation strategies needed in developing a nurse's independent action protocol for VAP
prevention
The implementation strategy needed in developing the nurse's independent action protocol in VAP prevention
consists of A) preparation for making protocols, where 1) Conduct a seminar related to VAP prevention, 2)
Conduct training on the use of tools. B) the material for the nurse's independent action protocol is needed,
wherein 1). Making the clinical signs form VAP, 2) Making guidelines for independent action by nurses, 3)
Making a clear flow. C) Preparation of HR, where 1) Adequacy of HR in conducting care, 2) Improvement of
nurses' knowledge, 3) Preparation of increasing skills performed by nurses in the prevention of VAP. C)
preparation of tools and materials used, where 1) Provision of tools used for VAP prevention, 2) Training of
tools used by patients during treatment in VAP prevention.
The implementation strategy needed in developing the nurse's independent action protocol in VAP prevention
can be seen from the following expression:
‘’ .... our knowledge is prepared so that we understand more about prevention, just like if we could trainings,
seminars and other things ... ’’ (Participant 2)
..... ’..... the support from the director and also the addition of knowledge should not only be seniors, but also
juniors made a clear guide ...’ ’(Participant 5)
‘’ ...... tools and materials that must be met ... ’’ (Participant 3)
3.2 Discussion
The results of the study stated that nurses 'knowledge of VAP in general was lacking which consisted
of low knowledge in the concept of VAP, new / junior nurses' knowledge and independent measures of VAP
prevention were still minimal, new nurses who did not understand the actions taken in preventing VAP. This is
in line with research conducted in Spain also mentions nurses' knowledge of VAP prevention is still lacking
(Perez, 2013).
Research conducted in Spain in 2013 showed that nurses' knowledge was still low, with 64% of nurses
knowing that washing their hands before performing suctioning and manipulating ventilator circuits and 18.5%
of nurses knowing that Cuff Endo Trcheal Tube (ETT) pressure must be maintained and 3.7% of nurses know
physiotherapy chest can reduce the risk of VAP as well as oral care to prevent VAP (Perez, 2013).
One factor in this lack of knowledge is the large number of junior nurses with minimal experience.
New / junior nurses must get guidance to improve skills (Ivey, 2012). Nurses' knowledge in VAP prevention is
influenced by the level of education, experience of nurses and training (Korhan, 2013). However, other opinions
Nurse's Perception about Nurse's Independent Actions in Preventing Ventilator Associated ..
DOI: 10.9790/1959-0901041923 www.iosrjournals.org 23 | Page
mention the knowledge of nurses in the prevention of VAP is not absolutely caused by factors of education,
tenure and training (Rifai, 2016).
Knowledge in implementing VAP prevention will be a barrier to compliance in VAP prevention so
efforts should be made to increase knowledge (El Khatib, 2010). VAP prevention training for nurses can
increase knowledge and sensitivity in terms of VAP prevention (Ali, 2013).
The provision of quality care provided to patients is very influential in terms of improving the quality
of service. This shows the need to provide education and training so as to increase knowledge and compliance
in implementing VAP prevention. Shahnavaz's research (2009) shows training and education influence work
creativity to improve work quality.
Retrieval of data by FGD process has the advantage that the data generated can be large and it is very
good for this research. In addition, researchers also took other data sources, namely by measuring the level of
knowledge of nurses and the level of compliance of nurses in implementing VAP prevention measures.
According to Sullivan (2013) the source of the data obtained from the FGD collected with other data
will strengthen the data. In this study the results of the Self Report are combined with the FGD result data to
obtain richer data.
During conducting research at this stage, the strengths and weaknesses experienced by researchers
were obtained. Where the advantages, researchers can interact directly with participants so that the data
obtained is more accurate and can provide mutual sharing of this research. The weakness experienced by
researchers is that there are some participants who have not been able to give their opinions and there are some
participants who cannot attend because of their busy schedule.
IV. Conclusion Based on the analysis results obtained by six themes that reveal nurses 'perceptions about nurses'
independent actions in VAP prevention in the ICU room of Mitra Medika General Hospital, Medan, namely 1)
Nurses 'knowledge about VAPs in general is still lacking, 2) There are obstacles to the implementation of
nurses' independent actions in VAP prevention 3) The lack of experience of nurses in taking independent
measures for VAP prevention, 4) The importance of making protocols for independent measures for nurses in
VAP prevention, 5) The nurse's independent actions for nurses needed in VAP prevention, 6) Implementation
strategies needed in developing independent actions for nurses in VAP prevention.
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Agus Surya Bakti,et.al. "Nurse's Perception about Nurse's Independent Actions in Preventing
Ventilator Associated Pneumonia (VAP)". IOSR Journal of Nursing and Health Science (IOSR-
JNHS), 9(1), 2020, pp. 19-23.
