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Major Article

Does educating nurses with ventilator-associated pneumonia prevention guidelines improve their compliance?

Sami M. Aloush * Adult Health Nursing Department, Faculty of Nursing, Al albayt University, Mafraq, Jordan

Key Words: Nosocomial infection Mechanical ventilator Evidence based guidelines

Background: This study aimed to compare the compliance with ventilator-associated pneumonia (VAP)- prevention guidelines between nurses who underwent an intensive educational program and those who did not, and to investigate other factors that influence nurses’ compliance. Method: A 2-group posttest design was used to examine the effect of the VAP-prevention guidelines ed- ucation on nurses’ compliance. Participants were randomly assigned to experimental and control groups. Results: The overall nurses’ compliance scores were moderate. There was no statistically significant dif- ference in compliance between the nurses who received VAP education and those who did not (t[100] = –1.43; P = .15). The number of beds in the unit and the nurse–patient ratio were found to influence nurses’ compliance. Conclusion: Education in VAP-prevention guidelines will not improve nurses’ compliance unless other confounding factors, such as their workload, are controlled. It is imperative to reduce nurses’ workload to improve their compliance and enhance the effectiveness of education.

© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Mechanical ventilators are widely used as a respiratory assis- tance device. Although a significant proportion of critically ill patients need mechanical ventilators as a life-saving measure, their use is associated with a variety of complications. These include in- creased cost of care,1 increased consumption of resources, comorbidity,2 and nosocomial infection.3

Ventilator-associated pneumonia (VAP) is considered among the most common nosocomial infections. It is an infection of the lung that occurs 48 hours after insertion of an endotracheal tube,4 and studies have reported that 27% of intubated patients develop VAP during hospitalization.5 VAP results in a significant increase in the cost of care,6 prolonged hospitalization,5 an extended number of days in need of the mechanical ventilator,7 and a significant increase in the rate of mortality.8

The prevalence of VAP varies across the world. In the United States, the incidence is as low as 3-5 cases per 1,000 ventilator-days,5

but this increases to 41 cases per 1,000 ventilator-days in Tunisia.9

The cost of care for each episode of VAP is $40,000.7 In the Middle

East, mechanically ventilated patients have twice the risk of developing VAP as in the Western world,10 and overall VAP results in significantly higher mortality in developing countries in com- parison with the rest of the world. For example, the VAP mortality rate in India was found to be 37%,11 compared with only 4.6% in the United States.5 VAP is a preventable disease; however, transla- tion of the findings from these studies in developing countries is challenging for several reasons,12 including lack of resources, shortage of staff, and lack of compliance with infection-control standards.3,13

In Jordan, very few studies have investigated VAP, although a study by Khuri-Bulos et al14 revealed a rate of 29 cases per 1,000 ventilator-days, and the rate of mortality related to VAP is 53%.15

Several factors contribute to the high level of VAP, including lack of resources, insufficient compliance with infection-control standards,16 and inadequate knowledge about VAP among health care providers.17

Professional organizations such as the Centers for Disease Control and Prevention and the American Thoracic Society released evidence- based guidelines to prevent VAP and improve mechanical ventilation outcomes. Studies report a significant reduction in the prevalence of VAP when these guidelines are applied correctly.18,19 However, nurses’ implementation of the VAP-prevention guidelines is uncertain,20 contributing to a high level of VAP. The extent to which educating nurses about VAP prevention can achieve a significant

* Address correspondence to Sami Aloush, PhD, MSN, RN, Adult Health Nursing Department, Faculty of Nursing, Al albayt University, PO Box 130040, Mafraq 25113, Jordan.

E-mail address: [email protected]. Conflicts of interest: None to report.

0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2017.04.009

AJIC: American Journal of Infection Control 45 (2017) 969-73

Contents lists available at ScienceDirect

AJIC: American Journal of Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

American Journal of Infection Control

improvement in their compliance and the amount of this improve- ment is still unclear. Thus, the aim of this study is to evaluate nurses’ compliance with VAP-prevention guidelines following an educa- tional program and the factors that influence their compliance.

METHODS

Design

This study was a randomized clinical trial (2-group posttest only design) in which participants were randomly assigned to either an experimental group or a control group. Participants in the control group underwent an intensive VAP education course, whereas the control group participants received nothing. Following the educa- tional program, participants in both groups were observed. A nonparticipatory approach was used in which the observers docu- mented the phenomena under investigation using a structured observation sheet.

Setting

The study was conducted in the intensive care units (ICUs) of 5 hospitals in Jordan. The participating hospitals were selected from different geographic locations and different sectors. One of the ICUs has 5 beds, 2 have 6-10 beds, and 2 have a total bed capacity ≥11. The nurse to patient ratio in these hospitals varies from 1:1 to 1:2. Permission to conduct this study was obtained from the institu- tional review boards of the researcher’s university and the participating hospitals. Informed consent was obtained from all par- ticipants before the study.

Participants

G*power 3.1 software (Heinrich-Heine University of Dussel- dorf, Dusseldorf, Germany) was used to calculate the required sample size. Based on a medium effect size ([d] = 0.6; α = 0.05; power = 0.8 based on 2 groups independent sample t test) the required sample size was estimated at 90. The study recruited a random sample of 120 participants from those nurses who agreed to participate; 60 were assigned to the experimental group and 60 to the control group, using a random-number generator. Participants in the experimen- tal group underwent an intensive course in VAP-prevention guidelines, whereas the control group received nothing. Of partici- pants in the control group, 17 withdrew from the study, whereas only 1 participant dropped out of the experimental group, result- ing in 59 participants in the experimental group and 43 in the control group. The participants who dropped out of the study were of dif- ferent ages, genders, and education levels. According to the continuing education departments in the participating hospitals, no VAP education courses had been given to the participants in any of those hospitals.

Inclusion criteria

All participants were registered nurses working full time in ICUs.

Data collection

The data collectors were knowledgeable ICU registered nurses who were not staff of the participating hospitals and who had at least 3 years of ICU experience. Each was involved in infection control activities at his or her own hospital. They received a short training course on the VAP-prevention guidelines. The course covered the development of VAP, the guidelines, the conduct of observations,

how to maintain consistency of the observations, and documenta- tion. Advertisements about the study were placed in each of the participating hospitals. Nurses were told about the observations but not when they would be observed. Observations were deliber- ately conducted over a 6-month period (June-December 2016) during day and night shifts to minimize the Hawthorne effect.

Educational course

The VAP-prevention guidelines course included 4 sessions of 2 hours per session. The first introduced mechanical ventilator man- agement and VAP, and the remaining sessions covered the most up- to-date guidelines. The guidelines included oral care, handwashing, suction, mechanical ventilator management, patient position, pro- phylactic use of antibiotics, peptic ulcer prophylaxis, and deep venous thrombosis prophylaxis. The sessions took place in classrooms at the researcher’s university. The educational strategies included class- room presentations, class discussion, and videotapes. The participants were provided with hard copies of the presentation’s slides.

Observation sheet

A 9-item structured observation sheet was developed based on VAP-prevention guidelines from the American Thoracic Society,21

the Centers for Disease Control and Prevention,22 and the Institute for Health Care and Improvement.23 The observation sheet had 2 parts: demographic characteristics and the 9 VAP-prevention guide- lines items with 3 options per item: “done correctly and completely” gained 2 marks, “done but not completely or not accurately” only 1 mark, and “not done” gained no marks. During the observations, for each guideline the data collector documented “done com- pletely and accurately” if the nurse correctly applied an intervention consistent with the updated VAP-prevention guidelines at every op- portunity to do so. If the nurse demonstrated an intervention not based on the guidelines, or missed an opportunity to do perform an intervention, the data collector recorded “done but not com- pletely or incorrectly.” If the nurse failed to apply the guidelines at all in any of the opportunities to do so, “not done” was recorded. The highest score on the observation sheet was 18 and the lowest zero. A panel of 3 experts in infection control and 3 critical-care nurses validated the content of the observation sheet. Items that were found not to be nursing responsibilities were deleted on the recommendation of the panel. A pilot study was conducted to iden- tify obstacles that might be encountered, but no necessary changes were found.

Observations

Participants were required to provide their work schedule each month to facilitate the observations. A data collector attended each ICU/critical care unit in the participating hospitals, asking partici- pants for the demographic data before observing them and completing the observation sheet. Each nurse was observed for an entire shift. After the observation was completed, the nurse was in- formed of the fact. A monthly rotation of observers between the participating hospitals was made to minimize bias. Observations were made during both day and night shifts.

Different methods were used during the observations to evalu- ate the nurses’ compliance with the VAP-prevention guidelines (Table 1).

Statistical analysis

SPSS version 21 (IBM-SPSS Inc, Armonk, NY) was used to analyze the study data. Descriptive statistics were used to evaluate the par-

970 S.M. Aloush / AJIC: American Journal of Infection Control 45 (2017) 969-73

ticipants’ compliance scores. An independent sample t test was used to compare the differences in the compliance scores between the experimental and control groups.

RESULTS

ICU nurses from 5 Jordanian hospitals participated in the study. Their mean age was 31 ± 5.6 years. There was no statistically sig- nificant difference in the baseline characteristics of the experimental group and the control group (Table 2). Of the 120 nurses who began, 17 (28%) dropped out of the control group but only 1 participant dropped from the experimental group. Participants who dropped out were of different ages, years of experience, and genders.

The overall compliance scores for VAP-prevention guidelines were moderate. The mean compliance score for the experimental group was 14.1 ± 4.4 compared with the control group mean of 12.8 ± 3.7. Although the participants in the experimental group scored higher, the difference was not statistically significant (t [100] = –1.43; P = .15).

Factors influencing compliance in the entire group

There was a statistically significant difference in compliance across the number of beds per unit and the nurse to patient ratio groups. Participants working in units with fewer beds and a 1:1 nurse to patient ratio had statistically significant higher compliance scores than those in units with more beds and a 1:2 nurse to patient ratio (Table 3).

DISCUSSION

This study found that the difference in the compliance with VAP- prevention guidelines between nurses in the experimental group and those in the control group was less than expected. These find- ings disagreed with those from previous studies, which revealed a significant improvement in nurses’ compliance following educa- tion and training.24,25 Factors other than the nurses’ level of knowledge influence their compliance with the guidelines; in our study, nurses’ workload appeared to be a major factor. NursesTa

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Table 2 Participants’ baseline characteristics

Variable No. of nurses (%)

(N = 102)

Gender Female 28 (27.5) Male 74 (72.5)

Nurse to patient ratio 1:1 58 (57) 1:2 44 (43)

Level of education 3-y diploma 12 (12) Bachelor’s degree 85 (83) Master’s degree 5 (5)

Position Staff nurse 78 (76) In-charge nurse 21 (21) Head nurse 3 (3)

Experience, y 1-5 46 (45) 6-10 45 (44) 11-20 11 (11)

Working unit Medical/surgical intensive care unit 64 (63) Coronary care unit 38 (37)

Number of bed in unit 1-5 23 (23) 6-10 56 (55) ≤11 22 (22)

971S.M. Aloush / AJIC: American Journal of Infection Control 45 (2017) 969-73

working in units with lower bed capacity and having to take care of only 1 patient at a time demonstrated higher compliance than those in units with higher bed capacity and having to take care of 2 patients at a time. These findings agree with other studies that have highlighted excessive workload as a major barrier to compli- ance with the VAP-prevention guidelines. Future studies should investigate more factors that may influence nurses’ compliance with the guidelines.

Strengths and limitations

A major strength of the study is that participants were ran- domly assigned to the study groups, minimizing bias. Another strength is the observational technique used to assess compli- ance, which prevented subjectivity of assessment and enhanced reliability. A limitation of the study that prevents generalizability of the findings is that it was conducted only on Jordanian nurses. Future studies should include nurses from different countries. Another possible limitation is that compliance in the study groups was not measured before the educational program. However, we believe that the random assignment of the participants to groups and the absence of any statistically significant differences among them act as baselines to help overcome this barrier. Moreover, the data collectors were not staff of the participating hospitals. This might have influenced the data because the participants saw them as out- siders. Future researchers are recommended to recruit data collectors from both the participating hospitals and other hospitals to enhance the reliability of observations. In addition, the observations could not be covert because the participants were requested to provide some information before the observation. This might have influ- enced the data because it possibly triggered the Hawthorne effect. For future studies, we recommended conducting covert observa- tions using cameras and to videotape nurses during their work. Furthermore, the study was conducted over a 6-month period, which might have increased the dropout rate, especially in the control group. A shorter period of observation might be better. A modifi- cation in the design of future studies might include providing the same educational course at the end of the study for participants in

the control group to reduce the dropout rate. Finally, the rate of VAP/ 1,000 ventilator-days could not be measured in any of the participating hospitals because there were insufficient data. Future researchers are recommended to conduct their observations in hos- pitals that have adequate data.

CONCLUSIONS

This study revealed that the effectiveness of education about VAP- prevention guidelines may be limited by some confounding factors such as nurses’ heavy workload. Policies in clinical settings must be revised to reduce the workloads, especially in critical care set- tings, to improve compliance with VAP-prevention guidelines and to enhance the effectiveness of VAP education.

References

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2. Yap V, Perlman JM. Neurologic complications of mechanical ventilation. Manual of neonatal respiratory care. Springer; 2017. p. 695-9.

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4. Rodrigues ME, Lopes SP, Pereira CR, Azevedo NF, Lourenço A, Henriques M, et al. Polymicrobial ventilator-associated pneumonia: fighting in vitro Candida albicans-Pseudomonas aeruginosa biofilms with antifungal-antibacterial combination therapy. PLoS ONE 2017;12:e0170433.

5. Spalding MC, Cripps MW, Minshall CT. Ventilator-associated pneumonia: new definitions. Crit Care Clin 2017. http://dx.doi.org/10.1016/j.ccc.2016.12.009

6. van Oort PM, Nijsen T, Weda H, Knobel H, Dark P, Felton T, et al. BreathDx– molecular analysis of exhaled breath as a diagnostic test for ventilator–associated pneumonia: protocol for a European multicentre observational study. BMC Pulm Med 2017;17:1.

7. Khan RM, Aljuaid M, Aqeel H, Aboudeif MM, Elatwey S, Shehab R, et al. Introducing the comprehensive unit-based safety program for mechanically ventilated patients in Saudi Arabian intensive care units. Ann Thoracic Med 2017;12:11.

8. Porhomayon J, Pourafkari L. Ventilator associated pneumonia and the role of tapered endotracheal tube with subglottic suctioning. J Crit Care 2017. http://dx.doi.org/10.1016/j.jcrc.2017.01.009

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Table 3 Factors that influence nurses’ compliance scores

Variable

Nurses’ compliance score

Mean ± standard deviation t P value

Gender Male 13.4 ± 4.1 –0.18 .68 Female 13.6 ± 4.2

Nurse to patient ratio 1:1 14.6 ± 3.7 3.2 .00 1:2 12.1 ± 4.3

F

Level of education Diploma 12.9 ± 2.2 0.87 .42 Bachelor’s degree 13.5 ± 4.4 Master’s degree 15.8 ± 3.2

Position in department Staff 13.6 ± 4.3 0.64 .53 In-charge 13.1 ± 3.8 Head nurse 16.0 ± 0.0

Years of experience, y 1-5 12.7 ± 4.2 1.77 .18 6-10 14.2 ± 3.9 11-20 14.4 ± 5.3

Number of beds 1-5 15.5. ± 3.2 4.65 .01 6-10 14.6 ± 4.3 ≤11 12.7 ± 4.1

972 S.M. Aloush / AJIC: American Journal of Infection Control 45 (2017) 969-73

21. ATS. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Resp Care Med 2005;171:388-416.

22. Hughes JM, Cardo DM, Cohen ML. Guidelines for preventing health-care- associated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Respir Care 2004;49:926-39.

23. IHI. How-to Guide: Prevent Ventilator-Associated Pneumonia. Cambridge (MA): Institute for Healthcare Improvement; 2012. Available from: www.ihi.org. Accessed February 1, 2017.

24. Akdogan O, Ersoy Y, Kuzucu C, Gedik E, Togal T, Yetkin F. Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization. Braz J Infect Dis 2017;21:276-81.

25. Kellough J, Perkins K, Sullivan H, Walker C, Rogers C. Ventilator care bundles and their effectiveness in reducing the incident of ventilator- associated pneumonia in intensive care units; 2016. Available from: http:// scholarworks.moreheadstate.edu/scholarship_posters/14. Accessed February 1, 2017.

973S.M. Aloush / AJIC: American Journal of Infection Control 45 (2017) 969-73