Abstract
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Background
- Protective lung strategies (PLS) are guidelines about recent clinical advances that deliver an air volume compatible with the patient’s lung capacity and are used to treat acute respiratory distress syndrome. These mechanical ventilation guidelines are not implemented within intensive care units (ICUs) despite strong evidence-based recommendations and a dedicated professional staff. Nurses’ familiarity with clinical guidelines can bridge the gap between actual and recommended practice. However, several barriers undermine this process. The objectives of this study were to identify those barriers and explore the knowledge, attitudes, and behavior of ICU nurses regarding the implementation of PLS.
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Methods
- This was a descriptive, cross-sectional study. The participants were nurses working in the six ICUs of a pediatric tertiary care hospital in Lahore, Pakistan. Using purposive sampling with random selection, the total sample size was 137 nurses. A summative rating scale was used to identify barriers to the implementation of PLS.
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Results
- Overall, the nurses’ barrier score was high, with a mean of 66.77±5.36. Across all the barriers subscales, attitude was a much more significant barrier (35.74±3.57) to PLS than behavior (6.53±1.96), perceived knowledge (17.42±2.54), and organizational barriers (7.08±1.39). Knowledge-related barriers were also significantly high.
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Conclusions
- This study identified important barriers to PLS implementation by nurses, including attitudes and knowledge deficits. Understanding those barriers and planning interventions to address them could help to increase adherence to low tidal volume ventilation and improve patient outcomes. Nurses’ involvement in mechanical ventilation management could help to safely deliver air volumes compatible with recommendations.
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Key Words: acute respiratory distress syndrome; implementation science; intensive care unit; mechanical ventilation; nurses; ventilator-induced lung injury
INTRODUCTION
Mechanical ventilation is a procedure frequently performed in pediatric intensive care units (PICUs); 20%–60% of PICU patients require ventilatory support [1]. However, mechanical ventilation has recently been associated with overdistension of the alveoli and the cyclical opening and closing of alveoli, which causes ventilator-induced injury such as pulmonary edema, diffuse alveolar damage, cytokine release, and increased permeability [2]. Furthermore, in acute respiratory distress syndrome (ARDS), over distension caused by high-volume ventilation can lead to inflammatory mediator release in the lungs and increased permeability due to the underlying disease causing dislocation of mediators, endotoxins, or bacteria in the systemic circulation. In that case, it involves other organs (e.g., the kidneys) and can lead to end-organ dysfunction or multiorgan failure [3]. Therefore, to maintain adequate oxygenation and ventilation while protecting the lungs from injury caused by the ventilator itself, protective lung ventilation procedures were developed. The aim of protective lung strategies (PLS) is to protect the lungs from overdistension, minimize the cyclical opening and closing of alveoli, and prevent biochemical mediators from affecting the lungs and other vital organs [4].
Despite the publication of the PLS guidelines, practice variability in managing pediatric mechanical ventilation has been reported among providers [5-7]. The barriers to the application of low tidal volume (LTV) ventilation most frequently identified among all providers were personal behavioral factors, the system, and the inertia of previous practice [8]. Although work examining providers’ perceptions of barriers is ongoing, a survey reported that clinicians have a positive attitude toward LTV ventilation, easily diagnoses ARDS, and applies PLS; nonetheless, according to patient data, only 19.3% of ARDS patients received LTV ventilation [9].
Persistent inconsistency in clinical practice indicates that a collaborative approach to guideline implementation is needed. Nurses are present bedside 24/7, and they are responsible for patient assessment and documentation, so they might be able to help implement the recommended mechanical ventilation guidelines. However, several barriers hinder them from doing so. A severe lack of knowledge about PLS was reported among nurses in a recent survey [10], primarily because they have been less exposed to the guidelines than doctors and respiratory specialists [11]. Another study reported an increased tendency in the barriers among nurses toward PLS usage [8]. This study sought to identify barriers among nurses to PLS implementation. The objective of this study was to explore nurses' knowledge, attitudes, and behavior regarding PLS and evaluate the perceived and organizational barriers to PLS use among nurses in the ICU.
MATERIALS AND METHODS
Ethical Consideration
Approval from the Ethical Review Committee of Aga Khan University was obtained (No. 2022-7250-21722). A permission letter was also obtained from the administration of the study setting. Written and verbal informed consent was obtained from the patients before data collection.
Study Design
This descriptive, cross-sectional study administered a self-reported questionnaire via researcher interaction with the participants. The questionnaire was adopted from another study [12]. It collected demographic information, PLS knowledge (using four scenario-based questions), and information about attitudes, behavior, and organizational barriers to PLS. The questionnaire was pilot-tested and found to be valid. The study population comprises nurses in the six PICUs of the Children's Hospital and Institute of Child Health, Lahore. A purposive, non-random sampling technique was used to recruit study participants, and written consent was acquired before the questionnaire was administered. Anonymity and confidentiality were maintained by assigning codes and analyzing non-identifiable data.
Sample
The population of interest was nurses in the six PICUs of the Children's Hospital and Institute of Child Health, Lahore (working at least 6-hour shifts). All participants were Pakistan Nursing Council registered nurses with qualifications of a diploma in nursing and midwifery (including specialization), a bachelor of science in nursing, or post-registered nurse (RN). They ranged from novices to experienced nurses, and they all independently handled ventilated patients. Head nurses with administrative roles and nurses in training were excluded. The sampling frame consisted of 210 nurses. A power analysis indicated that based on a 5% margin of error and 95% confidence level, the sample proportion was expected to be 50%. Therefore, a sample size of at least 137 nurses was calculated (Figure 1). The researcher used random assignment to select the subjects; every second participant was selected from a computer-generated list. Approximately 10% more subjects than needed were selected to ensure the ability to detect barriers.
Data Collection
The semi-structured questionnaire collected the following information. The first section assessed the demographic characteristics of the study participants: age, level of education, work experience, type of ICU, number of working hours per week, and training on mechanical ventilation. The second section consists of knowledge items about the LTV ventilation protocol and clinical scenario questions. The answers to these questions were measured as correct or incorrect responses, and they are presented as an additive score ranging from 0–4. The third section measured the nurse's perceptions of barriers using four subscales: attitude (10 items), behavior (3 items), perceived knowledge (5 items), and organizational barriers (3 items). This third section comprises statements of individual belief about patient condition to using PLS, other colleagues' awareness of PLS, and the care required for PLS. The participants responded using a Likert scale on which one indicated a minimal barrier, and six denoted maximum apprehension. The items alternated between positive and negative wording. In the analysis, disagreement with a positively worded item was assigned a higher score, indicating a higher barrier, and the responses to the negatively worded items were reverse coded. In this study, a high score is interpreted to reflect a pessimistic attitude or perceived barrier to the use of PLS.
Outcome Measures
The outcome measures include the assessment of nurses' knowledge, attitudes, and behavior toward PLS; the evaluation of perceived and organizational barriers to the use of PLS in ARDS among ICU nurse; and the analysis of demographic factors associated with the barrier scale and subscales.
Analysis
The analysis was performed using IBM SPSS 28.0.1 (IBM Corp.). Demographic data and knowledge questions were analyzed using frequency distributions and percentages. For each Likert scale item, the frequency distribution, mean, and standard deviation were examined. Using SPSS, negative items were recoded as positive ones while keeping the anchor value of 3 for "neutral." Furthermore, a summative rating scale was used to calculate an overall barrier score from the attitude, behavior, perceived knowledge, and organizational Likert-scale questions. The total responses on the summative rating scale were used to calculate the raw scores for the overall nurse's barrier scale, four subscales, and knowledge score. A robust regression analysis assessed the association or dependence of the overall barrier scale, four subscales, and knowledge score on the following covariates: years of experience, number of hours/week spent working in the ICU, and type of ICU. Variables assessed for interactions and confidence intervals were calculated on the premise of a non-normal distribution. Values <0.05 were considered statistically significant.
RESULTS
Demographic Characteristics of the Study Participants
The questionnaire was provided to 159 participants, and 137 complete responses were received (86% response rate). More than half of the participants were 25–30 years old (n=93, 67.9%). Approximately one-third of the participants had a specialization diploma (n=60, 43.8%) with a basic nursing degree/diploma. However, a sizeable proportion of the participants (n=93, 67.9%) reported that they had received mechanical ventilation training or educational workshops. Most of them (n=97, 70.8%) worked in the ICU for 36–40 hours per week (6 hr/shift), and most of them had less than 5 years of experience (n=83, 60.6%) in the ICU where they currently worked (Table 1).
Knowledge about PLS
The ICU nurses provided generally incorrect answers to the knowledge questions about the LTV ventilation protocol; only 14.6% (n=20) were familiar with the main goal of PLS, which is to keep the plateau pressure at 30 cm H2O.
Attitude, Behavior, Perceived Knowledge, and Organizational Barriers to the Use of LTV
Each item was analyzed as behavioral scale data, with higher scores associated with pessimistic responses.
Attitude
Most participants (81.7%, n=112) agreed with the statement that their patients were usually too sick for LTV ventilation, and 63.5% (n=87) considered their patients to have a contraindication to the use of LTV. However, most of the nurses (81%, n=111) stated that physicians are familiar with LTV ventilation, and 70.7 % (n=97) reported that other nurses were knowledgeable about LTV ventilation (Figure 2A).
Perceived knowledge
Contrary to their actual knowledge scores, most nurses (78.1%, n=107) were confident that they knew the ventilatory settings used to obtain LTV ventilation, and 61.3% (n=84) reported awareness of the survival benefit of LTV ventilation compared with the usual ventilatory strategies (Figure 2D).
Behavior
Contrary to the findings for attitude, most of the nurses (73.7%, n=101) suggested LTV, and 81.1% (n=111) reported discussing airway pressure on rounds for ARDS patients. Most of the nurses (70.8%, n=97) reported that the discussion of tidal volume is always in terms of cubic centimeters ml/kg of anticipated body weight (Figure 2C).
Organizational barriers
More than 50% of the nurses stated that they received sufficient instruction from the ICU on the process for ventilating ARDS patients. Most nurses (68.6%) agreed with the statement that the current RN-to-patient staffing ratio is inadequate to deal with patients using LTV (Figure 2B).
Barriers to the Use of LTV Ventilation
A high degree of overall nurses' perceived barriers was observed, with a mean score of 66.77±5.36 on a predetermined scale of 100, with higher scores indicating more barriers. Across all the subscales, the attitude subscale had the highest score (35.74±3.57), followed by perceived knowledge (17.42±2.54), organizational barriers (7.08±1.39), and behavior (6.53±1.96), in that order (Figure 3A). Based on the computed subscale scores, the nurses had negative responses (high barriers) to using PLS. Similarly, the computed knowledge score revealed that nurses answered more than half of the questions incorrectly. Only about 4% (n=6) of the participants knew about the recommended guidelines, and the mean knowledge score was 0.61 on a scale from 0 to 4. The knowledge scores of individual nurses ranged from 0 to 3 (Figure 3B).
Robust Regression Analysis
The beta coefficients calculated for experience (indicated category of >10 years), time per week spent working in the ICU (indicated category of >40 hours), and the type of the ICU (indicated category of medical ICU) did not indicate significant associations with the overall nurse's barrier scale, barrier subscales, or knowledge score (Supplementary Material 1).
DISCUSSION
Nurses’ adherence to the recommended PLS guidelines is affected by a variety of barriers. Most previous work on this subject focused on clinicians and respiratory therapists. Although those clinicians had a positive attitude and adequate knowledge, they still struggled to implement the guidelines. This study examined the barriers to LTV ventilation administration among ICU nurses and identified significant barriers to the use of PLS in the ICU.
A brief, objective assessment of knowledge revealed that ICU nurses had high knowledge barriers. Overall, the organizational and perceived barriers (i.e., attitude, behavior, perceived knowledge) were also high. The nurses' attitude was the most significant barrier to implementing LTV ventilation. The data here suggest that nurses did not adhere to the practice guidelines due to interruptions in the sequence of behavior change caused by the barriers based on cognitive (knowledge) and affective component (attitude), and restricted nurses’ ability (organizational barriers).
One of the surprising findings was that the participating nurses had taken courses or received mechanical ventilation-specific education or training. The overall findings thus raise concerns about the content of mechanical ventilation training and highlight how frequently the nurses attended the courses. Inadequate knowledge gained through those courses can result in under-compliance with PLS at bedside. Nurses are the basic workforce in an ICU and are responsible for service delivery; their understanding of clinical practice guidelines could thus help to correct this implementation failure. The presence of significant barriers among nurses highlights that very little is known about how nurses adopt guidelines or modify their behavior.
Overall, the nurses' barriers to the use of PLS were high. The available evidence to compare the barriers is the seminal work of Hynes et al. [8], who also found that barriers trended high among nurses. These results have several possible explanations. First, nurses lack the motivation to change their behavior and are more comfortable with the previous practice pattern. Consequently, they develop a habit or routine and continue to deal with patients in the same way. For instance, ICU nurses' primary concern is maintaining the oxygen saturation level by increasing the pressure and fraction of inspiratory oxygen to secure brain vitality, regardless of the tidal volume in ml/kg. However, those routine ventilation strategies can increase the risk of multi-organ dysfunction syndrome. Therefore, nurses need to look at the broader perspective of the patient's prognosis rather than merely dealing with hypoxia.
Second, the nurses might not agree with the guidelines in part or in total. For example, the high PEEP of 15 cm H2O (one of the components of the PLS guideline) might not be acceptable to nurses because they believe the patient could experience discomfort [9]. Nurses encounter situations and patients individually; they might be unable to determine success at the population level. Overlooking the existing literature (recommendations) can lead to non-adherence and negatively affect patient outcomes.
Identifying the barriers affecting nurses could significantly improve guideline compliance. Currently, modified physician and respiratory therapist behavior leads to the initiation of PLS. The 24/7 documentation and clinical competence of nurses could assess any deviation from that standard and help them to act accordingly. None of the recommended predictors showed any association with the barriers and knowledge of nurses. Alternatively, several other factors could be associated with barriers and knowledge deficits among nurses in this study setting. For example, nurses do not participate actively in ventilator management because it is the physician's responsibility. As a result, nurses might not respond or resist following a patient’s condition when ventilating a child with PLS. Therefore, there is likely to be a gap between the guidelines and their use at the clinical site.
The physicians' pre-set goals for tidal volume were not usually written on the patient's medical record. Nurses document the pressure delivered by the ventilator and the tidal volume on the record sheet, but the target tidal volume that should be achieved (associated with the patient’s predicted body weight) was missing. Incorporating the daily goals and target tidal volumes for each patient could be enough to address this issue, and the repeated reporting of tidal volume achievement could enhance nurses’ clinical decision-making and decrease the barriers to PLS. Multidisciplinary rounds and discussions of tidal volume goals among nurses and physicians also need to be considered.
Overall, learning depends on decision-making about a situation. The nursing scope of practice is oriented toward patient care, which decreases the autonomy needed for decision-making. As a result, learning declines and barriers increase. For example, according to nurses, the physician and respiratory therapist are responsible for ventilation control [11]. However, the importance of the nurses' role in caring for ventilated patients cannot be denied. ICUs require prompt action to deliver evidence-based care. Therefore, nurses must be trained to handle ventilated patients so that compliance with evidence-based care can increase. This aspect is important: nurses’ involvement in mechanical ventilation management should be reconsidered.
This work suggests several things, First, nurses work bedside 24/7 directly monitoring patients, putting them in the best position to ensure the implementation of the PLS guidelines. Therefore, efforts should be made to address their barriers, i.e., mechanical ventilation training sessions and simulation-based learning. Second, rather than documenting ventilator settings remotely on a chart, nurses should be involved in making decisions about ventilatory management. Third, ventilation certification should be a part of the nursing education system for ICU nurses, and it should be updated annually, like medication certification or basic life support. This will be a critical concept, and nurses’ perspectives should be explored to determine whether this approach can be used to improve compliance with mechanical ventilation guidelines.
Currently, research and science are conducted in disciplinary cycles that lack interprofessional practice. Excellence in clinical practice can only be achieved by a multidisciplinary approach, which will resolve knowledge gaps.
This study has limitations. The generalizability of the findings is limited because the data were collected from a single site. Although the response rate was high, the responses of respondents might still differ from those non-responders would have given, which could bias the findings. Non-probability (purposive) sampling can also decrease generalizability. The interpretation of the results could be limited because the questionnaire did not define what constitutes LTV ventilation. The knowledge of the mean pressure control mode for tidal volume achievement and a tidal volume of 3–6 ml/kg are similar, the responding nurses might have had different understandings of tidal volume. However, if they had been taught about PLS, they would easily have understood the concept. Nurses' understanding of their responsibility to deliver LTV ventilation (role ambiguity) might also have affected the outcomes of this study.
Nursing staff in the PICU have a knowledge deficit and high barriers to the PLS approach to mechanical ventilation. The 24/7 presence of nurses bedside makes them suitable people to implement the recommended guidelines and assess the delivery of care. PLS is underused when ventilating patients in ICUs, despite its benefits over other ventilation modalities. Unfamiliarity with nurses’ barriers can cause low adherence to LTV administration. Understanding the barriers will help in developing strategies to improve adherence to recommended guidelines. Further research is required to validate these findings and identify ways to correct these nursing-level barriers. If the barriers are addressed, adherence can improve.
KEY MESSAGES
▪ Most work about the use of protective lung strategies (PLS) has focused on clinicians and respiratory therapists.
▪ Although positive attitudes and adequate knowledge were observed, the implementation of PLS guidelines at bedside is still inadequate.
▪ Nurses directly monitor patients and document and chart mechanical ventilation settings. If their barriers to PLS implementation can be identified and corrected, adherence to this evidence-based practice could improve.
▪ Educational workshops for intensive care unit nurses are needed to introduce the recommended guidelines and teach nurses about the benefits of low tidal ventilation.
▪ Further research with an interprofessional approach is needed to correct this implementation failure.
NOTES
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CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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FUNDING
None.
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ACKNOWLEDGMENTS
We are grateful to Mr. Iqbal Azam (Assistant Professor Community Health Sciences, Aga Khan University Hospital) for guidance in the application of statistical analysis and immense support in the thesis journey. We would also like to thank all the ICU staff nurses for their support.
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AUTHOR CONTRIBUTIONS
Conceptualization: TZ, SR. Methodology: TZ, NA, HM. Formal analysis: TZ, HM. Investigation: TZ. Resources: TZ. Data curation: TZ. Visualization: TZ. Supervision: SR. Writing - original draft: TZ. Writing - review & editing: all authors. All authors read and agreed to the published version of the manuscript.
SUPPLEMENTARY MATERIALS
Supplementary materials can be found via https://doi.org/10.4266/acc.004761.
Figure 1.Sampling recruitment strategy. Flow diagram of nurses considered for inclusion in the study. CH&ICH: Children's Hospital & Institute of Child Health; ICU: intensive care unit.
Figure 2.Results for response options. (A) Attitude toward protective lung strategies (PLS) use among nurses. The right side of the midpoint for each Likert scale question shows the percentage of nurses with a positive response, and the left side represents a negative response. Red arrows indicate response options reverse-coded for further analysis. A red cross indicates inaccurate perceptions of nurses about PLS (mostly positive to questions that are negative in the composite measure). (B) Organizational barriers. (C) Behavior barriers. (D) Perceived knowledge barriers.
Figure 3.Barrier scale and knowledge of nurses about protective lung strategies (PLS) use. (A) Boxplot illustrates the median, with whiskers representing the data spread with adjacent upper and lower values. The cross indicates the mean of a given score. The possible scores range from 0–100, with higher scores on all scales and subscales indicating a greater barrier to the nurses’ implementation of low tidal ventilation. (B) Each bar represents a knowledge score, with possible scores ranging from 0–4, and higher scores indicating more accurate knowledge. The red circle indicates that most nurses scored “0.” Only 4% scored “3.”
Table 1.Demographic variables of study participants (n=137)
|
Demographic variable |
Number (%) |
|
Age (yr) |
|
|
25–30 |
93 (67.9) |
|
31–35 |
31 (22.6) |
|
>35 |
13 (9.5) |
|
Qualification |
|
|
Diploma nursing |
34 (24.8) |
|
BSc/post RN |
43 (31.4) |
|
Specialization |
60 (43.8) |
|
MV training |
|
|
Yes |
93 (67.9) |
|
No |
44 (32.1) |
|
Type of the ICU |
|
|
MICU |
30 (21.9) |
|
CICU |
10 (7.3) |
|
CSICU |
24 (17.5) |
|
SICU |
27 (19.7) |
|
MNICU |
30 (21.9) |
|
SNICU |
16 (11.7) |
|
ICU hours |
|
|
40 (12 hr/shift) |
40 (29.2) |
|
<40 (6 hr/shift) |
97 (70.8) |
|
Working experience (yr) |
|
|
0–5 |
83 (60.6) |
|
6–10 |
42 (30.7) |
|
11–15 |
12 (8.8) |
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