AJCC
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

American Journal of Critical Care. 2007;16: 371-377
Copyright © 2007 by the American Association of Critical-Care Nurses.
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Respond to This Article
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Labeau, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Labeau, S.

Critical Care Nurses’ Knowledge of Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia: An Evaluation Questionnaire

By S. Labeau, RN, MSc, D.M. Vandijck, RN, MSc, MA, B. Claes, RN, MSc, P. Van Aken, RN, MSc, S.I. Blot, RN, MSc, PhD on behalf of the executive board of the Flemish Society for Critical Care Nurses. S. Labeau is a PhD student in the Faculty of Healthcare, Ghent University College, Ghent, Belgium. D.M. Vandijck is a PhD student in the Intensive Care Department, Ghent University Hospital, and the Faculty of Medicine and Health Sciences, Ghent University. B. Claes is head of the ICU Nursing Department and P. Van Aken is director of the Nursing Department, University Hospital of Antwerp, Antwerp, Belgium. S.I. Blot is a researcher at Ghent University Hospital and a professor in the Faculty of Medicine and Health Sciences of Ghent University and at Ghent University College, Ghent, Belgium.

Corresponding author: Stijn Blot, PhD, Ghent University Hospital, Intensive Care Dept, De Pintelaan 185, 9000 Ghent, Belgium (e-mail: stijn.blot{at}UGent.be).


   Abstract
Top
 Abstract
Methods
 Results
 Discussion and Limitations
 Conclusion
 References
 
Background Nurses’ lack of knowledge may be a barrier to adherence to evidence-based guidelines for preventing ventilator-associated pneumonia.

Objective To develop a reliable and valid questionnaire for evaluating critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia.

Methods Ten nursing-related interventions were identified from a review of evidence-based guidelines for preventing ventilator-associated pneumonia. Selected interventions and multiple-choice questions (1 question per intervention) were subjected to face and content validation. Item difficulty, item discrimination, and the quality of the response alternatives or options for answers (possible responses) were evaluated on the test results of 638 critical care nurses.

Results Face and content validity were achieved for 9 items. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.10 to 0.65. The quality of the response alternatives led to the detection of widespread misconceptions among critical care nurses.

Conclusion The questionnaire is reliable and has face and content validity. Results of surveys with this questionnaire can be used to focus educational programs on preventing ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is defined as pneumonia that develops more than 48 to 72 hours after initiation of mechanical ventilation.1–4 With an incidence of 8% to 68%,5,6 VAP is the most common hospital-acquired infection among patients who require ventilatory support.6–8 Moreover, VAP is associated with high morbidity and mortality rates, increased duration of ventilatory support and hospitalization, and increased use of healthcare resources.9–13 Prevention of VAP focuses on avoiding microaspiration of subglottic secretions, preventing oropharyngeal colonization with exogenous pathogens, and preventing contamination of ventilator equipment.5,14,15 Evidence-based guidelines for the prevention of VAP have been developed4,14,16 and have been promoted by programs and campaigns of authoritative organizations.17,18 Nevertheless, nonadherence to these guidelines has been reported.5,19–21 Also, the results of assessments22–25 of nurses’ knowledge of evidence-based practice in general have been disappointing.

Recently, lack of knowledge was indicated as a barrier for adherence to evidence-based practice.23 Although knowledge does not ensure adherence, misconceptions about effective prevention strategies can be important in decision making. The reductions in the rates of hospital-acquired infection26,27 that occurred after educational programs on strategies to prevent infection provide indirect evidence for the value of knowledge.

Our objective was to develop a reliable and valid questionnaire to determine critical care nurses’ knowledge of evidence-based guidelines for preventing VAP.


   Methods
Top
 Abstract
 Methods
Results
 Discussion and Limitations
 Conclusion
 References
 
Selection of Interventions and Design of the Questionnaire
The selection of interventions or strategies to prevent VAP was based on a recently published review14 of evidence-based guidelines. In a search for relevant randomized, controlled trials and systematic reviews that involved adults who were treated with mechanical ventilation and that were published before April 2003, Dodek et al14 looked for physical, body positioning, and pharmacological interventions that might influence the development of VAP. Independently and in duplicate, these authors scored the validity of trials; the effect size and confidence intervals; the homogeneity of results; and safety, feasibility, and economic issues. On the basis of this review,14 a total of 10 interventions or strategies with relevance for nursing practice were selected:

  1. Use of oral endotracheal tubes
  2. Frequency of ventilator circuit changes
  3. Use of a heat and moisture exchanger
  4. Frequency of humidifier changes
  5. Use of a closed suction system
  6. Frequency of change in suction system
  7. Drainage of subglottic secretions
  8. Use of kinetic beds
  9. Use of semirecumbent positioning
  10. Chest physiotherapy

A multiple-choice question with 4 response alternatives or options (the correct answer/response and 3 distractors or alternatives that are not the answer) was developed for each item on the list28 (Table 1Go). For each test item, the response alternatives included the phrase "I do not know" to avoid gambling by the respondents and 2 interventions with investigated preventive value. In their evidence-based clinical practice guideline for the prevention of VAP, Dodek et al14 advise consideration of 2 interventions, drainage of subglottic secretions and use of kinetic beds, but make no specific recommendations for their use because of cost concerns. Therefore, questions on these 2 interventions were designed to assess knowledge about the impact of the interventions on the risk for VAP. For 2 other interventions, closed suction system and frequency of ventilator circuit changes, the recommendations of Dodek et al are based on economic considerations.


View this table:
[in this window]
[in a new window]

  		Table 1 Questionnairea

 
Expert Validation
The selected preventive interventions and questionnaire were presented to a panel of 8 experts for face and content validation.29 Each expert had at least 3 years of experience in an intensive care unit (ICU), a master’s degree in nursing sciences (or medicosocial sciences), and a particular interest in ICU-acquired infections.

To achieve face validity, the experts were asked if all questions were clearly worded and would not be misinterpreted. For content validity, the experts evaluated the nursing relevance of the 10 selected interventions by using a scale of 1 to 3, where 1 = not relevant, 2 = relevant but not necessary, and 3 = absolutely necessary. Additionally, the experts were asked if questions about any other preventive interventions should be added to the questionnaire.

The remarks of the panel were collected and discussed and were used to revise the questionnaire. After the revision, the experts examined the questionnaire again; they unanimously declared agreement with its content and clarity.

Assessment of the Questionnaire
Revising tests on the basis of test scores is an essential part of improving instruction.28 Therefore, the items on the questionnaire were analyzed to determine their level of difficulty and discrimination, and the quality of the 4 response alternatives or options for each question was evaluated.28,30,31

  Difficulty Level.   The difficulty level of an item or question is defined as the proportion of respondents who answer the question correctly.28,30,31 Possible values range from 0.0 to 1.0. Items that are answered correctly by more than 90% of the respondents (value >0.9) are considered too easy; items answered correctly by less than 10% of the respondents (value <0.1) are considered too difficult.

  Item Discrimination.   A discrimination index indicates the extent to which items on the questionnaire discriminate between high scorers and low scorers. The following formula was used to divide respondents into high scorers and low scorers, with 27% of respondents in each group: (number of correct answers in the high-scorer group – number of correct answers in the low-scorer group)/total number of correct answers in both groups. Values of 0.35 and higher are (very) good, values from 0.25 to 0.35 are satisfying/good, values 0.15 to 0.25 are mediocre/satisfying, and values less than 0.15 are bad/mediocre.

  Quality of the Response Alternatives.   The quality of a response alternative is defined by calculating the proportion of respondents who choose the alternative. Values range from 0.0 to 1.0. Response alternatives with a value of 0.0 are not attractive, and those with a value of 1.0 might be too attractive.


Nurses’ lack of knowledge may be a barrier to adherence to evidence-based guidelines for preventing ventilator-associated pneumonia.

 

Population Surveyed
The questionnaire was distributed and collected during the annual congress of the Flemish Society of Critical Care Nurses (Ghent, Belgium, November 25, 2005). Of the 855 registered participants, 638 completed the questionnaire (response rate 74.6%). The responses were collected anonymously. The questionnaire also included questions on general characteristics of the respondents: sex, years of ICU experience, number of ICU beds in the hospital where the respondent worked, and whether the respondent had a special degree in emergency and intensive care.


   Results
Top
 Abstract
 Methods
 Results
Discussion and Limitations
 Conclusion
 References
 
Expert Validation
The experts reported that some items needed to be slightly reworded to be clear. According to the experts, question 10 (on chest physiotherapy) was irrelevant for nurses. Therefore, this question was omitted; the final questionnaire consisted of 9 items on interventions to prevent VAP.


Nurses may be convinced that an intervention without evidence-based preventive value is preferred over the evidence-based intervention.

 

Item Analysis
Overall values for item difficulty and discrimination were very good to satisfying (Table 1Go). For question 9 (patient positioning), however, the values were borderline, indicating that respondents had a good knowledge of this intervention. Nevertheless, question 9 was kept in the questionnaire because of the enormous impact of patient positioning on the prevention of VAP and the major relevance of this question for ICU nurses. Also, because the questionnaire is a criterion-referenced test, an item that is valuable for the content does not necessarily have to be excluded because the item is too easy.32

In the analysis of the quality of the response alternatives, some had values of 0.0, suggesting that reformulation should be considered. Nevertheless, this finding also may indicate that inclusion of the standard response alternative "I do not know" restrained respondents from gambling. In addition, because the response alternatives were restricted to interventions with an investigated preventive value, our formulation possibilities were limited. Of note, the score for the question 9 (patient positioning) option "Supine positioning is recommended" was 0.0, although this intervention is often used in daily practice. This finding illustrates a discrepancy between knowing what is prescribed and what is actually implemented in daily practice. Therefore, despite its low score, this option was not changed for the final version of the questionnaire.

The quality of the response alternatives also indicated the extent of existing misconceptions about the preventive value of certain interventions. The responses to the final questionnaire indicated that nurses thought that both the oral and nasal routes for intubation were recommended (value 0.6); however, the oral route (value 0.2) is recommended in the guidelines. Respondents also thought that a change in humidifiers every 48 hours (or when clinically indicated) was recommended (value 0.6), whereas guidelines recommend weekly changes (or when clinically indicated; value 0.1). The respondents thought that both open and closed suction systems were recommended (value 0.7), but only closed suction systems (value 0.2) are recommended in the guidelines. For frequency of change of suction systems, nurses thought that daily changes (or when clinically indicated) were recommended (value 0.5), whereas the guidelines recommend changes for every new patient who needs mechanical ventilation (or when clinically indicated; value 0.2).

For all 4 of these items, respondents are convinced that an intervention without evidence-based preventive value is preferred over the evidence-based intervention. Mapping out this kind of widely spread misconception is important for better focusing education of critical care nurses.

Characteristics of the Sample
Most of the 638 respondents were women (n = 472, 74%; Table 2Go). A total of 274 respondents (43%) had more than 10 years of ICU experience, and 274 worked in units with more than 15 beds. Most respondents (n = 437, 68%) had a special degree in intensive care and emergency nursing.


View this table:
[in this window]
[in a new window]

  		Table 2 General characteristics of the population surveyed (n = 638)

 

   Discussion and Limitations
Top
 Abstract
 Methods
 Results
 Discussion and Limitations
Conclusion
 References
 
We developed a reliable questionnaire for evaluating critical care nurses’ knowledge of evidence-based guidelines for preventing VAP. Face and content validity were achieved. As a result of experts’ validation, the original 10-item questionnaire was adapted and reduced to 9 items.

In the United States, some of the interventions mentioned in the questionnaire, such as frequency of ventilator circuit changes and frequency of humidifier changes, are implemented by respiratory care practitioners. In Belgium, where this study was conducted, and in the rest of Europe, these 2 interventions are implemented by critical care nurses. We are convinced that all the interventions mentioned in the questionnaire are relevant for critical care nurses, because nurses have a major role in monitoring patients’ care to determine if best practices are followed. Additional interventions or strategies that are directly under the control of nurses in both the United States and Europe, such as chlorhexidine mouth rinse, were not included in our questionnaire because the questions address only evidence-based interventions from the review by Dodek et al.14


In the United States, respiratory care practitioners manage ventilator circuit and humidifier changes; in Belgium and elsewhere in Europe, critical care nurses manage these strategies.

 

Item analysis of the questionnaire was based on the responses of 638 nurses who attended the annual congress of the Flemish Society of Critical Care Nurses. This convenience sampling may have led to selection bias and may have created a barrier to extrapolating our results. Nevertheless, our sample represents 21% of all Flemish critical care nurses. Moreover, this bias should be limited because the federal government in Belgium requires all critical care nurses who have a special degree in intensive care and emergency nursing to attend at least 16 hours a year of continuing education to maintain the degree.

Finally, guidelines can changes over time. Adaptation and reevaluation of the questionnaire will be needed each time new evidence-based interventions for preventing VAP are discovered.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion and Limitations
 Conclusion
References
 
A reliable questionnaire was developed to assess critical care nurses’ knowledge of evidence-based interventions for preventing VAP. Face and content validity were achieved. The results of surveys with this questionnaire can be used to focus educational programs on VAP. The questionnaire also can be used before and after educational programs to assess the effect of the programs on nurses’ knowledge of interventions to prevent VAP.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

FINANCIAL DISCLOSURES
None reported.

eLetters
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ajcconline.org and click "Respond to This Article" in either the full-text or .pdf view of the article.

SEE ALSO
To learn more about preventing ventilator-associated pneumonia, visit www.aacn.org and read the AACN Practice Alert titled "Ventilator-Associated Pneumonia (VAP)" (issued February 2004).


   REFERENCES
Top
 Abstract
 Methods
 Results
 Discussion and Limitations
 Conclusion
 References
 

  1. Flanders SA, Collard HR, Saint S. Nosocomial pneumonia: state of the science. Am J Infect Control. 2006;34:84–93.[Medline]
  2. Chastre J. Conference summary: ventilator-associated pneumonia. Respir Care. 2005;50(7):975–983.[Medline]
  3. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med. 2004;32(6):1396–1405.[Medline]
  4. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.[Free Full Text]
  5. Heyland DK, Cook DJ, Dodek PM. Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units. J Crit Care. 2002;17(3):161–167.[Medline]
  6. Salahuddin N, Zafar A, Sukhyani L, et al. Reducing ventilator-associated pneumonia rates through a staff education programme. J Hosp Infect. 2004;57(3):223–227.[Medline]
  7. Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30(11):2407–2412.[Medline]
  8. Depuydt PO, Myny D, Blot SI. Nosocomial pneumonia: aetiology, diagnosis and treatment. Curr Opin Pulm Med. 2006;12:192–197.[Medline]
  9. Heyland DK, Cook DJ, Griffith L, Keenan S, Brun-Buisson C. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Respir Crit Care Med. 1999;159(4 pt 1):1249–1256.[Abstract/Free Full Text]
  10. Myny D, Depuydt P, Colardyn F, Blot S. Ventilator-associated pneumonia in a tertiary care ICU: analysis of risk factors for acquisition and mortality. Acta Clin Belg. 2005;60(3):114–121.[Medline]
  11. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115–2121.[Medline]
  12. Rello J, Rue M, Jubert P, et al. Survival in patients with nosocomial pneumonia: impact of the severity of illness and the etiologic agent. Crit Care Med. 1997;25(11): 1862–1867.[Medline]
  13. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med. 2005;33:2184–2193.[Medline]
  14. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141(4):305–313.[Abstract/Free Full Text]
  15. Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Respir Care. 2005;50:725–741.[Medline]
  16. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1–36. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm. Accessed April 12, 2007.[Medline]
  17. McKay CA, Speers M. Watch for AACN practice alerts: new communication to advise on clinical practice standards. AACN News. 2004;21(2). http://www.aacn.org/AACN/aacnnews.nsf/GetArticle/ArticleThree212. Accessed April 12, 2007.
  18. Institute for Healthcare Improvement. 100 000 Lives Campaign: prevention of ventilator-associated pneumonia. http://www.ihi.org/NR/rdonlyres/35B687FE-D4D0-44E5-A671-E76D74BB8D9F/0/cap.pdf. Accessed November 29, 2006.
  19. Rello J, Lorente C, Bodi M, Diaz E, Ricart M, Kollef MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest. 2002;122:656–661.[Medline]
  20. Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med. 2003; 1:2693–2696.
  21. Sierra R, Benitez E, Leon C, Rello J. Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in southern Spanish ICUs. Chest. 2005;128: 1667–1673.[Medline]
  22. Mott B, Nolan J, Zarb N, et al. Clinical nurses’ knowledge of evidence-based practice: constructing a framework to evaluate a multifaceted intervention for implementing EBP. Contemp Nurse. 2005;19(1–2):96–104.[Medline]
  23. Pravikoff DS, Tanner AB, Pierce ST. Readiness of US nurses for evidence-based practice: many don’t understand or value research and have had little or no training to help them find evidence on which to base their practice. Am J Nurs. 2005;105(9):40–52.[Medline]
  24. Thompson C, McCaughan D, Cullum N, Sheldon TA, Mulhall A, Thompson DR. The accessibility of research-based knowledge for nurses in United Kingdom acute care settings. J Adv Nurs. 2001;36(1):11–22.[Medline]
  25. Biancofiore G, Barsotti E, Catalani V, et al. Nurses’ knowledge and application of evidence-based guidelines for preventing ventilator-associated pneumonia. Minerva Anestesiol. 2006;72:1–10.[Medline]
  26. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014–2020.[Medline]
  27. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene [published correction appears in Lancet. 2000;356(9248):2196]. Infection Control Programme. Lancet. 2000;356(9238):1307–1312.[Medline]
  28. HaladynaTM. Developing and Validating Multiple-Choice Test Items. Hillsdale, NJ: Lawrence Erlbaum Assoc; 1999.
  29. Lynn MR. Determination and quantification of content validity. Nurs Res. 1996;35:382–385.
  30. Thorndike RM, Cunningham GK, Thorndike RL, Hagen EP. Measurement and Evaluation in Psychology and Education. 5th ed. New York, NY: Macmillan Publishing Co; 1991.
  31. Wiersma W, Jurs SG. Educational Measurement and Testing. 5th ed. Boston, MA: Allyn & Bacon; 1990.
  32. Wiberg M. Classical test theory vs item response theory: an evaluation of the theory test in the Swedish driving license test. EM No. 50. 2004. Umeå University Department of Educational Measurement Web site. http://www.umu.se/edmeas/publikationer/pdf/EM%20no%2050.pdf. Accessed April 12, 2007.



This article has been cited by other articles:


Home page
 Am J Crit CareHome page
A. Dawes and M. Perrecone
Article Spreads the Word About VAP Prevention
Am. J. Crit. Care., November 1, 2007; 16(6): 532 - 533.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Respond to This Article
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Labeau, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Labeau, S.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS