Factors Influencing Intensive Care Nurses' Adherence To 'Prevention of Ventilator-Associated Pneumonia' Clinical Practice Guidelines in Saudi Arabia: A Mixed-Methods Study

Abstract

Background: Patients who are critically ill and require mechanical ventilation in hospital intensive care units face a substantial health risk attributed to ventilator-associated pneumonia (VAP). Previous studies have shown that a significant portion of intensive care nurses in Saudi Arabia fail to comply with the VAP prevention guidelines. Within those guidelines, there are a number of strategies that fall within the specific remit of nurses, including oral hygiene, elevation of head of bed, and hand hygiene. There is a scarcity of research studies in the Saudi Arabian context that explore the factors influencing nurses' adherence to VAP prevention guidelines. Aim: The study aimed to gain a deeper understanding of the factors that influence intensive care nurses’ adherence to VAP prevention guidelines in the Saudi Arabian context. Methods: A sequential explanatory mixed methods design was used to assess the problem in a comprehensive manner. The data collection occurred in two phases: initially, a quantitative phase was undertaken, which was subsequently followed by a qualitative phase. The quantitative data collection procedure involved an audit of current practice, using a combination of direct observation and medical record review using a non-participant approach, and a self-administered questionnaire. The data collected in the quantitative phase was analysed using SPSS statistical software (version 24) and the p-value <0.05 was regarded as statistically significant. The findings from the quantitative phase informed the subsequent qualitative phase to delve deeper into and comprehend the factors influencing ICU nurses' adherence to the VAP prevention guidelines. Qualitative data was collected through Zoom interviews and analysed through inductive content analysis approach. Integration of the data from both quantitative and qualitative phases was performed using following a thread and join display techniques to provide a deeper insight into the issue. Finally, the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used for assessing and discussing the integrated data, with an aim to form practical recommendations/solutions to the issue. Results: A total of 62 visits were carried out across 8 intensive care units in two hospitals to audit three recommendations from the VAP prevention guidelines. The highest observed adherence score was for hand hygiene (76.1%), followed by oral hygiene (74.1%) and elevation of head of bed (55.9%). Survey data from 316 nurses were collected in the quantitative phase. Only 56.3% of the participants had an education level of a degree or above. Over 80% of the participants reported that they complied with the VAP prevention guidelines. However, there was a significant deviation from the nurses’ self-reported adherence and observed adherence to the VAP prevention guidelines (Chi–square p values 0.005, < 0.001 and < 0.001 respectively, for the oral hygiene, elevation of head of bed and hand hygiene guidelines). Further, on subdimension scale regression analysis, it was identified that only 53.8% (n=170) had a positive attitude towards the VAP prevention guidelines. Over 70% of the respondents stated that shortage of time, availability of supplies, and/or patient condition hindered their adherence to the hand hygiene, oral hygiene and elevation of head of bed recommendations. The results of the regression analysis revealed that nursing experience significantly influenced self-reported adherence to VAP prevention guidelines. The associations varied: a negative correlation was observed for oral hygiene (OR =0.921, 95% CI: 0.883–0.961, p < 0.001) and head of bed elevation (OR = 0.899, 95% CI: 0.829–0.974, p = 0.011), while a positive correlation was found for hand hygiene (OR = 1.657, 95% CI: 1.357–2.023, p < 0.001). Analysis of the qualitative data supported the findings of the quantitative phase and revealed that both internal and external factors influence the intensive care nurses’ adherence to the VAP prevention guidelines. Integration of the quantitative and qualitative results affirmed the role of influential factors like nurses’ knowledge scores, workload, availability of supplies, nurses experience and patient’s condition. Conclusion: The intensive care nurses’ knowledge levels, excess workload, lack of supplies, lack of adequate experience in the intensive care settings were the main factors influencing the nurses’ adherence to the VAP prevention guidelines. Subsequently, this study provides recommendations informed by the i-PARIHS framework to facilitate the implementation of VAP prevention guidelines in the Saudi Arabian healthcare system. Keywords: Ventilator-associated pneumonia, VAP prevention guidelines, clinical practice guidelines, adherence or compliance or non-adherence or non-compliance, critical care or intensive care, and nurses or nursing staff.