This study aimed at determining knowledge, compliance, and barriers to implementation of EBGs for VAP bundle prevention in Tanzania as a resource-limited setting. The mean knowledge score was 38.6%. This score is below the mean scores ever reported in various studies, ranging from 41.2% among nurses during the annual congress of the Flemish Society for Critical Care Nurses in November 2005[21] to 78.1% in USA [22]. Poor knowledge regarding the EBGs related to VAP prevention has also been reported in Iran [18], Yemen [20] and Taiwan [31] in Asia, and Egypt [23] and Ethiopia[24] in Africa. The differences in knowledge scores may be explained by the differences in models of healthcare delivery in ICUs[22], and lack or differences in specific guidelines and policy regarding training and practice of EBGs for VAP prevention in ICUs [27]. Developing a specific guideline and policy for training VAP prevention by considering the challenges in the resource-limited setting, without compromising the effectiveness in VAP prevention, could be helpful in minimizing the knowledge differences in resource-limited settings. Such standardized guidelines would take into consideration the costs related to recommendations for VAP prevention.
This study reveals a higher range of knowledge among nurses (10-90%) not only among ICU nurses in different hospitals but also within the same hospital. This higher range in knowledge between the lowest and the highest knowledge score may imply the difficulty in sharing evidence- based information among staff. The difficulty in sharing knowledge in hospitals in resource-limited settings has been extensively documented [32][33]. Some associated factors to information sharing include: Differences in educational levels, limited resources, job dissatisfaction, lack of motivation, and lower level of professional education[32, 33]. Other factors may include high workload, lack of organized on-the-job training, and lack of emphasis to improve knowledge or practice regarding EBGs. Yonkaitis and Maughan[34] have provided a simplified and useful guide for EBG knowledge sharing and evaluation (the 6 ‘A’s’ of EBPs) which may be adopted in resource-limited settings to assess the need, acquire the best evidence, appraise the evidence, apply evidence and disseminate evidence [34].
In our study, nurses with a degree or higher level of nursing education performed significantly better than the nurses with a diploma or lower level of nursing education. These results are consistent with studies in Taiwan [31], Ethiopia [24], and Belgium [27] but are contrasted by the study in New Zealand [35]. However, contrary to other studies[21, 22, 27, 28], and consistent with others [26], nursing assistants were included because they are also involved in bedside care of critically ill patients in ICU. However, their proportion was very low (1.7% of the entire sample), and therefore the results should be interpreted with caution.
Our study, unlike several others [21, 27, 36] revealed that there was no differences in knowledge between more experienced nurses and less experienced nurses. These results are consistent with studies in New Zealand[35],Ethiopia [24], and USA[22].In resource-limited countries like Tanzania, continuing education programs for in-service nurses are not common. The reliable source of knowledge remains college nursing training. Therefore, nurses with lower nursing education are likely to remain with little knowledge despite their increased clinical experiences, most of which is based on routine works and fulfilling medical orders.
In our study, the mean self-reported adherence to EBGs for the prevention of VAP was 60.8%. This score is below the adherence scores ever reported in various studies, ranging between 77.7% in Spain [28] and 83% in USA [37]. Consistent with other studies [26], neither nursing level of education nor experience was associated with significant variability in adherence. In a similar study in Ethiopia [24], only higher nursing experience was associated with increased adherence to EBGs for VAP prevention. It implies that there are other factors than the nursing level of education, and experience that affect compliance to the EBGs for VAP prevention, which may range from institutional factors such as lack of sufficient management support and policy, to individual factors such as heavy workload and increased job stress in a resource-limited setting.
Consistent with other studies[26], the most commonly self-reported adherences were related to semi-recumbent positioning. Others include patient positional treatment, enteral feeding protocol/avoidance of gastric over distension, use of a formal infection-control program, sterility of suction catheter maintained until inserted into airway, sodium chloride instillation and disposal of used catheter and gloves in a manner that prevents contamination from secretions. The reason for high adherence score could be because these are part of the local guideline for ICU care of critically ill patients in most ICUs in Tanzania, and therefore, are routinely performed. The least adhered component was related to presuctioning analgesia(0.4%),which is much lower than the previously reported studies[26].In Tanzania, administering presuctioning analgesia is almost not done in ICUs.
The main barriers to the implementation of EBGs for VAP prevention were lack of skills (96.6), lack of staff (95.5%), and lack of knowledge(79.3%).These factors are also reported in several other studies[38][37]. Lack of knowledge and skills may be attributed to inability to transform research into practice, and poor information sharing among nurses as the majority of ICU nurses have lower nursing education levels [22][38]. Poor information sharing among ICU nurses is revealed by a wider range of knowledge score of 80% (10%-90%) in the present study. Others include lack of guidance (78.4%), and laziness(75%)[26]
In summary, it is necessary that the knowledge, compliance, and barriers are assessed so that measures are taken for the improvement of clinical outcomes of our ICU patients. The knowledge levels and compliance of ICU nurses in Tanzania regarding EBGs for VAP prevention are lower than the lowest ever reported level of knowledge in the published studies. This may be the single most important barrier to the implementation of the EBGs for VAP prevention.
Implication and recommendation for practice
Considering the implication of VAP in the quality of ICU patients, and the role of adherence to the EBGs in prevention of VAP and improving quality of ICU patient care, educational measures to improve knowledge, preparing local guidelines and enhancing information sharing among nurses may have significant outcomes in prevention of VAP. Whenever possible, increasing the Nurse to patient ratio in ICUs will add to the implementation of the recommended EBGs for VAP prevention. The results of this study will help in guiding local practice and education, and will be the baseline of reference after implementation of educational measures. Furthermore, being the first study regarding knowledge and compliance to EBGs for VAP prevention in Tanzania using standardized international questionnaire, the results of this study adds to the existing literature regarding the state of sub Saharan Africa and other resource-limited settings.
Limitations
This study had some limitations worth mentioning. First, the participant ICU nurses outside Dar es Salaam City were conveniently obtained at St. John’s University. These may not be representative of all other nurses in their respective hospital. Second, this study did not exhaustively evaluate other factors that may affect compliance, such as managerial factors.