Intensive Care Unit Registered Nurses' Perceived Barriers Towards VAP Prevention in Southeast Iran: An Observational Study

Background: Health Care-Associated Infections are the most common complications in hospitalized patients. Ventilator-Associated Pneumonia is a subset of Healthcare-Associated Pneumonia. This study aimed to investigate the intensive care unit registered nurses' perceived barriers towards VAP prevention in southeast Iran. Methods: This was a cross-sectional descriptive-analytical study investigating ICU registered nurses in hospitals aliated to Kerman University of Medical Sciences, Kerman, Iran. The study population consisted of nurses in ICUs and EDs in three hospitals. The sample size was estimated as 242 nurses. The data was collected through a demographic characteristics questionnaire and a researcher-made ventilator-associated pneumonia barriers prevention questionnaire. Results: Nurses’ mean age was 32.9 ± 5.87. 80.2% of the participants were female. The job experience mean score was 9.51 ± 5.14 years. 45% of nurses had received VAP prevention training. The mean score of nurses' perceived barriers towards VAP prevention was 2.82 ± 0.46. The highest mean score of perceived barriers were related to items of "Lack of staff", "Lack of a team-based approach to care and interventions ", and "Lack of support from Management”. Conclusions: According to the present study, most of the barriers mentioned were related to organizational factors such as lack of teamwork. One of the major problems of most Kerman hospitals seems to be the shortage of staff. Further studies are needed in Kerman and other cities of Iran to obtain more accurate results.


Background
Health Care-Associated Infections are the most common complications in hospitalized patients. Although Intensive Care Units (ICUs) account for about 5-15% of hospital beds, they account for more than 30% of hospital-acquired infections. Ventilator-Associated Pneumonia (VAP) is a subset of Healthcare-Associated Pneumonia that develops 48 hours or longer after intubation and being under Mechanical Ventilation (MV) (1).
VAP is associated with serious complications such as morbidity, mortality, prolonged ICU stay, nursing workload increase, and nancial problems (2). It is estimated that the incident will increase the length of hospital stay in ICUs by 14 days, with a mortality rate of 9-13%, and it is expected to bring an additional cost of 41,000 USD (3)(4)(5).
Paying attention to VAP is a serious challenge for ICU nurses, and its prevention has been reported as a priority in these units (6). Previous studies have shown that the prevention of VAP improves the patients' condition and affects their quality of life. Also, strategies to prevent VAP are e cient, and thereby reduce the costs incurred on the health care systems (7). Soni and Mehta (2017) reported that prevention measures for VAP are important components of the nursing care plan among ICU nurses (8). Recently, the prevention of VAP has also been included as a component of patient safety guidelines (2), and it should be noted that in many health care systems, safety is considered as an indicator for quality improvement and criteria for evaluating ICUs (9, 10).
Since many factors might impede prevention in any eld, studies have tried to evaluate the barriers to the prevention of VAP. Sole (2005) reported factors such as a shortage of time, lack of equipment, costs, and personnel as barriers to the prevention of this type of pneumonia (11). Studies exploring the barriers to the quality of care and its evidence-based core in various units, including ICU, have reported the most important barriers to oral care in ICUs as poor management and supervision, maladaptation, lack of time, insu cient sta ng, and the gradual loss of their knowledge and lack of a standard protocol for care (12). In their study, Ricart et al. (2003) identi ed the most signi cant barriers to the adherence to evidencebased guidelines for the prevention of VAP in ICUs as unavailability of resources, patient discomfort, disagreement with reported trial results, fear of potential adverse effects, and costs. The most important barriers to adherence were environment-related (13). The results of Jansson et al. (2013) indicated that the performance of More experienced nurses was signi cantly better than their less-experienced colleagues. They reported the overall, self-reported adherence as 84.0%, and the main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge, and guidance (7).
Given the importance of VAP and the consequences of this infection in ICUs and considering nurses as one the most important members of the health care team, the results of such studies enhance nurses' knowledge and help them play a more effective role by using appropriate prevention methods. Therefore, this study aimed to investigate the intensive care unit registered nurses' perceived barriers towards VAP prevention in southeast Iran.

Study Design and Setting
This was a cross-sectional descriptive-analytical study investigating ICU registered nurses' perceived barriers towards VAP prevention in hospitals a liated to Kerman University of Medical Sciences, Kerman, Iran.

Sample Size and Sampling
All nurses in ICUs and Emergency Departments (EDs) of Shafa, Bahonar, and Afzalipour Hospitals formed the study population. According to the information obtained from these hospitals, there were 321 nurses (Shafa = 77, Bahonar = 112, and Afzalipour = 132) at the time of the study. The sample size was estimated based on the pilot study as 242 nurses, by a con dence coe cient of 95% and the power of 80.
Inclusion criteria were a) having B.Sc. or higher degree; b) job experience of six months in ICUs. The participants were excluded if they voluntarily withdrew from the study or avoided sharing their experiences. Eligible nurses were selected by quota sampling method from each unit and shift, according to its speci ed proportion.

Measures
The data was collected through a 2-part researcher-made questionnaire.
Demographic Characteristics Questionnaire: This questionnaire included age, sex, education, unit name, job experience, experience of working in ICUs, and having training courses on VAP as well as the type of protocols they adhere to (hand hygiene, oral care and suctioning).

Ventilator-Associated Pneumonia Barriers Prevention Questionnaire: This questionnaire contained 18
items with 4-point Likert scales (one = strongly disagree, four = totally agree). It was developed using various sources in the literature (2,7,8,11). The minimum and maximum score of the questionnaire was 18 and 72, respectively. The higher the average score of each item represents that the barrier was perceived more by nurses. The validity of the questionnaire was evaluated between 0.85 to 1 by giving the questionnaire to 10 faculty members of Kerman University of Medical Sciences, and for the reliability, the questionnaire was provided to 30 target populations. Internal consistency was calculated using Cronbach's alpha (α = 0.95).

Data collection and Analysis
After obtaining necessary permissions, the researcher referred to the research setting and started sampling. The eligible nurses were invited to participate in the study. After giving explanations about the process of the study, written consent was taken. Then, the questionnaires were given to nurses to be completed in the form of self-report. Two hundred forty-two nurses were enrolled in the study starting from January to May 2017, lasting for ve months, and there were no dropouts.
Data were analyzed by SPSS version 18 (SPSS Inc., Chicago, IL, USA). Descriptive statistics (frequency, percentage, mean, and standard deviation) were applied to describe the participants' demographic characteristics. The repeated measure ANOVA and Independent t-test or their nonparametric equivalents Mann-Whitney U test and Kruskal-Wallis test were used to compare the mean scores between nurses' demographic characteristics and their perceived barriers towards VAP prevention. The signi cance level of the p-value was considered to be 0.05.

Ethical Consideration
The study protocol was approved by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.REC.1395.908). The study objectives were presented to all participants before their enrollment, and the written informed consent was taken. All participants were assured that all information was con dential, and their participation was optional, and they could withdraw from the study at any time.

Results
Two hundred forty-two nurses enrolled in the study and completed the questionnaires. Nurses' mean age was 32.9 ± 5.87 (min = 22, max = 50), that 43% of them were 30 years old or younger. 80.2% of the participants were female. Only eight nurses had M.Sc., and the rest had B.Sc. Most of the nurses 66.1% were in ICUs, and the rest were in the ED. The job experience mean score was 9.51 ± 5.14 years (min = 1, max = 27), and the mean experience of working in ICUs was 6.33 ± 3.7 (min = 1, max = 20) ( Table 1).   Table 3, the highest mean score of perceived barriers were related to items of "Lack of staff" (3.1 ± 0.7), "Lack of a team-based approach to care and interventions " (2.93 ± 0.77), and "Lack of support from Management" (2.91 ± 0.69) ( Table 3).
There was no signi cant correlation between the mean score of nurses' perceived barriers towards VAP prevention and any of the demographic characteristics.

Discussion
The mean score of nurses' perceived barriers towards VAP prevention was 2.82 ± 0.46, which was higher than the median of the questionnaire ranges of scores (1 to 4; Median = 2.5). The highest mean score of perceived barriers were related to items of 'Lack of staff', 'Lack of a team-based approach to care and interventions', 'Lack of support from Management', and 'Lack of time' which indicate that most perceived barriers were related to the organization of the health care system. The lowest mean scores of perceived barriers were related to items of 'The concern of detachment of attached tubes to the patient', 'The concern of harming the patient', and 'The concern of the side effects it has on the patient'. It seemed that from nurses' point of view, perceived barriers towards VAP prevention were more related to the management of the system than the procedures or nurses. Such results could be because the barriers towards VAP prevention were only collected from the nurses' point of view. It may also be due to the shortage of nursing staff in the ICUs under study, which makes having team-based approaches hard or even impossible.
Reviewing literature, the results of Soni and Mehta's study on 136 ICU nurses indicated that the major nurses' perceived barriers towards prevention of VAP were lack of adequate resources, inadequate staff, and lack of time which was only in line with the results of this study regarding staff shortage and lake of time (8 Finland on 101 critical care nurses revealed that the main barriers towards the prevention of VAP were inadequate resources which was not consistence with the results of this study. Also, lack of staff and patient-related barriers were in the least important barriers which were totally in the opposite of the results of this study. This inconsistency could be because of different health care system sets in two countries (7).

Conclusions
According to the present study, most of the barriers mentioned were related to organizational factors such as lack of teamwork. One of the major problems of most Kerman hospitals seems to be the shortage of staff. Therefore, it is obvious that due to the current conditions of Kerman hospitals, there was no signi cant correlation between the mean score of nurses' perceived barriers towards VAP prevention and any of the demographic characteristics. On the other hand, since no similar study has been found in this eld, the results of the present study cannot be con rmed or rejected. Further studies are needed in Kerman and other cities of Iran to obtain more accurate results.

Declarations
Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.REC.1395.908). The study objectives were presented to all participants before their enrollment, and the written informed consent was taken.

Consent for publication
The written informed consent and consent for publication was taken from each individual for the study.
Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.