International Emergency Nursing xxx (xxxx) xxxx

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International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

Emergency nurses’ knowledge about ventilator-associated pneumonia

Hossein Rafieia, , Sara Rahimia, Mahya Shafaeia, Mirmostafa Ommatmohammadib
⁎

a
Department of Nursing, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran
b
Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran

ARTICLE INFO ABSTRACT

Keywords: Introduction: Given the increasing number of patients requiring mechanical ventilation in emergency depart-
Emergency department ments in recent years, prevention of pneumonia is very important. Nurses play a significant role in prevention of
Mechanical ventilation ventilator-associated pneumonia. This study aimed to determine the level of knowledge of nurses working in the
Respiratory care emergency departments on the prevention of ventilator-associated pneumonia.
Nurses’ knowledge
Methods: The present descriptive-analytic study was conducted in Iran, in 2018. All the nurses with at least a
Hospital-acquired infection
bachelor degree, who are working in two emergency departments of two teaching hospitals, were asked to
Ventilator-associated pneumonia
participate in this study. The “knowledge about ventilator-associated pneumonia” questionnaire consisting of 9
questions was used to assess the knowledge of nurses about pneumonia. The results were analyzed using SPSS-
16.
Results: On the whole, 53 nurses participated in this study. The mean score of correct answers of nurses to these
9 items was 4.4 ± 1.6. Nurses give the most correct answer to the item about patient’s position on the bed in
order to reduce the risk of pneumonia with 72.9% of the response. The least correct answer was also given to the
item about how humidifier was changed with 1.9% of the response. None of the nurses participating in the study
were able to answer all the questions correctly. The mean score of knowledge of nurses who had participated in
workshops about taking care of patients on mechanical ventilation was significantly higher than those who
hadn’t participated in such workshops (4.8 vs. 3.8) (p = 0.045). The mean score of knowledge in nurses who
were familiar with the international guidelines for ventilator-associated pneumonia prevention was significantly
higher than those who were not familiar with such guidelines (5.1 vs. 4.1) (p = 0.045).
Conclusion: Emergency nurses participated in this study did not have sufficient knowledge about the prevention
of ventilator-associated pneumonia. Considering the importance of this issue, it is necessary to improve the
knowledge of the emergency nurses in this matter by holding training courses.

1. Introduction
Ventilator-associated pneumonia refers to lower airways infection
that occurs in people who are on a ventilator which usually develops
48 h or longer after the intubation of the patient [1–3]. Ventilator-as-
sociated pneumonia is the most common infection among patients re-
quiring mechanical ventilation [4]. According to the findings of pre-
vious studies, more than 80% of hospital-acquired pneumonia is related
to ventilator- associated pneumonia [2]. The prevalence of such infec-
tions has been reported to be different in different countries, but what is
certain is that the problem is more prevalent in less developed and
developing countries [5,6]. The occurrence of ventilator-associated
pneumonia in one patient increases the number of days requiring me-
chanical ventilation, the length of hospital days in the intensive care
unit, the number of hospital admission days, the treatment costs, and
mortality rates [3,7,8]. The results of a study in the United States re-
ported the direct and indirect costs of ventilator-associated pneumonia
to be approximately $57,000 [9]. Factors such as male gender, aging,
underlying diseases, chronic obstructive pulmonary diseases, low level
of consciousness, the need for prolonged mechanical ventilation, the
need for reintubation after extubation, patient's position (supine posi-
tion), infections of other organs, the need for tracheostomy, the use of
anti-acids, the excessive use of antibiotics and bronchoscopy can in-
crease the chance of the occurrence of ventilator-associated pneumonia
in a patient [8,10].
Given the high mortality rate of such infections, prevention has
always been an area of special importance [11]. In order to prevent the
occurrence of ventilator-associated pneumonia, nurses who are taking
care of patients on mechanical ventilation play a significant role [12]
and it is necessary that they have enough knowledge and information in

⁎
Corresponding author.
E-mail address: Hosseinr21@gmail.com (H. Rafiei).

https://doi.org/10.1016/j.ienj.2019.06.006
Received 29 January 2019; Received in revised form 20 May 2019; Accepted 8 June 2019
1755-599X/ © 2019 Elsevier Ltd. All rights reserved.

Please cite this article as: Hossein Rafiei, et al., International Emergency Nursing, https://doi.org/10.1016/j.ienj.2019.06.006
H. Rafiei, et al.
this regard. This has led researchers from different countries to study it.
In a major study from 2006 to 2007, Labeau and et al. examined the
knowledge of nurses working in the intensive care units of 22 European
countries. In this study, the mean of the total score of nurses’ knowledge
was 45. The results indicated that only 55% of the nurses know the best
method of intubation, 35% of them know how to replace the ventilator
interface paths, 38% of them know how to use moisturizers, 46% of
them know how to use suction with a closed system and 85% of them
know the patient's correct position in order to prevent pneumonia [13].
In another study in 2014, Curhan et al. examined the knowledge of
nurses working in ICUs regarding ventilator-associated pneumonia. The
results of this study showed that nurses’ knowledge is poor in this re-
gard. Also, they mentioned the level of education, work experience and
the history of participation in workshops on pneumonia as factors in-
fluencing the nurses’ knowledge [14]. In another study in 2014, Al-
Sayaghi studied the knowledge of 387 nurses working in intensive care
units in Yemen regarding pneumonia prevention. Similar to the most of
the previous studies, the results of Al-Sayaghi study indicated the poor
knowledge of nurses regarding the prevention of ventilator-associated
pneumonia. Based on the results, the nurses were most frequently
correct (> 60%) regarding regular oral care, semi-recumbent position,
preventing unplanned extubation. Nurses had the least knowledge
(< 24%) regarding frequency of humidifier and suction systems
changes and oral route for tracheal intubation [15].
Increasing the number of patients attending hospitals to receive
services and the need for special care has led many of these patients on
mechanical ventilation to be hospitalized in departments other than the
intensive care units. One of these departments is emergency depart-
ments. Evidences revealed that in many cases, patients on mechanical
ventilation are hospitalized in emergency departments for days, and
nurses working in these departments are responsible for taking care of
them. As mentioned, the prevention of ventilator-associated pneumonia
is very important, and nurses should be well informed about this
matter. Our investigation have not yet shown a study that demonstrates
the knowledge of nurses working in emergency departments regarding
the prevention of ventilator-associated pneumonia, and previous re-
searches have all sought to examine the knowledge of nurses working in
the intensive care units, while nurses working in the emergency de-
partments always provide a major part of the care of patients on me-
chanical ventilation. Therefore, this study aimed to determine the level
of knowledge of nurses working in the emergency departments on the
prevention of ventilator-associated pneumonia.
2. Methods
The present descriptive-analytic study was conducted in Iran, in
2018. The participants were selected through a convenience sampling
method. The study sample consisted of all the nurses working in
emergency departments of Bou-Ali and Velayat teaching hospitals. The
emergency departments of these hospitals admit patients with problems
such as heart, neurological, poisoning, endocrine, blood and oncology
diseases. In Iran, nursing is a 4-year academic course which after gra-
duation, nurse become Registered Nurse (RN), and can work in dif-
ferent departments. Nurses in Iran can also continue their postgraduate
degrees as well as Ph.D. in various disciplines. Since about 6 years ago,
the license for commissioning the master’s degree in emergency nursing
was issued in Iran, and today, students are studying in this major in
some of the medical universities.
The inclusion criteria for the study were having at a least a bachelor
degree in nursing and a minimum work experience of 6 months in the
emergency department. Nurses who were not available at the time of
study, for examples those who were on holiday, and those who were
reluctant to participate in the study were excluded. After granting the
necessary permissions from Qazvin University of Medical Sciences and
the target hospitals, the researcher referred to the hospitals’ nursing
offices and received the list of nurses working in emergency
2
International Emergency Nursing xxx (xxxx) xxxx
departments. The researcher then referred to the departments and after
coordination with the head nurse, asked nurses to complete the ques-
tionnaires and return them to the researcher. Attempts were made to
distribute the questionnaires at a time that would not interfere with
nursing care. At the time of distributing and completing the ques-
tionnaires, one of the researchers was present in the department and
responded to the participants’ questions in case of any ambiguity.
The instrument used in this study consisted of two parts. The first
part was related to the demographic information of the nurses. This part
included age, gender, work experience, level of education, history of
participation in related workshops, having enough information about
care of a patient on mechanical ventilation, the need for further training
courses in case of taking care of patients on mechanical ventilation. The
second part was related to the knowledge of nurses about the preven-
tion of ventilator-associated pneumonia. The questionnaire consists of 9
questions that were developed by Labeau et al. in 2007 [16]. This
questionnaire examines the nurses’ knowledge about the best intuba-
tion method, the best suction method, the best position for the patient,
the best replacement time for tubes and connections, the best replace-
ment time for suction equipment and how to moisten the patient’s
airways.
The results were analyzed using SPSS-16. In order to analyze the
descriptive data, mean, standard deviation and frequency were used.
Pearson correlation test was used to determine the relationship between
the mean of the total score of knowledge and demographic variables
such as age and work experience. The independent t-test was used to
determine the difference in the mean of the total score of knowledge
between the two groups, for example men and women. The p-value less
than 0.05 was considered significant in all tests.
3. Results
3.1. Demographic
Of all the 53 participants in the study, 41 (77.4%) were women and
others were men. The meanage of participants in this study was
29.9 ± 4.7 years. The average work experience of participants in this
study was 6.6 ± 4.5 years. In total, 84.9% of the participants reported
that they passed mechanical ventilation training course during their
education, and 62.3% reported that the received training course was
sufficient. 62.2% of the participants stated that they had participated in
mechanical ventilation workshops. 84.9% of the participants stated that
they needed more workshops on the care of patients on mechanical
ventilation. 68.8% of participants stated that they are not familiar with
the international guidelines for ventilator-associated pneumonia pre-
vention. More than half of the participants (52.8%) stated that taking
care of patients on mechanical ventilation was difficult for them. Also,
88.7% of them stated that taking care of patients on mechanical ven-
tilation takes a lot of time.
3.2. Knowledge about ventilator-associated pneumonia
The average number of correct answers of nurses to these 9 items
was 4.4 with a standard deviation of 1.6. Nurses give the most correct
answer to the item about patient’s position on the bed in order to reduce
the risk of pneumonia with 72.9% of the response. The least correct
answer was also given to the item about how humidifier was changed
with 1.9% of the response. None of the nurses participating in the study
were able to answer all the questions correctly. Also, none of the
questions was answered correctly by all nurses. Table 1 shows how
nurses responded to the questions of the questionnaire in more details
(Table 1).
The mean scores of men and women’s knowledge were 5 and 4.3,
respectively (p = 0.288). The results showed no significant relationship
between nurses age and work experience (p > 0.05). The mean score
of nurses, who received the information about mechanical ventilation
H. Rafiei, et al.
Table 1
Emergency nurses’ responses to knowledge questionnaire items.
Items Number and percent of
correct answer
1) Oral versus nasal route for endotracheal 35 (66%)
intubation
2) Frequency of ventilator circuit changes 25 (47.2%)
3) Type of airway humidifier 15 (28.3%)
4) Frequency of humidifier changes 1 (1.9%)
5) Open versus closed suction systems 28 (52.8%)
6) Frequency of change in suction systems 12 (22.6%)
7) Endotracheal tubes with extra lumen for drainage 23 (43.4%)
of subglottic secretions
8) Kinetic versus standard beds 40 (75.5%)
9) Patient positioning 42 (79.2%)
during the education period, was 4.5 and those who did not, was 4.3.
This difference was not statistically significant (p = 0.834). The mean
scores of knowledge in nurses who reported that the training course
during their education period was sufficient and those who reported
that the training course during their education period was not suffi-
cient, were 4.7 and 1.4, respectively. The mean difference between the
two groups was not statistically significant (p = 0.188). The mean score
of knowledge of nurses who had participated in workshops about taking
care of patients on mechanical ventilation was significantly higher than
those who hadn’t participated in such workshops (4.8 vs. 3.8)
(p = 0.045). The mean scores of knowledge in nurses who needed more
workshops on the care of patients on mechanical ventilation was 4.4
and in those who did not, was 4.6. The difference between the two
groups was not statistically significant (p = 0.808). The mean score of
knowledge in nurses who were familiar with the international guide-
lines for ventilator-associated pneumonia prevention was significantly
higher than those who were not familiar with such guidelines (5.1 vs.
4.1) (p = 0.045).
4. Discussion
The present study aimed to determine the level of knowledge of
nurses working in the emergency departments on the prevention of
ventilator-associated pneumonia. Based on our findings, nurses parti-
cipated in this study did not have enough knowledge about the pre-
vention of ventilator-associated pneumonia. The results showed that
participating in training course on the care of patients on mechanical
ventilation and being familiar with the international guidelines of
prevention of ventilator-associated pneumonia are such factors that
have a positive impact on nurses’ knowledge. It was while 84.9% of the
participants stated that they needed more workshops on the care of
patients on mechanical ventilation and 68.8% of participants stated
that they are not familiar with the international guidelines for venti-
lator-associated pneumonia prevention.
The results of different studies show that ventilator-associated
pneumonia is significantly prevalent in patients hospitalized in emer-
gency department [17]. One of the aspects of taking care of patients on
mechanical ventilation is the prevention of ventilator-associated
pneumonia. Given the increasing number of patients requiring me-
chanical ventilation in emergency departments in recent years, pre-
vention of pneumonia is very important. Nurses play a significant role
in prevention of ventilator-associated pneumonia [18]. In order to this,
nurses should have enough knowledge about it. The searches did not
show a similar study that, like the present study, that examined the
knowledge of emergency nurses about ventilator-associated pneu-
monia. However, limited studies have examined other aspects of taking
care of critically ill patients on mechanical ventilation in the emergency
departments. In a study in Canada in 2012, Rose and Ramangana
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International Emergency Nursing xxx (xxxx) xxxx
examined the responsibilities of emergency nurses in taking care of
patients on mechanical ventilation. They examined 247 nurses. Only
51% of nurses participating in the Rose and Ramangana study had
trained in relation to taking care of the patients on mechanical venti-
lation. Also, 57% of nurses in the study stated that their competency
related to the care of patient’s mechanical ventilation has never been
evaluated. Rose and Ramangana also stated that the high proportion of
patients to nurses, the lack of training, the lack of examination of the
competency of nurses related to the care of patient’s mechanical ven-
tilation and the lack of using the guidelines and protocols related to the
care of patient’s mechanical ventilation in emergency departments can
be considered as a threat to the safety and health of patients in these
departments [19]. In another study in this regard, Denno studied the
different aspects of the care of patients in need of emergency care in the
emergency department. In a part of his article, Denno studied the role of
nurses in the prevention of ventilator-associate pneumonia. Denno re-
commended that emergency nurses use Ventilator-associated pneu-
monia prevention bundles to prevent ventilator-associated pneumonia.
Lifting the head of patient, using prophylaxis preventive medications
for prophylaxis, the use of prophylaxis for deep vein thrombosis, per-
iods of patient’s sedations and the use of dental solutions are Denno’s
effective measures that he addressed them to prevent the ventilator-
associated pneumonia in the emergency departments [20].
As previously mentioned, according to our searches, this study is the
first one that particularly evaluates the knowledge of nurses in the
emergency departments regarding ventilator-associated pneumonia.
Based on the results, nurses did not have enough knowledge in this
regard. In order to improve the knowledge of nurses about ventilator-
associated pneumonia, it is recommended to consider short-term solu-
tions as well as long-term strategies. Holding workshops on ventilator-
associated pneumonia is one of the short-term strategies in this regard.
The results of this study showed that nurses who had participated in
workshops related to the care of patient’s mechanical ventilation had
significantly more knowledge in this regard than others. Previous stu-
dies have also shown that holding workshops related to ventilator-as-
sociated pneumonia for nurses significantly improves their knowledge
and performance [21]. Teaching the pathophysiology of the disease,
introducing the respiratory ventilation system, the correct suctioning of
patients’ airway, the correct position of patient and the replacement of
tubes and connections of the ventilator, using dental solutions for pa-
tient are items that can be included in the educational content of these
courses. Also, studying the emergency nursing at higher education le-
vels can be considered as a long-term opportunity for teaching nurses
about different emergency cases such as taking care of patients on
mechanical ventilation.
5. Limitation
The small sample size is the main limitation of the present study. It
is recommended that further studies be conducted with a larger sample
size.
6. Conclusion
The present study showed that nurses have poor knowledge about
ventilator-associated pneumonia. Given the importance of this matter,
workshops on ventilator-associated pneumonia are needed for emer-
gency nurses. The findings of this study can be used as a guide for the
organizers of these workshops. Due to the lack of similar studies, it is
strongly recommended that similar studies be conducted in this study.
It is also recommended that the knowledge of emergency nurses in
relation to other aspects of the care of patients on mechanical ventila-
tion, such as sedation and pain management, eye care, oral care, and
prevention of pressure ulcer be evaluated in further studies.
H. Rafiei, et al.
Acknowledgement
The authors would like to thank and appreciate the participants in
this study because of their cooperation in the study.
Conflict of interest
The authors declared no conflict of interest.
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