Introduction

Mechanical ventilation is used to offer ventilator support regularly to patients in intensive care units (ICUs). However, mechanical ventilation is associated with a high incidence of adverse outcomes, such as mortality, prolonged ventilation, and extended hospital stays, increasing the financial burdens on patients and creating a high demand for healthcare resources [1]. Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infection (HAI) occurring in ICUs and is a major cause of mortality among patients admitted to such units [2]. Recent studies have reported a worrisome prevalence of VAP in various Southeast Asian countries, indicating a significant rise in mortality rates from 16.2% to 74.1% and VAP incidence ranging from 2.13 to 116 per 1,000 patient-days from the year 2000 and 2020 [3]. In Malaysia, a tertiary centre reported a VAP incidence density of 7.1 per 1,000 ventilator-days [4].

Many guidelines and protocols have been proposed, but there is still a gap in the translation of such guidelines and protocols into bedside among critical care nurses [5]. Several factors that may account for this gap in care delivery include unfamiliarity with recommendations, content, time, resources, education, and training in VAP prevention, as well as protocol compliance [5]. Nurses who provide around-the-clock bedside care to mechanically ventilated patients play a crucial role in implementing non-pharmacological prevention measures that are directly related to lower VAP incidence rates [6]. Nurses should, therefore, be fully informed and apply evidence-based practices in their daily practice to minimize the incidence of VAP among ICU patient.

Concerns have been raised about the ability of nurses in critical care to prevent VAP. Zeb et al. reported that critical care nurses demonstrated a poor understanding of VAP prevention measures [7]. Similarly, a systematic review by Al-Mugheed et al. included 23 studies, of which 14 reported a poor level of awareness regarding VAP knowledge among nurses [8]. The general results determined an inadequate level of compliance with the VAP prevention measures among institutions. For effect, such knowledge gaps could thwart the successful delivery of VAP preventive practices and the translation of interventions into practice. Notably, critical care nurses caring for ventilated patients be knowledgeable of the guideline-recommended evidence-based guideline practices for VAP prevention. Indeed, nurses with high-level understanding of VAP prevention show high levels of engagement in practices that aim to reduce the incidence of VAP.

The fundamental principles of evidence-based care for preventing VAP must align with compliance measures to translate the essential elements into effective practice would thus need to conform to the basic elements of evidence-based care to prevent VAP. The research on nurses’ perceptions of barriers for preventing VAP has unraveled a heterogeneous set of contributing factors, including suboptimal working conditions, poor organizational culture, deficiencies in educational resources and policy frameworks, and poor protocol guidelines, in addition to poor staffing levels [9].

The main aim of this research was to assess the knowledge and self-reported practices about prevention strategies for VAP among critical care nurses, various knowledge and self-reported practices variations based on sociodemographic characteristics, and the predictors of their self-reported practices on the prevention of VAP. The study also established barriers to compliance with prevention protocol. To date, there is inadequate information comprehensively describing the knowledge, practice and barriers to VAP prevention among nurses working in critical care areas in Malaysia.

Methods

Results

Out of 454 eligible critical care nurses, the minimum required sample size was 213, as calculated using Yamane’s formula. After adjustment for a 20% attrition rate, the final target sample size was 267. The researchers successfully obtained 298 completed responses, which exceeded the required sample size and represented a response rate of 65.6%. This higher-than-expected response rate strengthens the reliability and generalizability of the study findings [12].

Of the 298 critical care nurses’ respondents, 285 (95.6%) were women and 13 (4.4%) were men. Participants’ ages ranged from 20 to 40 years, with the majority (52.0%) having 10 years or less of nursing experience. Most (96.0%) had a diploma, and 48.7% had 6–7 years of experience in the Intensive Care Unit (ICU). Additionally, 79.2% did not possess advanced specialty training in intensive care nursing (locally termed as post-basic qualification in ICU). The participants represented diverse critical care settings, with 42.6% working in a General Intensive Care Unit. Regarding facility size, 44.6% were in settings with fewer than 10 beds and 88.6% cared for two ventilated patients. All participants were nurses. The majority (74.8%) were bedside clinical staff nurses (entry-level registered nurses), while 20.5% were senior registered nurses with 13–15 years of service, promoted through structured time-based pathways, who frequently take on supervisory and mentoring roles in addition to their clinical duties. A smaller proportion (4.7%) were nurse managers (ward or unit leaders with broader administrative responsibilities). Majority worked fewer than 45 hours per week (58.1%), and 98.0% were permanent staff members. Furthermore, the majority had received education and training on VAP prevention (87.6%), with 69.8% of that training obtained through in-service education. Characteristics of critical care nurses described in “Table 1”.

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Table 1. Sociodemographic characteristics of critical care nurses (N = 298).

https://doi.org/10.1371/journal.pone.0325637.t001

Nurses’ knowledge of VAP prevention

In general, the knowledge score about VAP prevention was low 7.40 ± 2.24 as shown in “Table 2”. The sequence of individual items from highest to lowest scores in the knowledge questionnaire was as follows: regular comprehensive oral care (82.0%), frequency of the ventilator circuit changes (75.0%), type of airway humidifier (75.0%) and oral versus nasal route for endotracheal intubation (71.0%) (S1 Table). Significant variables associated with the nurses’ knowledge about the prevention of VAP in this group were age, years of nursing experience, ICU nursing experience, unit type, number of official beds and job position.

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Table 2. Critical care nurses’ knowledge level of ventilator-associated pneumonia (VAP) prevention.

https://doi.org/10.1371/journal.pone.0325637.t002

Self-reported practices towards VAP prevention

The general score of self-reported practices to prevent VAP was high: 27.98 ± 3.04, indicating a high level of compliance, as shown in “Table 3”. In rank order from most frequent to least, the items were as follows: washing hands after any approach to a patient, 99.0%, washing hands before any approach to a patient, 98.7% using sterile gloves when open suction is necessary, 96.6%; and using the heat and moisture exchanger humidifier, 88.6% (S2 Table). The variables that are significantly associated with compliance by critical care nurses with the VAP prevention guidelines are the type of units, number of official beds, and the nurse-to-patient ratio for ventilated patients.

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Table 3. Critical care nurses’ self-reported practices level and correlation with knowledge of ventilator-associated pneumonia (VAP) prevention (N = 298).

https://doi.org/10.1371/journal.pone.0325637.t003

Predictors of critical care nurses’ self-reported practices in VAP prevention

Hierarchical multiple regression analysis further revealed that knowledge was positively related to practices. Sociodemographic variables of type of units, number of beds, and nurse-to-patient ratio for ventilated patients accounted for 12.9% of the variance in self-reported practices in Model 1 (R² = .129, r = .36, F = 14.55, p < .001) as shown in “Table 4”. As seen, Model 2 canvases VAP prevention knowledge to comfortably increase the explanatory power of this model, accounting for 14.1% of the variance in self-reported practice (R² = .141, r = .37, F = 12.03, p < .001. It added another 1.2% to the variance. Knowledge, although positive effect (B = .156, p < .001), means it improves the ability to explain variance in the dependent variable. It had a partly effect when compared with sociodemographic factors (ΔR² = .012). while knowledge also has a significant role, the sets of sociodemographic characteristics have more significant predictive power on self-reported practice regarding the prevention of VAP.

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Table 4. Predictive Model: Hierarchical Multiple Regression Analysis for Self-Reported Practices of Ventilator-Associated Pneumonia (VAP) Prevention.

https://doi.org/10.1371/journal.pone.0325637.t004

Discussion

The overall knowledge of critical care nurses regarding the prevention of VAP was found to be decidedly low, below the acceptable threshold ≤ 60.0%, and was consistent with several other studies [11,13–15]. The lowest accuracy rate, as reported by the nurses, was for statements on the frequency of humidifier heat and moisture exchanger changes at 98.0% accuracy. Although recommendations generally suggest that the frequency of change for heat and moisture exchangers (HMEs) be weekly or as clinically indicated, practices related to HME replacement and change frequency vary widely. In General ICUs, for example, HMEs are changed every shift; in other critical care units, they are replaced every 24 hours or as clinically indicated, such as if clogged. Whereas most manufacturers recommend replacing HMEs every 24 hours, there is debate over this recommendation; for instance, it has been suggested that alternative intervals could be 48 hours, 96 hours, or even on a weekly basis [16,17]. Logically, HMEs should be checked for signs of resistance every 24 hours and replaced as necessary, which may be required every few days, though the time frame does vary significantly [17]. 77.0% of nurses also scored poorly in identifying different types of endotracheal tubes, similar to those in previous studies [18–21]. Recommendations include the use of subglottic secretion drainage (SSD-ETTs) over the traditional endotracheal tubes. Although financial constraints favour the use of standard ETTs, guidelines on the prevention of VAP recommend SSD-ETTs due to their efficacy in reducing VAP rates and shorter ICU stays without increased adverse events or mortality [22]. However, SSD-ETTs have low and underutilized adoption in ICUs [23].

The majority of the nurses expressed a high 76.2% and an acceptable 23.5% self-reported practice regarding VAP prevention, and aligning with earlier studies [24–26]. One reason for this is the inclusion of the bundle for the prevention of VAP prevention in the undergraduate nursing curriculum [24]. Consequently, subglottic suctioning through an additional lumen in ETTs contributed to less likelihood in 49.7% of the nurses. In regard to these observations, a study by Al-Sayaghi [24], also revealed several shortcomings related to coursework and curricula in undergraduate nursing. Till recently, there were only a few ETTs available with an additional lumen, and compliance rates for performing subglottic secretion suctioning ranged from 5.8% to 32.6% between 2010 and 2016 [27]. Indeed, Jahansefat et al. [28] reported that some settings recorded no usage of interventions related to subglottic secretion. The general low compliance score in this item could thus be due to unfamiliarity with types of ETTs designed for the facilitation of subglottic secretion drainage. Standard endotracheal tubes were widely used across all units, where the secretions were ventilated and suctioned through one tube. This obviously reduces the use of the subglottic drainage tube.

Nurses were even reluctant to perform activities regarding the use of chlorhexidine solution for oral care 39.3%. it was probably due to prevailing ICU practice and customs observed in general ICUs, which have been discontinued based on recommendations by intensivists, which are in line with updated evidence-based practice [28]. There were similar trends in pediatric units where chlorhexidine was not suitable and for which there is some evidence that it does not reduce VAP in critically ill children [29]. In Neuro High Dependency Unit’s (HDU), chlorohexidine gluconate mouthwash was used for oral care. The notable point here is that no standardized prevention measures were made for use by nurses in their respective settings. The Center for Disease Control and Prevention (CDC) does not recommend the routine oral administration of chlorhexidine mouthwash while awaiting further data; conflicting recommendations are made between the most recent evidence and institutional policies [29–31]. Recent evidences recommended a worldwide cessation of chlorhexidine mouthwash use [32,33]. Ricard & Lisboa [34] recommended that more evidence was needed before its use in ventilated patients was stopped. Such inconsistencies in the literature may have influenced nurses’ responses in this study. In particular, the significant barriers to the implementation of guidelines for VAP prevention include a shortage of nursing staff, which is consistent the findings from other studies [9,15,24,35–38]. Poor staffing invariably results in heavy workloads for the nurses, especially for those working in the ICUs. This indirectly affects the quality of care accorded to the patients and compromise patient safety in general [38].

Such findings indicate a gap between the evidence-based guidelines on VAP prevention and the actual knowledge and practices among CCNs, suggesting possible risks to patient safety, quality of care and clinical outcomes. For instance, while 98.7% of the nurses reported self-reported adherence to trusted practice in the prevention of VAP, 66.8% of the nurses had inadequate knowledge of VAP prevention. This contrast suggests that the high compliance reported may not fully reflect actual practice, but could be influenced by reporting tendencies, underscoring the need for more objective assessments. So far, only one study has demonstrated the existence of such findings, and few studies have addressed this issue yet [39]. This disparity thus indicates that knowledge gaps may be translated into inappropriate practice in preventive measures of VAP, leading to higher rates of VAP. Future professional development through targeted program and continued education would play a role in enhancing CCNs’ competencies, making care practice standardize, thereby improving patient’s outcome by reducing the incidence of VAP [38–43]. Moreover, it needs to be considered whether stress and workload factors affect nurses’ compliance with the VAP protocols. The ability to address these factors could provide a practical way of motivating CCNs to follow these guidelines consistently.

Hierarchical analysis resulted in only a significant negative association between unit type and self-reported practices toward VAP prevention. It may be perceived that certain unit types may encounter struggles in maintaining effective VAP prevention measures compared to others. This observation is supported by the study conducted by Al-Sayaghi [24]. He highlighted that the type of ICU influences adherence to VAP guidelines. These findings presented differences in VAP prevention practices across different clinical settings. The number of beds also has a positive and significant impact on self-reported practice, as supported by several studies [24,43]. The units with higher bed counts have a positive and significant impact on self-reported practices in the prevention of VAP. This would imply that larger units with more beds may have more resources, staffing, or structured protocols that contribute to better adherence to guidelines on VAP. The nurse-to-patient ratio for ventilated patients shows a positive association with self-reported practice in both models, although at a non-statistically significant level. Higher ratios may positively impact practices related to VAP prevention and thus reinforce notions of adequate staffing being imperative for the delivery of quality care. This finding is in agreement with the study conducted by Aloush [4], which had similar results. From the analysis, it also emerged that knowledge has a slight positive influence on self-reported practices toward VAP prevention, though minimal in effect size and not statistical significance. This finding agrees with that by Darawad [25], who reported a statistically significant positive correlation between VAP guideline adherence and total VAP care knowledge (r = 0.175, p > .05). The nonsignificant influence in this study implies that knowledge alone may not be strong enough to ensure meaningful changes in self-reported practice; it nonetheless plays an assuring role in guiding adherence to established guidelines. Knowledge improvement may be, therefore the cornerstone for improving VAP prevention practices, complemented by other factors, including sufficient staffing, practical training, and institutional support in effectively improving VAP prevention practices.

These findings support the updating and standardization of guidelines on VAP prevention in various healthcare settings, due to staffing shortages and workloads affecting adherence. Encourage the nurses to participate in quality improvement projects, have regular professional growth and training, and provide a supportive culture for the nurses to apply the VAP prevention strategies. For nursing education, extensive training on VAP pathophysiology and prevention, simulation-based learning and emphasis on communication, teamwork, and safety are all critical [41]. Nursing research shall study the obstacles to VAP prevention by investigating the workload of the staff against the availability of resources for infection control. Consequently, it is with the help of qualitative research that an emphasis on such issues will pay dividends in policy changes and result in better outcomes for the patients.

Conclusion

This study has indicated a gap in knowledge about the prevention of VAP, despite the reported high self-reported practice score by critical care nurses in Sarawak, Malaysia. Shortage of staff was identified as the major barrier to effective prevention of VAP. Nurses handle the care of mechanically ventilated patients, therefore the identification of such knowledge gaps and barriers is crucial if any improvement in patient safety and health outcomes is to be achieved. Future studies should be conducted on the factors affecting long-term knowledge retention, as well as behavioural and psychological factors such as stress and workload. Besides, the impact of newer guidelines on the incidence of VAPs and length of stay in an ICU has to be reviewed. Qualitative studies are also recommended to raise a more detailed description of problems considered by CCNs; better survey tools and overall review in all sectors of healthcare in Malaysia is necessary. The efforts below can support policy changes, address staffing concerns, and promote better training programs.

Supporting information

Acknowledgments

We would like to thank the Director General of Health Malaysia for his permission to publish this article.