Indian Journal of Medical Specialities

: 2022  |  Volume : 13  |  Issue : 2  |  Page : 95--100

Improvement of the nurses' awareness toward ventilator-associated pneumonia based on evidence guidelines

Zainab Mohamed ALaswad, Magda Bayoumi 
 Department of Nursing, College of Health and Sport Sciences, University of Bahrain, Manama, Bahrain

Correspondence Address:
Dr. Magda Bayoumi
Department of Nursing, College of Health and Sport Sciences, Manama


Background: Ventilator Associated Pneumonia (VAP) is a common hospital acquired infection that occurs as complication in patients who are connected to Mechanical Ventilation (MV). Nurses in intensive care unit (ICU) should be updated with the latest evidence-based practice to prevent such complication. This study aimed to assess improvement of the nurses' awareness toward ventilator-associated pneumonia based on latest evidence guidelines. Methods: A quantitative pretest-posttest design has been conducted. Using a convenience sample of 58 nurses who are working in the ICU were recruited. Tools: A self-administrative questionnaire was adapted to assess the nurse's knowledge about VAP and VAP prevention bundle. Results: The results highlighted that all ICU nurses had improvement of knowledge level pre-post regarding VAP (p <0.001), VAP prevention (p <0.001), and the overall knowledge score improvement revealed significantly higher after the educational program (p <0.001). Conclusion: Periodic refreshing on-services education program should be provided to nurses in ICU to improve their knowledge and to maintain high level of information, moreover hospital policies should include updated guidelines for VAP prevention bundle and protocol from international evidence.

How to cite this article:
ALaswad ZM, Bayoumi M. Improvement of the nurses' awareness toward ventilator-associated pneumonia based on evidence guidelines.Indian J Med Spec 2022;13:95-100

How to cite this URL:
ALaswad ZM, Bayoumi M. Improvement of the nurses' awareness toward ventilator-associated pneumonia based on evidence guidelines. Indian J Med Spec [serial online] 2022 [cited 2022 May 26 ];13:95-100
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Full Text


Ventilator-associated pneumonia (VAP) is a pneumonia that occurs after two calendar days in mechanically ventilated patients, considering the day of intubation as day one.[1] It is one of the most common nosocomial infections with a prevalence rate of 10%–70% in the intensive care unit (ICU) that can be attributed to increase in the length of stay in hospital with a rate of 20%–30%. In the ICU, the VAP incidence is 22.8% in patients on mechanical ventilation.[2] Moreover, the VAP rate was found to account for 47% of all infections among ICU patients, and it can occur in 9%–27% of all intubated patients, which can lead to serious consequences.[3]

Therefore, VAP has significant consequences that are associated with increasing the length of ICU and hospital stays, which subsequently can increase the overall health care cost. Furthermore, it plays an important role in developing antimicrobial resistance secondary to the burden that results from the treatment of the respiratory tract infection in the ICU, which contributes to delayed extubation and increased mortality and morbidity rates. Therefore, VAP is considered an expensive complication.[2],[4]

Many hospitals focus on adaptation of a preventable strategy in which the Institute of Health Improvement has recommended a series of interventions that are recognized as the VAP prevention bundle. This strategy consists of five steps that can be used to prevent VAP and promote the patient's safety during intubation. Meanwhile, the bundle of care is an evidence-based practice that is grouped together to provide a consistent delivery of care to prevent VAP. These interventions include elevation of the head of bed (30–45 degrees), daily sedation vacation, oral care with chlorhexidine, use of peptic ulcer disease prophylaxis, and Deep Venous Thrombosis Prophylaxis.[5]

The prevention of VAP is a clinical challenge and lack of knowledge can be considered a barrier to adhering to the evidence-based guidelines that can prevent the development of VAP. However, staff educational programs and multi educational interventions can result in a significant reduction in VAP cases.[6]

Samra et al., stated that a VAP prevention bundle has been applied in ICUs in order to reduce VAP, but this has not been studied effectively in developing countries.[3]

Likewise, the Gulf Cooperation Council countries have a health care system that shares the same challenges as the developing countries, making the health care indicators lower than expected in those regions. Although the VAP prevention bundle was implemented in the Kingdom of Saudi Arabia (KSA) at the end of 2007 and in the second half of 2008 in Bahrain, the VAP rates in KSA for critically ill patients are limited, and unfortunately, the specific rates of VAP in Bahrain are not reported.[7] Therefore, such a study is needed to report the estimated VAP rate and highlight that the implantation of all items in the VAP bundle together is a must in the care of critically ill patients who are mechanically ventilated. Similarly, in Bahrain, no studies have been reported to highlight the role of nurses in preventing VAP at ICUs. The study aimed to assess improvement in the nurses' awareness of ventilator-associated pneumonia based on the latest evidence guidelines.


Population: A quantitative pretest-posttest design has been used, the nonprobability convenience sampling method [Figure 1] in the ICU at Salmaniya Medical Complex (SMC) Hospital.{Figure 1}


Tool (1): Demographic Data Sheet: A self-administered-questionnaire was designed by the researcher and utilized to be filled by staff nurses in 5 min. It included data related to the subject such as age, sex, years of experience, educational level, marital status, and duty shift.

Tool (2): A self-administered questionnaire to assess the nurse's knowledge of VAP and the VAP prevention bundle was adopted from the Lin et al. study after obtaining permission. Twelve questions were in the form of multiple-choice questions. The first six questions were about general VAP knowledge and the second six were about the VAP prevention bundle. This tool has been used in pre- and post-program implementation and answers were checked with a model answer obtained from the original researcher. One score was assigned for a true answer and zero score for a false answer.[8] The sum of scores was computed for each nurse and divided by the number of items, and then multiplied by 100 to find the final knowledge score for the nurse out of 100 before and after intervention.

Study procedure

This study consisted of the following three phases:

Pretest phase

Participants were given a multiple-choice knowledge questionnaire to assess their knowledge, and the researcher observed them during the filling period to prevent them from using their smart phones for searching or to avoid sharing answers between them. The time allotted for completing the questionnaire ranged between 7 and 10 min.

Intervention phase

During the implementation, the nursing staff were educated all over the three shifts about the VAP bundle throughout an educational package, and the schedule of teaching sessions was arranged with the nursing supervisor at ICU to not disturb the sequence of the work timetable, which was designed only for 20–30 min. Nurses received extensive educational courses in an innovative teaching method. A banner containing VAP bundle elements sized 116 cm × 160 cm was kept This area was chosen for the banner in front of the ICU's entering door [Figure 2] to attract nurses' attention at the start of the shift and to set the expectation for the education to develop in their minds. Then nurses on the specified shift were divided into two groups based on their workload; one group received the lecture and the second group was with patients to avoid work disturbance. Then the groups were switched. A group discussion, a PowerPoint presentation, and a brainstorming question card were given to the nurses.{Figure 2}

Posttest phase

During this phase, the nurse's knowledge was reassessed after the intervention by using the same questionnaire that was distributed in the prephase.

Ethical consideration

The ethical clearance was obtained from the Institutional Review Board from the higher studies committee department at the University of Bahrain to comply with the university's guidelines for ethical research, then approval from the ethics committee board at the Ministry of Health by members of the Research Technical Support Team was obtained. As well as approval from the Scientific Research and Publication Committee at the College of Health and Spout Sciences (CHSS SRPC recommendation No: 2/2020-21U) was gained. Finally, ethical consideration from the Secondary Health Care Research Committee has been taken. Formal consent has been taken from all nurses who were willing to participate.

Data analysis

IBM SPSS software package version 26.0. (Armonk, NY: IBM Corp) was used for data entry and analysis. Frequencies and percentages were computed for the categorical variables. Means and standard deviations were computed for the quantitative variables. The McNemar test, Wilcoxon Singed Ranked, and Kruskal–Wallis tests were used to determine whether there is a significant difference in proportion. The Chi-square test was used to determine whether there is a significant relationship between two categorical variables. In all statistical tests, a P < 0.05 was statistically considered significant.


The demographic characteristics of nurses in the study sample are described in [Table 1]. Nurses' age ranged between 30 and 50 years, with a mean ± standard deviation 37.1 ± 6.8 years, the majority of the nurses were female (81%). Regarding nurses' educational level, that around a quarter of nurses were holding Associate degree (20%) and the highest proportion were bachelor's degree holders (67.2%) while (12.1%) were only diploma holders. Concerning the years of experience, around two fifth of the nurses had 5–10 years of experience (37.9) and 27% of them had experience above 15 years.{Table 1}

[Table 2] describes the improvement in nursing knowledge pre-post educational program, and the results of all items were statistically significant except for one item regarding the type of oral care solution (P = 0.250). The pretest results revealed that more than half of the nurses (56.9%) did not know what the correct definition of VAP was, identified incorrect signs of VAP (67.2%), oral intubation protocol (72.4%), pathogenesis of VAP (63.8%), weaning process (32.8%), recommended position for ventilated patients (44.8%), and use of sedative and analgesic agents (74.1%). However, the result during the posttest highlights clearly the improvement in the nurse's knowledge.{Table 2}

[Table 3] indicates the improvement of the nurses' knowledge level in both gender with all age categories, different levels of education and duration of working in ICU, which obviously noticed the improvement with all relevant demographic characteristics. Unlike our expectations senior nurses might have better knowledge about VAP but the age group ≥40 years had the most participants who possess low knowledge level in pre phase (59.8 ± 11.1) but this age group had the highest proper knowledge after intervention (93.2 ± 6.6). This can be attributed to the effect of the educational program along with their age of experiences. As well as, being an ICU nurse for several year did not match what we thought regarding their knowledge, even nurses who worked in ICU from 11 to 15 years found to have low level of knowledge before the intervention (60.3 ± 12.8) and this had been changed to raised awareness in the post phase (91.7 ± 7.6), P < 0.002.{Table 3}

[Table 4] describes the total improvement of nurse's knowledge pre-post intervention, the results highlight clearly that almost all of ICU nurses had improvement of knowledge level pre-post regarding VAP (P < 0.001), VAP prevention (P < 0.001), and the overall knowledge score improvement revealed significantly higher after the educational Program (P < 0.001).{Table 4}


Knowledge is the backbone to preventing nosocomial infections and continuing nursing education is extremely important to improving patients' care.[9] Because nurses are the largest human resource in the health-care system, it is necessary to promote their knowledge to improve their quality of care and to provide safe services.[10]

In line with the demographic findings of the current study, Abdulfatah et al., 2020 reported that female nurses outnumbered male nurses, and 50.6% of them were married.[11] Nevertheless, as regards to age distribution, the author has reported a higher mean age of 28 years. However, Bankanie et al., 2021 who carried out a cross-sectional study to identify ICU nurse's knowledge and compliance toward evidence-based guidelines to prevent VAP and noticed the participants' age group between 31 and 39 years.[12] For the level of education in the present study the bachelor's degree holders were a large proportion which is consistent with Hassan et al., 2021 findings, who reported 76.7% of nurses were graduates. On the other hand, Dipanjali et al., 2021 have reported 56% of his population carries Diploma in nursing.[13]

The foregoing present study finding illustrating the improvement of nurses' knowledge about the definition of VAP, identification of Indicators of VAP and diagnostic criteria as in agreement with Hawsawi et al., have revealed statistically significantly higher score level post training program.[14] Bhandari et al., 2021 recently assessed the nurses' knowledge to identify the indicators of VAP and found that only 5.3% of nurses answered correctly.[15] Moreover, the findings of Khalifa and Eldin, 2020 were in accordance with our study findings as the authors highlighted the level of nurses' general knowledge was improved post educational program to identify the diagnostic criteria of VAP and the result showed statistically significant.[16] Therefore, in congruence with the present study findings, Sameen et al., who have stated 66.7% of participants provided correct answer for signs and symptoms of VAP.[17]

Moreover, concerning nurse knowledge about the best route of intubation, pre-post nurse's knowledge improved. This finding is contradicted with the cross-sectional study of Yeganeh et al., 2019 who assessed ICU nurse knowledge about evidence-based guideline for VAP prevention on 219 nurses, and found that more than half of nurses know the best route of intubation (56.7% had correct answer) and only 43.2% had misunderstanding.[18]

The pathogenesis and pathophysiology of VAP are always critical matters on which the treatment depends. The study finding highlighted that the nurses had information regarding the organisms that can be attributed to VAP development but didn't recognize the pathogenesis of VAP. Therefore, the participants got satisfactory knowledge level after the implementation of the educational program. These results are congruent with Khalifa and Eldin, 2020 who had identified the improvement of nurses' information regarding the same item post receiving training about 60%.[16] On the other hand, Manap, 2019 showed disagreement as described and found that 95% of the participants understood the common source of bacteria that causes VAP among intubated patients.[19]

As aspiration events are major risk factors for VAP, placing mechanically ventilated patients in the proper position would be effective in preventing this complication. In accordance with our finding the descriptive cross-sectional study that was done by Mohammed et al., 2020 who assessed the nurse's knowledge about the best position to prevent VAP and found that around half of nurses in the ICU recognized the preferred position to decrease risk of VAP (51.6%).[20] Nevertheless Branco et al., 2020 study results agree with the current study results in which their findings were statistically significant about head end of bed elevation P < 0.001. Similarly, Rafiei et al. 2020 carried descriptive study about emergency nurse's knowledge on VAP and 72.9% of them were knowing the correct answer of position strategies.[21]

Peptic ulcer disease prophylaxis and oral care knowledge and implantation are influenced by the organizational guidelines. That's why the nurse's knowledge of them in this study during the pretest is almost competent. This result is on the same line with Ismail, and Zahran's study, which identifies that 75% of nurses recognized the importance of Peptic ulcer prophylaxis as an element in the bundle.[22] Moreover, Mohammed et al. also mentioned that half of their population gave correct answers (51.6%).[20] In contrast, the descriptive study of Sobeih, et al., who reported an unsatisfactory level of knowledge about Peptic ulcer prophylaxis (85%).[23] As for oral care with chlorhexidine, result of this study is not significant, most of nurses know chlorhexidine 0.12% is the best solution to use for oral care in patients connected to mechanical ventilator, these results agree with cross sectional study finding of Mohammed et al. 2020 who found only 61 nurses out of 216 recognized the preferred solution for oral care.[20] Nevertheless, Abou Zed and Mohammed 2019 experimental study that was done to assess neonate nurses' knowledge about prevention of VAP showed significant difference in nurses' knowledge through pre-post program about oral hygiene with chlorhexidine.[24]

In line with the present study findings, Khaja whose study result was statistically significant between the total experience and knowledge toward prevention of VAP (P < 0.001) and found that as the years of experience increase, the level of knowledge increases.[25]

According to the study findings, the overall knowledge score indicates improvement in the area of general knowledge about VAP and knowledge about VAP bundle, this agrees with recent study done by Dipanjali et al., 2021 who reported significant difference in the knowledge of nurses after the intervention (P < 0.01).[6] Correspondingly, Elbilgahy et al., reported similar results in their quasi-experiment study about the effect of implementing training program on prevention of VAP among nurses, their results were statistically significant between pre-post training (P ≤ 0.0001).[26] Likewise, Hassan et al., 2021 mentioned that nearly half of ICU nurses answered correctly about VAP prevention measures and most of them had moderate knowledge about that.[13] In the light of study findings, the authors recommended that periodic refreshing on-services education program should be provided to nurses in ICU to improve their knowledge and to maintain high level of information, hospital policies should include updated guidelines for VAP prevention bundle and protocol from international evidence, further studies are recommended to be conducted in the future especially critical area units in SMC like CCU of COVID-19 ICU units to address the knowledge status, eventually assessing the impact of similar educational intervention over a longer period.


Updating ICU nurses with the most recent evidence-based practice in order to maintain a high level of quality care and prevent the most common infection in the ICU, reducing the length of stay and the Ministry of Health's financial burden. The study findings highlighted that the nurses had a poor level of knowledge regarding VAP and VAP prevention measures. Therefore, the improvement in nurses' awareness post educational program was statistically significant about the VAP prevention updated protocol, and the results of this research can be used to stimulate the theoretical knowledge into clinical practice.


Due to the pandemic of COVID-19 breakout, it was estimated that the existing ICU facilities would not be sufficient as 60% of occupancy was for medical ICU cases with 161 ventilator-occupied beds. Therefore, four ICU facilities were established to accommodate the positive cases of corona with 500 capacity beds. Consequently, the SMC ICU remained occupied with medical and some surgical cases without positive cases of COVID-19. However, due to the standardized precautions, the capacity of the ICU was reduced to almost half from 7 to 11 beds, and some of the nurses were shifted from the ICU to COVID-19 facilities. This can be considered a limitation of this study because it reduced the total sample size.


The authors would like to thank the nurses in the ICU for their participation in this study. They also extend their gratitude to the head nurses and ICU director for supporting this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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