Introduction

Background of Study

Ventilator-associated pneumonia (VAP) is common in the intensive care unit (ICU), affecting 8 to 20% of ICU patients and up to 27% of mechanically ventilated patients.[1]

Several risk factors have been reported to be associated with VAP, including the duration of mechanical ventilation, and the presence of chronic pulmonary disease, sepsis, acute respiratory distress syndrome (ARDS), neurological disease, trauma, prior use of antibiotics, and red cell transfusions.[2]

Mortality rates in patients with VAP range from 20 to 50% and may reach more than 70% when the infection is caused by multi-resistant and invasive pathogens.[3]

The incidence of VAP-attributable mortality is difficult to quantify due to the possible confounding effect of associated conditions, but VAP is thought to increase the mortality of the underlying disease by about 30%. VAP is also associated with considerable morbidity, including prolonged ICU length of stay, prolonged mechanical ventilation, and increased costs of hospitalization.[4]

Delayed diagnosis and subsequent delay in initiating appropriate therapy may be associated with worse outcomes in patients with VAP on the other hand, an incorrect diagnosis may lead to unnecessary treatment and subsequent complications related to therapy. Early, accurate diagnosis is, therefore, fundamental in the management of patients with VAP.[5,6]

Several criteria have been proposed for diagnosing VAP in clinical settings, including clinical manifestations, imaging techniques, methods to obtain and interpret bronchoalveolar specimens, and biomarkers of host response. Due to the lack of an acceptable gold standard, the accuracy of these methods in diagnosing VAP is controversial.

The aim of this qualitative review was, therefore, to compare various criteria for diagnosing VAP in the ICU with a special emphasis on the value of clinical diagnosis, microbiological culture techniques, and biomarkers of host response.

In today’s health care environment, there is heightened awareness of the importance of infection control and prevention. This concern is partly in response to the high number of nosocomial infection acquired each year, posing serious problem in terms of morbidity, mortality and overall costs for health care system.[7]

Need of the Study

Patient in any hospital are exposed to healthcare – acquired infections and it become critical when they are in intensive care unit to their various diseased conditions. Hence the heath care personal should take enough steps to prevent or break the chain of infection.

There is a global consensus regarding the gap, between the importance of infection control training in basic health science programs and in work – place.[8]

The experts in the line of infection control are very few. Hence creating awareness about different ways and means to prevent and control infection among the nurses become inevitable in order to deliver quality care. To improve the access to training, a research was initiated to develop an online infection control and prevention program.[9]

In intensive care unit when patient are on ventilators they are at a very high risk for developing ventilator associated pneumonia. Ventilator associated pneumonia which results in increased mortality, increased length of stay and increased cost.[10]

Education intervention on ventilator associated pneumonia among intensive care unite nurses will bring awareness and motivation in preventing and controlling ventilator associated pneumonia in intensive care units. This is also increase in the confidence level in nurses, making them powerful advocates for their patients and their right which, in turn, result in faster recovery. The researcher wants to increase the motivation and confidence level in nurses which will give a quality output.

A descriptive cross-sectional survey was carried out in 37 ICUs of 23 hospitals in Sana’a city, Yemen. A self-administered multiple-choice questionnaire listing 15 evidence-based preventive strategies was distributed to all nurses. Nurses had the least knowledge (<24%) regarding frequency of humidifier and suction systems changes, use of kinetic beds, and oral route for tracheal intubation. The nurses’knowledge mean total score was 47.3% (7.1 on 15 items). Holding a bachelor degree in nursing and acquisition of a short course in respiratory therapy were shown to be associated with better knowledge scores. Knowledge of evidence-based strategies for preventing VAP is low among most nurses working in Yemen ICUs.[11]

A study was conducted to evaluate the knowledge of nurses working in general intensive care units concerning evidence-based measures for the prevention of ventilator-associated pneumonia. Cross-sectional design was used. It was carried out on nurses working in the general intensive care units of anesthiology. The median value of total points scored by nurses on the questionnaire was 4.00 ± 2.00. The difference between the nurses' education levels, duration of work experience and articipation in in-service training programmes on ventilator-associated pneumonia prevention and the median value of their total scores on the questionnaire was found to be statistically significant (p < 0.05). The conclusion of the study was that critical care nurses' knowledge about ventilator-associated pneumonia prevention was found poor.[12]

A study was conducted on Ventilator-associated pneumonia (VAP) continues to be a common and potentially fatal complication of ventilator care. The aim of this study is to assess the critical care nurses' knowledge and compliance with ventilator associated pneumonia bundle. A sample of convenience of 45 critical care nurses was recruited from different critical care units at Cairo university hospital for this study. Questionnaire and direct observation of nurses who provided nursing care to mechanically ventilated patients was carried out utilizing VAP bundle compliance checklist. The results of 20- items questionnaire revealed unsatisfactory knowledge scores (mean= 7.46 + 2.37) and most of the nurses were not compliant with ventilator associated pneumonia bundle practices (average mean = 8.62 + 7.9 out of 29). The findings of the study recommended the need for developing and implementing a protocol for VAP prevention in ICUs.[13]

A study was conducted to examine critical care nurses’ knowledge about the use of the ventilator bundle to prevent VAP. After the education sessions, the nurses performed better on 8 of the 10 items tested (P from 0.3 to <.001). The areas of most significant improvement were elevation of the head of the bed (P < .001), charting of the elevation of the head of the bed (P= .009), oral care (P= .009), checking of the nasogastric tube for residual volume (P = .008), washing of hands before contact with patients (P < .001), and limiting the wearing of rings (P < .001) and nail polish (P = .04). Even after the education sessions, the nurses’ compliance with hand-washing recommendations before contact with patients was low, though statistically some improvement was apparent.[14]

During my clinical experience, I had found that many of prolonged bed ridden patient develop ventilator associated pneumonia and the main cause is poor sterile technique while doing improper suctioning, improper positioning, improper ryles tube feeding etc. For that I felt to enhance the knowledge regarding prevention of ventilator associated pneumonia among staff nurses.

Statement of the Problem

“A Study to Assess the Effectiveness of structured teaching program on knowledge regarding prevention of Ventilator Associated Pneumonia Among Staff Nurses in Selected Hospital At Jaipur”.

OBJECTIVE OF THE STUDY

1.To assess the knowledge level of intensive care unit nurses on prevention of ventilator associated pneumonia.

2.To assess the effectiveness of the structured teaching program.

3.To determine the association between the pre test and post test scores with selected demographic variables.

OPERATIONAL DEFINITION

Knowledge

In this study it refers to the correct level of response from the participation regarding ventilator association pneumonia elicited through structured questionnaire.

In this study it refers to significant gain in knowledge and practice as determined by pre test and post test knowledge scores on prevention of ventilator associated pneumonia.

Structured teaching program

In this study structured teaching program refers to the information providing to intensives care unit nurses regarding ventilator associated pneumonia through a systematically developed instruction and teaching aid.

Staff nurse

A person who had received the appropriate education and training in the discipline of nursing, a person specially trained to provide services essential to or helpful in the promotion, maintenance and restoration of
health and well being, a person skilled in nursing.

Ventilator associated pneumonia

In patients receiving invasive mechanical ventilation, a new and persistent infiltrate seen on chest x-ray associated with fever, elevated or depressed white blood cell counts, and sputum that is either purulent or full of disease-causing bacteria.

ASSUMPTIONS

The study assumes that:-

1.The staff nurses may have some knowledge regarding prevention of ventilator associated pneumonia.

2.Demographic variables may influence the knowledge regarding prevention of VAP.

3.STP is useful strategy to increase knowledge of staff nurses regarding VAP.

4.Staff  nurses knowledge regardingprevention of ventilator associated pneumonia may decrease the future incidence of VAP.

Delimitation

The study is limited to Staff nurses working in ICU

Conceptual Frame Work

A conceptual framework is the processor of a theory. It provides broad perspectives for nursing practice, research and education. Conceptual frame work plays several interrelated roles in the progress of science. In nursing, conceptual model identify concepts and describe their relationships to the phenomena of central concern to the discipline. It helps to conceptualize and plan care. Their overall purpose is to make scientific findings meaningful and generalizable.[27]

Polit and Hungler state that “A Conceptual framework is an interrelated concept on abstractions that are assembled together in some rational scheme by their virtue of their relevance to a common theme. It is a device that helps to simulate research and the extension of knowledge by providing both direction and impetus” Present study aimed at evaluating the effectiveness of structure teaching programme on knowledge regarding prevention of ventilator associated pneumonia among staff nurses working in selected hospitals at Jaipur.[27]

The conceptual framework of the present study was developed by the investigator based on Imogene King’s Goal Attainment Model. This model focus on interpersonal relationship between the client and staff nurse and this interaction is influenced by the perception leads to both client and nurses. This interaction leaded to mutual goal setting that are to be achieved by the subjects, in the present study the interaction took place between the investigator and staff nurses.[27]

Perception

Perception is a process in which data obtained through senses and from memory are organized, interpreted and transformed, which are related to past exercise, concept of self and educational background. In the present study investigator and staff nurses perceived the need to gain knowledge regarding ventilator associated pneumonia. Both the investigator and the staff nurse set the goal to gain knowledge regarding prevention of ventilator associated pneumonia and to improve the practices.