Knowledge, Practice, Compliance, and Barriers toward Ventilator-Associated Pneumonia among Critical Care Nurses in Eastern Mediterranean Region: A Systematic Review

Background: Ventilator-associated pneumonia (VAP) has been identified as a serious complication among hospitalized patients and is associated with prolonged hospitalizations and increased costs. The purpose of this study was to examine the knowledge, practices, compliance, and barriers related to ventilator-associated pneumonia among critical care nurses in the eastern Mediterranean region. Methods: The PRISMA guidelines guided this systematic review. Four electronic databases (EMBASE, MEDLINE (via PubMed), SCOPUS, and Web of Science) were used to find studies that were published from 2000 to October 2021. Results: Knowledge of ventilator-associated pneumonia was the highest outcome measure used in 14 of the 23 studies. The review results confirmed that nurses demonstrated low levels of knowledge of ventilator-associated pneumonia, with 11 studies assessing critical care nurses’ compliance with and practice with respect to ventilator-associated pneumonia. Overall, the results showed that most sampled nurses had insufficient levels of compliance with and practices related to ventilator-associated pneumonia. The main barriers reported across the reviewed studies were a lack of education (N = 6), shortage of nursing staff (N = 5), lack of policies and protocols (N = 4), and lack of time (N = 4). Conclusions: The review confirmed the need for comprehensive interventions to improve critical care nurses’ knowledge, compliance, and practice toward ventilator-associated pneumonia. Nurse managers must address barriers that impact nurses’ levels of knowledge, compliance with, and practices related to ventilator-associated pneumonia.


Introduction
Ventilator-associated pneumonia (VAP) is the most common nosocomial pneumonia, occurring two and three days following endotracheal intubation [1]. VAP is distinguished by having a new progressive infiltrate, alteration in sputum characteristics, high white blood cell count, and high body temperate [2]. The first five days of intubation are considered the highest risk incidence of VAP, and the mean period from the time of intubation to the development of VAP is four days [3]. and Web of Science, were searched to identify relevant full-text studies in humans published between 2000 and October 2021. The first step was to search via online electronic databases and then analyze the article's title and abstract in-text words. Then, a second search was performed using all selected keywords and index terms across all of the listed databases. Finally, the reference lists of previous studies were examined for further relevant articles, and keywords were combined with Boolean operators, including AND and OR.

Inclusion and Exclusion Criteria
All published studies that examined knowledge, practice, compliance, and barriers toward VAP prevention guidelines among critical care nurses in the eastern Mediterranean region were included in this review. The eastern Mediterranean region is defined based on the WHO category [30]. (See http://www.emro.who.int/countries.html (accessed on 10 march 2020).Also, studies that used the cross-sectional design, randomized controlled trial or quasi-experimental study design, pre-post-test design, and self-report or observation method for data collection were included. All published studies that used several types of participant groups such as healthcare providers or students, unpublished graduate theses, review articles, case studies, conference abstracts, studies with low quality, and studies not in English were excluded.

Study Identification
In the filtration and screening phase, two researchers independently filtered for duplicates of the titles and abstracts of all studies. After removing duplicates, the independent authors performed a screen for potential relevance to the eligibility criteria and coded it as "cover". After independent screening, disagreements were resolved by reaching a consensus. A third independent reviewer was consulted to resolve the disagreement if a consensus could not be reached. Studies with appropriate data were included in the systematic review. The required data extracted included study characteristics (year of publication, data collection method, participants, sampling method) and levels of nurses' knowledge, practice, and compliance with VAP.

Risk of Bias
The Office of Health Assessment and Translation (OHAT) tool was used to assess the risk of bias [31]. The OHAT tool was adopted according to CLARITY Group guidance at McMaster University. The OHAT tool includes six domains (selection, confounding, performance, attrition/exclusion, detection, and selective reporting). The risk-of-bias ratings for each domain four answers "definitely low," "probably low," "probably high," and "definitely high." Two authors assessed each paper for risk of bias, and discussions resolved any discrepancies.

Study Selection
A total of 2520 articles were identified from the initial search in 4 online electronic databases. After the deletion of duplicates, 1719 studies were addressed for further screening. After reading the abstract and full texts, 1625 articles were excluded. Full-text articles were assessed for eligibility, and 94 articles were included. A total of 71 articles were excluded for several reasons, including studies not conducted in the Eastern Mediterranean region (49 articles), mixed populations (15 articles), written in languages rather than English (6 articles), and conducted on nursing students (1 article). Finally, according to the independent researcher's agreement, 23 studies were included in the final review ( Figure 1).

Used Instruments
Of the 23 studies, 10 studies used standardized instruments and mentioned the number of instrument items [22][23][24][25][32][33][34]40,44]. Two studies used probing questions and openended interview questions [36,38]. Two studies had the lowest number of instrument items (N = 9) in terms of VAP knowledge [39,48], while the study of Al Shameri (2017) had the highest number of instrument items (N = 40) [50]. In terms of compliance and practice, Aloush's (2017) study included the lowest number of instrument items (N = 8) [23], while two studies included the highest number of instrument items (N = 17) [40,44]. In terms of instruments' psychometric properties, 11 studies reported the validity score of the instrument. The reported Cronbach's alphas in the reviewed studies ranged from 0.69 to 0.92. See Table 2 for further details.

Nurses' General Knowledge of VAP
The knowledge of VAP was the highest measure used in 14 studies of the 23 studies. In most studies, the knowledge level was classified as low, inadequate, significant improvement after education, or poor. Only one study reported that nurses had "adequate knowledge" [24]. Of the 14 studies, 4 studies reported nurses' level of knowledge as "low", 3 studies characterized the level of knowledge as "inadequate," and another 3 studies mentioned that nurses had "significant improvement after education". The remaining two studies reported that nurses had "poor knowledge". In the last remaining study, nurses had "unsatisfactory knowledge". The overall results showed that nurses had a low VAP knowledge level. See Table 2 for further details.

Nurses' Compliance and Practice of VAP
Of the 23 studies, 11 assessed critical care nurses' compliance with VAP practices. Critical care nurses' practice and compliance levels were classified as high, insufficient, and acceptable. Only one study mentioned that nurses had a "high level" of compliance and practice of VAP [32]. Of the 11 studies, 4 reported participants' insufficient compliance and practice of VAP, and in 2 studies, the participants had an "acceptable level." The overall results showed that most nurses had insufficient compliance with and knowledge of VAP practices. See Table 2 for further details.

Quality of Studies
In general, the majority of studies reported as having a high quality level with low bias. The most commonly found terms "Definitely High" and "Probably High" were related to the confounding, performance and attrition/exclusion. Of the 23 studies, 4 studies reported "Definitely High" in terms of confounding [26,39,42,43]. Two studies reported "Probably High" related to performance [28,43]. See Table 3 for further details.

Barriers to Adherence to VAP Guidelines
Nine studies assessed barriers to adherence to VAP guidelines of the overall included studies. The most-reported barriers in several studies were (1) lack of education (N = 6), (2) shortage of nursing staff (N = 5), (3) lack of policies and protocols, and lack of time (N = 4). Table 4.

Discussion
This systematic review examines knowledge, practices, compliance levels, and investigates barriers to VAP prevention among critical care nurses in the eastern Mediterranean region. The overall results showed that nurses in the eastern Mediterranean region had a low level of knowledge of VAP prevention than critical care nurses in Europe, in which studies reported that the nurses had adequate knowledge of VAP prevention [51,52]. The possible reason for this variance may be attributed to differences between education systems and institutional policies. Intervention studies are efficient for improving nurses' VAP knowledge and considering vital for a significant decrease in VAP incidence and the cost of treatment [33,35]. For example, in a prospective cohort study conducted in 5 different countries among 44 ICUs to examine the effect of multidimensional sessions, the study showed that VAP rates were significantly reduced after implementing the training and educational sessions [53]. The level of nurses' knowledge was raised after the implementation of the training, as they were enabled to identify the correct evidence-based VAP preventive measures [52]. Additionally, after the training, nurses were able to identify which preventive measure priorities are classified as highly, moderately, and less recommended based on VAP guidelines [21].
Of the 11 studies, only one mentioned that nurses had high compliance and practice levels related to VAP [32]. Higher adherence to VAP bundles may present challenges outside a nurse's control, such as gaining resources, continuing education, and observation schedules [25]. In addition, applying active strategies, such as incentives, support for the decision, regular observation, and assessing bundle issues might be more cost-effective than appropriate to encourage nurses to perform and adhere to the bundle [52]. Reinforcement of compliance and practice of VAP should be conducted regularly and evaluated for proper performance during their clinical work.
The current study observed variability in the study design, instrument standards, validity, and data collection methods. The cross-sectional, descriptive design was utilized in more than half of the reviewed studies. Although these designs are quick and inexpensive to conduct, they may demonstrate several challenges, such as difficulty interpreting relationships identified and making a causal inference [54][55][56][57]. Using a qualitative or mixed-method design would have given in-depth and more specific responses from the participants than the self-reported instruments used [58][59][60]. Furthermore, qualitative design may be more convenient for focusing on barriers faced by nurses and how nurses' knowledge influences their compliance toward using VAP bundles in clinical practice [36]. Most instruments were adopted for measuring variables knowledge, compliance and practice of VAP, but there have often been many adaptations and replications of the same instrument. These frequent adaptations and replications may limit the clarity of the instrument construct by retaining the original name and using the instrument without re-validation. Eleven studies did not examine the instrument's validity. These findings were similar to international studies that do not report the reliability and validity of VAP instruments [61][62][63]. This indicates that survey results may not be consistent as various instruments were utilized to examine the same variables. The strength of instruments depends on the magnitude and their psychometric test scores [64]. The majority of studies used self-report and self-administrated methods for measuring their variables. Although self-report and self-administrated questionnaires are useful with a large sample and are inexpensive, their response rates can be low [54]. Previously published studies have demonstrated that the self-report method has several limitations, such as exaggeration of compliance rate, recall biases, high floater answers, and acquiescence or agreement bias [25,35]. Using direct observation as a collecting data method with validated instruments may lead to a more precise evaluation of VAP practices [22]. A convenience sampling method was used in the majority of the selected studies. Convenience sampling may yield difficulty generalizing the findings and have limited external validity [65][66][67]. Future studies should use rigorous sampling from a large population.
Several recommendations are mentioned for the reviewed studies. The lack of education was the most reported barrier to optimal management of VAP, highlighting a significant weakness in nursing curricula (as reported in prior studies) [35,68]. These studies indicated that the lack of in-service education could have increased the risk of VAP complications. Continuous education has been strongly recommended as the cornerstone of nurses' knowledge and compliance improvement for VAP management [23]. In this study, nurses also reported that shortage of nursing staff and lack of policies and protocols as the most common barriers encountered in clinical practice settings. Having these kinds of barriers might cause a lack of compliance. This finding was consistent with studies noted that developing policies and protocols to standardize the implementation of a bundle was a substantial factor in implementing a bundle [23,68].

Limitations
The main methodological shortcoming in this study is the inadequate number of covered studies. Another limitation is excluding published studies in languages other than English, which may introduce a selection bias. The studies have not discussed how to address common method bias. Common method bias can be reduced by the utilization of several data collection methods, number of items, validity of contents, and times and locations required to obtain accurate results. However, this exclusion was applied to ensure that identified studies had high quality and integrity. The selected studies were conducted only in the Eastern Mediterranean region, which yielded only seven countries, and this may limit the generalizability of the results.

Conclusions
This is the first systematic review conducted to examine knowledge, practices, compliance levels and investigate barriers to VAP prevention among critical care nurses in the eastern Mediterranean region. The review results confirmed that nurses in the eastern Mediterranean region showed low levels of knowledge and insufficient levels of compliance of ventilator-associated pneumonia. This indicated that nurse managers and policymakers take on their considerations enhancing nurses' preparation for working in critical care units. Although several barriers might interfere with nurses' best practice such as a lack of education, shortage of nursing staff, lack of policies and protocols, and lack of time, applying tailored educational programs may help improve nurses' knowledge and compliance and help eliminate these barriers.