Knowledge Regarding Mechanical Ventilation and Practice of Ventilatory Care among Nurses Working in Intensive Care Units in Selected Governmental Hospitals in Addis Ababa, Ethiopia: A Descriptive Cross-Sectional Study

Introduction Mechanical ventilation (MV) is a backbone and major supportive modality in intensive care units (ICUs) even though it has side effects and complications. Knowledge of nurses about mechanical ventilators and good practice of nursing care for the ventilated patient plays a crucial role in improving the effectiveness of mechanical ventilation, preventing harm, and optimizing the patient outcome. This study intended to assess the knowledge regarding MV and the practice of ventilator care among nurses working in the ICU. Method A descriptive cross-sectional study design was conducted. All nurses working in the intensive care unit of selected governmental hospitals were included in the study. The data were collected from March 1 to 30, 2021 with structured and pretested self-administered questionnaires. The collected data were evaluated with SPSS version 26 software. The variables, which have an independent association with poor outcomes, were identified based on OR, with 95% CI and a p value less than 0.05. Results Of 146 nurses who participated in the study, 51.4% were males. About 71.4% had a BSc in nursing and 57.5% of them had training related to MV. More than half (51.4%) of nurses had poor knowledge regarding MV and the majority (58.9%) of them had poor practice in ventilatory care. The educational level (AOR, 5.1; 95% CI, 1.190–22.002) was positively associated with knowledge. Likewise, the educational level (AOR 5.0 (1.011–24.971)) and work experience (AOR 4.543 (1.430–14.435)) were positively associated with the practice of nurses. Conclusions Knowledge regarding mechanical ventilators and the practice of ventilatory care among nurses in the selected public hospitals was poor. The educational levels were found statistically associated with both the knowledge and practice of nurses. To improve nursing care offered for MV patients, upgrading the educational level of intensive care nurses plays a vital role.


Introduction
One-third of the patients admitted to the intensive care unit (ICU) in the world need mechanical ventilation (MV) treatment. Mechanical ventilator support is one of the main indications for admission to the intensive care unit (ICU).
Te continuous development of mechanical ventilators and their clinical use have been critical factors for the development and growth of critical care and respiratory professions [1,2].
A mechanical ventilator is a machine that is essential to support patients to breathe when they are unable to ventilate and oxygenate on their own due to critical illness or having surgery. Patients are connected to a ventilator by a hollow tube that goes from their mouth to their trachea, thereby providing the function of respiratory muscles. In the meantime, the patient remains on the ventilator until they can breathe independently [3].
Even though mechanical ventilation can save lives, it also carries several side efects and complications such as asynchrony, auto-PEEP, barotrauma, hemodynamic compromise, nosocomial infection, anxiety/stress/sleep deprivation, ulcers/gastritis malnutrition, and muscle deconditioning/vent dependence. Increased intrathoracic pressure may lead to systemic edema because the venous return is decreased [4]. Tis is often with prolonged mechanical ventilation, increased mortality, prolonged hospital stay, and high cost to the patient [5]. In developed countries, 2 to 3 million intensive care unit patients receive invasive mechanical ventilation per year at estimated costs of 15-27 billion dollars [6].
Te management of critically ill patients has become increasingly important in modern medical and nursing systems. Critical care nurses play a crucial role in improving the efectiveness of mechanical ventilation, preventing harm, and optimizing patient outcomes. Te skills and knowledge of health teams regarding the care of a patient on a mechanical ventilator and patients' clinical status enable them to fne-tune ventilator settings to maximize the benefts of ventilator support while minimizing complications [5,6].
Knowledge of nurses about the functions and limitations of ventilator modes, causes of distress, dyssynchrony with ventilator, and appropriate management enable them to provide high-quality centered care [7,8]. As nurses are the frst-line manager challenged with patients' and ventilators' problems, it is crucial to recognize the problems such as respiratory distress, dyspnea, and increased work of breathing, and the actions to be taken to solve these problems. So, the nurses who provide care for ventilated patients must understand the basic ventilator support including ventilator mode, setting, and alarms. It is also important to be skilled in promptly identifying and managing common patient and ventilator-related problems to provide optimal patient-centered care and prevent complications [9].
Studies have shown that ICU nurses' knowledge of mechanical ventilation is globally poor. A study conducted in South Africa has reported that even in high-income countries where nursing education is advanced, the levels of knowledge on mechanical ventilation are not perfect [8].
Terefore, this study is anticipated to be crucial, as it will intend to discover more data regarding the levels of knowledge and practice of nurses working in the ICU on mechanical ventilator utilization.

Study Design.
A cross-sectional study design was conducted to assess the knowledge regarding mechanical ventilators and the practice of ventilatory care among nurses working in the intensive care unit.

Study Setting and Period.
Te study was conducted in Addis Ababa, which is the capital city of Ethiopia. Te town is the seat of the Africa Union and diferent continental organizations. Te city consists of 34 private hospitals and 14 public hospitals [7,9]. Te study was conducted in purposively selected fve intensive care units of selected public hospitals. Tese are Tikur Anbessa, St. Peters, AaBET, Yekatit12, and Menelik II Hospitals where well-organized ICU services with a full mechanical ventilator are provided. Te study was conducted from March to April 2021 among intensive care nurses at selected public hospitals.

Study Participants.
Te source population was all nurses who were working in intensive care units of the selected governmental hospitals in Addis Ababa, Ethiopia. Eligibility criteria included having experience in the intensive care unit at least for six months and having consent to participate in the study. Tus, this study included participants from fve selected public hospitals.

Sample Size Determination.
All nurses working in the ICU of selected hospitals who fulflled the inclusion criteria were taken as the sample size of the study.

Dependent Variables.
Te dependent variable in this study was the knowledge of nurses regarding mechanical ventilators and the practice of ventilatory care.

Independent
Variable. Independent variables of the study included sociodemographic variables such as age, sex, educational level, work experience, and training.

Data Collection Techniques and Instrument.
A selfadministered structured questionnaire was utilized to collect information from each participant. Te English version of the questionnaire was adopted from diferent literature based on elements intended to study. Te questionnaires have three parts; part one sociodemographic factors, part two knowledge assessment consisting of 16 items, and part three practice assessment questions consisting of 25 items.

Data Quality Assurance.
Te questionnaire was pretested before data collection and the possible corrections were made. Besides, two days of training were provided for the data collectors and supervisors. Te data collectors were health professionals, who hold a Bachelor of Science in Emergency and Critical care nursing, for better understanding and interpretation of the questionnaire. Additionally, a pilot test was conducted but the results were excluded from the actual study. Based on the feedback from the pilot study, immediate corrective measures were taken. Furthermore, continuous and close supervision of the data collecting procedures, proper categorization, and coding of the data were conducted. Te Principal Investigators and the 2 Critical Care Research and Practice supervisors checked the completeness and consistency of data daily.

Data Entry and Analysis
Procedure. Te collected data were entered with Epi-Data version 4.6 and analyzed with SPSS version 26.0 software. Participants' characteristics were examined using frequency, percentage distribution, mean, and standard deviation. Te binary logistic regression analysis was conducted and all independent variables with a p value less than 0.25 were included in a multivariable logistic regression model to identify factors associated with knowledge regarding MV and practices of ventilatory care. Te level of association and statistical signifcance was measured using an odds ratio with a 95% confdence interval. Te statistical signifcance was set at p value <0.05.

Ethical Consideration.
Permission to conduct the research was obtained from AAU, CHS research standards, Ethics Committee, and Addis Ababa public health and emergency directorate. Te research purpose, benefts, and procedures were explained to each potential respondent. Te respondents gave an informed written and oral consent and any respondent seeking further clarifcation was provided. Te information that the respondents provided during the study was kept confdential.

Sociodemographic Characteristics.
Te average age of the participant was 29.84 years (SD � 4.95). Approximately half of the participants were male 71 (51.4%), and the majority 104 (71.2%) had a bachelor's degree. Concerning training, most (57.5%) of the respondents had training related to a mechanical ventilator (Table 1).

Description of the Knowledge of the ICU Nurses Related to
Mechanical Ventilation. More than half of the participants, that is, 75 (51.4%) had poor and 71 (48.6%) had good knowledge regarding mechanical ventilators ( Figure 1).  (Figure 2).

Te Item-Wise Practice of Nurses Related to Ventilator
Care. Practice related to ventilator care revealed that most of the 134 (90.4%) participants preoxygenated the patient before suctioning, 61 (41.8%) of them did suction as per needed, and more than two-thirds of 106 (72.6%) nurses instill normal saline before suctioning. Te Majority of 117 (80.1%) nurses check the level of the endotracheal tube and 54 (37%) of them change the position of ETT every 24 h (Table 3).
Nearly half of 74 (50.7%) participants recognized the complications of ETT. Study participants employed various eye care methods. Among these, the majority 105 (71.9%) of the participants were wiping eyes from the inner canthus to out, 59 (40.4%) taped their eyes shut, and 46 (31.5%) of them used teardrop as an eye care method. A total of 79 (54.1%) of these individuals practice oral hygiene once a day, whereas 52 (35.6%) practice it twice a day. Additionally, two-thirds of the participants, 90 (61.6%), used chlorhexidine to clean patients' mouths, while 30 (20.5%) of them used sodium bicarbonate.
More than half of 78 (53.4%) participants recognized anxiety-related fndings on a mechanical ventilated patient. Various methods have been used to relieve the anxiety of the patient receiving ventilation. Most 106 (69.2%) relaxed the patients by talking to them, 52 (35.6%) helped the patients to express themselves in writing, and 72 (49.2%) helped them by contacting family members. More than two-thirds of 101 (69.2%) participants were not following the ventilator care bundle.

Factors Associated with Knowledge of Nurses Working in ICU Regarding Mechanical Ventilation.
In multivariate logistic regression analysis, the educational level was Critical Care Research and Practice 3 found to be a statistically signifcant positive association with the knowledge level at a p value of less than 0.05, but the other variables were not found to be statistically signifcant. Te odds of those who had a diploma were 5.116 times more likely (AOR, 5.116; 95% CI, 1.190-22.002) to have poor knowledge than those who had an MSc (Table 4).

Factors Associated with Nurses' Level of Practice toward Caring for Patients on Mechanical Ventilation Support.
Regarding the factors associated with the level of practice educational level and work experience had a signifcant positive association at a p value less than 0.05. Te probability of those who had a diploma was 5.024 times (AOR 5.024 (1.011-24.971)) less likely to have a good practice than those who had MSc. On the other hand, those who had an experience of more than ten years were 4.543 times (AOR 4.543 (1.430-14.435) more probable to have good practice than those who had an experience of 1-5 years (Table 5).

Discussion
Nurses play a crucial role in the management of patients on mechanical ventilators. Tere is no doubt that nurses must have in-depth scientifc knowledge and demonstrate evidencebased practice in providing care to mechanically ventilated patients. So, this study aimed to determine the knowledge level of nurses working in ICU regarding MV and their practice level towards caring for a patient on MV support.
In this study, more than half (51.4%) of the study participants were male and a majority (58.9%) of the nurses were in the age group of (20-29) years old. Tis fnding was similar to a study conducted in Iraq and India, which showed that 58% and 64% of the participant were male and the majority 55% and 58% of nurses were in the age group below 29 [4,8].
Regarding the training-level majority (57.8%) of ICU nurses had training related to a mechanical ventilator. However, the study conducted in Egypt, Iraq, and Turkey showed a lower level of trained nurses in their ICUs, which are 36%, 56%, and 30%, respectively [5,8,10]. Tis diference might be due to this research conducted where considerable attention is given to critical care.
More than half (51.4%) of the study participants had poor knowledge of mechanical ventilation. Tis fnding agrees with the study conducted in southern India in which 53.5% of the nurses had poor knowledge [11]. On the other hand, the study conducted in Sri Lanka and Eastern India showed a higher knowledge level among nurses, which are 73% and 69.7%, and had good knowledge regarding mechanical ventilation [6,12]. Tis discrepancy could be attributed to the sociodemographic diference and the diference in the type of ICU.     Te majority (58.6%) of nurses had poor practice regarding the care of a patient on a mechanical ventilator. Tese results are consistent with other research which found that the majority (93%) of ICU nurses had poor practice regarding the care of a patient on a mechanical ventilator [11]. However, the study from Sri Lanka revealed that the majority (57.8%) of the nurses had good practice regarding the care of ventilated patients [13]. Tis inconsistency may be due to the diference in the tool used to assess the practice and another possible explanation for this is the diference in the study setting.
A signifcant relationship was found between nurses' educational level and their knowledge in this study. Nurses who had diplomas were found to have less knowledge about mechanical ventilators than BSc and MSc holders. Tis fnding is consistent with that of the study in Sri Lanka, in which the educational level was statistically associated with nurses' knowledge level. Similarly, those who had diplomas had less knowledge than BSc and MSc holders [13].
Te educational level and work experience of nurses were signifcantly associated with the practice of nurses. Our fnding is diferent from the study conducted in Egypt, which showed job position as a factor that afects the practice level. Tese results are probably related to the socioeconomic diferences between study settings.

Limitations of the Study.
Te results of this study are subject to some limitations. Due to the cross-sectional nature of the study, no direct intervention or direct observation of the study participant was conducted. Te limited number of nurses is another limitation. Although this study has limitations, it also has a strength. It is the frst study that attempts to assess the level of knowledge regarding the MV and ventilatory care practice among nurses working in the ICU of selected government hospitals in Addis Ababa, possibly in Ethiopia. It also tried to incorporate most of the pertinent components of ventilator care.

Generalizability.
Te potential generalizability of the evidence generated by this study to other settings should be considered in view of the study setting, context, methods, and limitations described in this study.

Conclusion
Knowledge regarding mechanical ventilators and the practice of ventilatory care among nurses in the selected public hospitals was poor. Te educational level was found to be statistically associated with both the knowledge and practice of nurses. Additionally, years of experience were also signifcantly associated with the level of practice. To improve nursing care ofered for mechanically ventilated patients, upgrading the educational level of intensive care nurses plays a vital role.

Data Availability
Te datasets used and/or analyzed during the current study are available without restriction.

Ethical Approval
Ethical approval was obtained from Addis Ababa University and Addis Ababa Health Bureau Public Health Research and Emergency Directorate.

Consent
Permission letter was secured from Addis Ababa University and Addis Ababa Health Bureau Public Health Research and Emergency Directorate. Te written consent was taken from study participants after the purpose of the study had been explained. Tey were informed to withdraw at any time and/or to refrain from responding to questions. Moreover, participants were told that personal identifers would be replaced by codes to ensure the confdentiality of their data.

Conflicts of Interest
Te authors declare that they have no conficts of interest.