Barriers to Safe Oxygen Therapy and the Effect of the Training on the Knowledge and Performance of ICU Nurses

Introduction Proper oxygen therapy is crucial in hospitals, particularly intensive care units, to ensure safety and accuracy. The role of nurses during oxygen therapy is vital, as their knowledge and correct performance significantly impact patients' clinical conditions. A study was carried out to examine the knowledge and performance of nurses regarding safe oxygen therapy. The study aimed to identify the obstacles hindering safe oxygen therapy and assess the impact of training on the knowledge and performance of intensive care nurses. Methods This study was conducted among the ICU nurses at Shahid Rahnemoun Teaching Hospital in Yazd, Iran. The study method is a sequential combination of descriptive, qualitative, and educational phases. The first stage involved examining the knowledge and performance of 80 ICU nurses in oxygen therapy. The study employed content analysis to elaborate on participants' perspectives on safe oxygen therapy challenges and potential solutions. The third phase involved a two-group study with pre- and post-tests to examine the effect of training on ICU nurses' knowledge and performance in oxygen therapy. Results The study found that intervention and control groups had low average scores in knowledge, performance, and total score of oxygen therapy before the study, with no significant difference. There was a significant difference between intervention and control groups one and three months after the intervention in the areas of knowledge (after-1 month 24.41 vs. 20.29, 95% CI [3.144–5.098], after-3 month 22.13 vs. 20.24, 95% CI [0.729–3.053]), performance (after-1 month 21.54 vs. 18.05, 95% CI [2.898–4.073], after-3 month 19.74 vs. 18.63, 95% CI [0.400–1.824]), and total score of oxygen therapy (after-1 month 45.95 vs. 38.34, 95% CI [6.288–8.925], after-3 month 41.87 vs. 38.87, 95% CI [1.394–4.613]). Conclusion The study's findings revealed that nurses in ICUs lack the appropriate knowledge and performance in oxygen therapy. A lack of knowledge and correct practice, insufficient monitoring of oxygen therapy, and defects in hospital equipment are contributing factors. The training was found to improve the knowledge and performance of nurses significantly. Consistent training at shorter intervals is suggested for nurses to keep their knowledge current.

Introduction.Proper oxygen therapy is crucial in hospitals, particularly intensive care units, to ensure safety and accuracy.Te role of nurses during oxygen therapy is vital, as their knowledge and correct performance signifcantly impact patients' clinical conditions.A study was carried out to examine the knowledge and performance of nurses regarding safe oxygen therapy.Te study aimed to identify the obstacles hindering safe oxygen therapy and assess the impact of training on the knowledge and performance of intensive care nurses.Methods.Tis study was conducted among the ICU nurses at Shahid Rahnemoun Teaching Hospital in Yazd, Iran.Te study method is a sequential combination of descriptive, qualitative, and educational phases.Te frst stage involved examining the knowledge and performance of 80 ICU nurses in oxygen therapy.Te study employed content analysis to elaborate on participants' perspectives on safe oxygen therapy challenges and potential solutions.Te third phase involved a two-group study with pre-and post-tests to examine the efect of training on ICU nurses' knowledge and performance in oxygen therapy.Results.Te study found that intervention and control groups had low average scores in knowledge, performance, and total score of oxygen therapy before the study, with no signifcant diference.Tere was a signifcant diference between intervention and control groups one and three months after the intervention in the areas of knowledge (after-1 month 24.41 vs. 20.29,95% CI [3.144-5.098],after-3 month 22.13 vs. 20.24,95% CI [0.729-3.053]),performance (after-1 month 21.54 vs. 18.05, 95% CI [2.898-4.073],after-3 month 19.74 vs. 18.63, 95% CI [0.400-1.824]),and total score of oxygen therapy (after-1 month 45.95 vs. 38.34,95% CI [6.288-8.925],after-3 month 41.87 vs. 38.87,95% CI [1.394-4.613]).Conclusion.Te study's fndings revealed that nurses in ICUs lack the appropriate knowledge and performance in oxygen therapy.A lack of knowledge and correct practice, insufcient monitoring of oxygen therapy, and defects in hospital equipment are contributing factors.Te training was found to improve the knowledge and performance of nurses signifcantly.Consistent training at shorter intervals is suggested for nurses to keep their knowledge current.

Introduction
Oxygen therapy for various diseases started at the end of the 18th century and is used for many medical treatments today [1].Oxygen is a drug prescribed to patients with diferent health conditions, with doses and concentrations adjusted based on clinical requirements [2,3].Te administration of oxygen relies on the patient's needs and the medical team's assessments [2].Various devices are available for oxygen therapy in hospitals [4][5][6].Nurses should follow the same protocol with this treatment as with other drug therapies and only administer it with a printed and direct physician order [7].Te doctor's prescription must specify the oxygen therapy equipment, treatment procedure, patient dosage, and target oxygen saturation level [1,8].
It should be noted that oxygen therapy is benefcial when used with the correct dose and method [2].Like any other medication, the inappropriate use of this drug can lead to adverse efects, such as hypotension, atelectasis, retrolental fbroplasia, and nasal mucosa irritation [1,9,10].
Lung tissue is afected by oxygen.High oxygen concentrations inhibit surfactant production, leading to the alveoli's collapse and reduced gas exchange on the alveolicapillary surface [11,12].Inappropriate oxygen prescriptions can result in more extended hospital stays, higher ICU admission rates, and an increased risk of death [7].Terefore, patients should receive this treatment appropriately, safely, and conveniently [2].To attain this objective, staf should acquire the essential expertise to determine the appropriate oxygen delivery method based on the patient's requirements and with a secure therapeutic quantity [3].Tus, they should continuously monitor oxygen administration and gradually reduce supplemental oxygen to eliminate these risks [11].
Regular monitoring of patients is essential during oxygen therapy, and nurses play a vital role in it [13].Tey need to be familiar with the basic principles, indications, methods of use, complications of oxygen therapy, and the causes of hypoxemia.Patients receiving oxygen therapy require proper care, and their care measures should be recorded [1,10].
Like other drugs, nurses may face barriers when administering oxygen to patients.Barriers to proper oxygen therapy may be attributed to nurses' inadequate knowledge of devices and hospital-related obstacles, such as lack of training or access to equipment and protocols [14].
A couple of studies evaluated nurses' knowledge of oxygen use and found their scores to be low [15,16].Issues related to inadequate knowledge, attitude, and practice regarding oxygen administration still need to be addressed for adequate oxygen therapy.Nurses' skills are crucial to delivering quality care [11].Many educational interventions in nursing are based on the assumption that knowledge acquisition improves clinical decision-making.Identifying nurses' knowledge level about oxygen therapy helps to determine the need for training and improve performance [17].
Tis study examined the knowledge and performance of nurses in the ICU regarding oxygen therapy, as well as the barriers and solutions associated with its safe administration.

Methods
Tis study was conducted among the Shahid Rahnemoun teaching hospital ICU nurses in Yazd, Iran.Tis hospital has four ICUs and thirty-six beds for trauma and nontraumatic medical patients.Te study method involves a sequential combination of descriptive, qualitative, and educational phases.Te frst phase involved assessing the knowledge and performance of ICU nurses in oxygen therapy through a questionnaire.Te second phase used the qualitative method to explore the views of nurses and specialists on the barriers to safe oxygen therapy in hospitals and the proposed solutions to achieve this goal.Next, in the third phase, a twogroup quasi-experimental design with pre-and post-tests was used to explore the level of knowledge and performance in oxygen therapy among ICU nurses.
Te tool is design to designed and determine its validity and reliability.Nurses' knowledge and performance were evaluated by extracting items from nursing textbooks and articles related to oxygen therapy [1,2,[17][18][19][20][21]. At frst, 101 items were pulled by the research team; after removing duplicate items, 55 items were confrmed in the area of knowledge.In the performance section, the items mentioned in the principles and techniques of nursing in the feld of oxygen therapy and the articles [1,2,[17][18][19][20][21] were used.30 items were extracted by the research team (including the nursing professor, head nurse of the ICU, pulmonologist, ICU specialist, and supervisor of education in the hospital) for the performance section.After removing duplicates, the research group confrmed and applied 24 items after discussing and reviewing the performance area.Ten, the validity and reliability of the questionnaire were examined.Te validity and reliability of the questionnaire were established through face validity (quantitative and qualitative) and content validity (quantitative and qualitative), as well as internal consistency and stability testing.For internal consistency, Cronbach's alpha index (Cα) was used to calculate the correlation between the questions in each dimension and the entire questionnaire.Te ICC (intraclass correlation index) [22] was utilized to evaluate the tool's stability over time (test-retest), with a 95.0% confdence interval.For this purpose, the tool designed by a sample of 30 nurses in two stages was completed with a time interval of two weeks.Usually, alpha values higher than 0.7 are considered to be a sign of the acceptable reliability of the tool [23].After verifying its validity and reliability, the questionnaire was designed to measure nurses' knowledge, performance, and demographic information.Te knowledge section and the checklist of the performance section related to the oxygen therapy of nurses were approved (Figure 1).Te data collection tool has three sections: demographic information, knowledge, and performance area.Te demographic information encompasses age, gender, marital status, ICU work experience, type of ICU, educational level, and completion of an ICU course.Te knowledge section comprises 30 questions covering indications of oxygen therapy, oxygen poisoning, diferent devices for oxygen therapy, and precautions.One point will be awarded for each correct answer, while incorrect ones will receive no score.Te range of the feld of knowledge's score is from 0 to 30.Te performance checklist comprises 24 items.One point will be awarded if it is executed correctly.Te performance is rated on a scale of 0-24.Te questionnaire has a total score

Descriptive
The psychometric stages of the questionnaire, knowledge, and performance of nurses about oxygen therapy

Face validity
Qualitative: interviews with ten nurses regarding the items Quantitative: determination of impact score, filling of the questionnaire by ten hospital nurses

Results
Qualitative: All items were preserved.The writing style of 16 items was revised.
Quantitative: All items with scores more than 1.5 were retained.
A number of items: 55 in the knowledge area and 24 questions in the performance area remained.

Content validity
Qualitative: Comments of 10 experts (Nursing professors, head nurse of ICU, pulmonologist and ICU specialist, internal medicine, supervisor of education in hospital) Quantitative: determination of CVI and CVR with ten experts in the field of oxygen therapy

Results
Qualitative: All questions were retained with corrections.
Quantitative: In the knowledge area, 25 questions were omitted during the CVR (below 0.6 points).
No questions were deleted in the CVI (CVI scores were above 0.79).
The number of approved questions in the knowledge area: 30 with CVI=0.95 In  Critical Care Research and Practice of 0-54 points.Te research team determined the validity and reliability of the questionnaire with 0.95 and 0.71, respectively.
Nurses' knowledge and performance were evaluated by extracting items from nursing textbooks and articles related to oxygen therapy [1,2,[17][18][19][20][21]. At frst, 101 items were pulled by the research team; after removing duplicate items, 55 items were confrmed in the area of knowledge.In the performance section, the items mentioned in the principles and techniques of nursing in the feld of oxygen therapy and the articles [1,2,[17][18][19][20][21] were used.30 items were extracted by the research team for the performance section.After removing duplicates, the research group confrmed and applied 24 items after discussing and reviewing the performance area.Ten, the validity and reliability of the questionnaire were examined.Te validity and reliability of the questionnaire were established through face validity (quantitative and qualitative) and content validity (quantitative and qualitative), as well as internal consistency and stability testing.For internal consistency, Cronbach's alpha index (Cα) was used to calculate the correlation between the questions in each dimension and the entire questionnaire.Te ICC (intraclass correlation index) [22] was utilized to evaluate the tool's stability over time (test-retest), with a 95.0% confdence interval.For this purpose, the tool designed by a sample of 30 nurses in two stages was completed with a time interval of two weeks.Usually, alpha values higher than 0.7 are considered to be a sign of the acceptable reliability of the tool [23].After verifying its validity and reliability, the questionnaire was designed to measure nurses' knowledge, performance, and demographic information.Te knowledge section and the checklist of the performance section related to the oxygen therapy of nurses were approved (Figure 1).

Qualitative Phase.
Based on the previous step's results of nurses' knowledge and performance, the views of nurses and experts on barriers to safe oxygen therapy and recommendations to achieve it were presented.Conventional content analysis was utilized in this qualitative study through semistructured interviews held from January 2023 to February 2023.
Te primary data collection method in this research was semistructured interviews.To conduct the study, the researcher established a proper relationship, informed the participants about the interview's duration, obtained informed consent, and recorded the conversations.Confdentiality of information and interview fles was assured to the participants during the study.Te interviewee requested further explanation or confrmation if there was any ambiguity during the conversation.Te questions were designed to ft the research's purpose and serve as an interview guide.Te order of questions changed per the participant's responses and the study's stages.Te interview began with general questions and then proceeded based on the participants' responses.Te questions for the interview were selected based on an analysis of previous discussions.Te process of sampling continued until data saturation.
Questions such as "What are the barriers to safe oxygen therapy from your point of view?" "In your opinion, what solutions implement safe oxygen therapy?" were asked.Te interview was able to progress smoothly due to these openended questions.Te qualitative data were analyzed using Granheim and Lundman's conventional content analysis method (2004) [24].All contents (notes and recorded audio fles) were transcribed word for word at the end of each interview.Te typed interviews were reviewed multiple times and broken down into minor semantic units or codes.Te primary codes were compared and grouped into subcategories based on their similarities.
Te main category was extracted by continuously comparing subthemes according to their compatibility and similarity.Te interviewer provided feedback to ensure the accuracy of the interviewee's impressions and prompted them to elaborate and give examples as needed.In this research, the Lincoln and Guba criterion [25] was used to increase the accuracy and strength of the data.To ensure data credibility, the researcher established a long-term relationship with participants and aimed for maximum diversity in knowledge, experience, work length, service places, age, and gender.Te data's reliability was boosted by the step-by-step repetition of data collection and analysis and the consultation of the research team and experts.Also, a constant analysis was conducted, and the data were collected, coded, and analyzed simultaneously.A summary of the interview was given to the interviewees after the implementation to verify its accuracy.Te Prolong Engagement method was utilized to ensure validity and acceptability.
In addition, the member check technique was utilized to compare the researcher's interpretation with the participants' intended meaning, and the interview summary was given back to the participants to ensure the interview's precision.Qualitative experts and the author evaluated the codes throughout the coding process.Te duration of the interviews was in the range of 20 to 60 minutes.Te interviewees chose the location for the interviews, mostly at their workplaces.Experts with difering viewpoints spent most of their time extracting codes.Numerous meetings were held to establish a rational connection between codes and categories.

Educational Phase.
Based on the qualitative phase of the study, one of the barriers to safe oxygen therapy was the need for more training.On the other hand, according to the results of the descriptive phase of the study, the majority of nurses were at an unfavorable level of knowledge and performance in the feld of oxygen therapy, so at this stage, the efect of training interventions on the knowledge and performance of ICU nurses was investigated.At this study stage, nurses who participated in the research's descriptive phase were considered for inclusion criteria.Participants who failed to attend all training sessions or complete the questionnaire were excluded.Eighty nurses were randomly assigned into intervention and control groups using allocation software during the descriptive phase.

4
Critical Care Research and Practice Te educational supervisor and department ofcials in the intervention group made arrangements for shift planning, enabling nurses to attend the classes.Te classes were planned with necessary arrangements such as location, schedule, educational materials, and reception.Te educational content was presented by the researchers in the form of lectures, discussions, questions and answers, and demonstrations.Over two consecutive days, a 4-hour workshop provided educational content on respiratory system anatomy and physiology, indications for oxygen administration, oxygen poisoning, and nursing care for patients receiving oxygen, complications of incorrect oxygen therapy, familiarity with oxygen therapy devices, and their proper use.Te control group did not receive any training.Te descriptive phase scores were utilized to determine the nurses' knowledge and performance scores before the training intervention.Te intervention and control groups of nurses were assessed for knowledge and performance levels one and three months after the training sessions.Upon completing the study, the educational package was given to the control group for reading.
Te ethics committee authorized the study at Shahid Rahnemoun Hospital, Yazd, with the ethics I.D. I.R.SSU.SRH.REC.1400.010.Te nurses involved in the study provided written informed consent after being informed of the study's objectives and the confdentiality of the information.
Data were analyzed using SPSS version 26 software.Descriptive statistics included absolute and relative frequency, mean, and standard deviation.Te inferential statistics used included an independent t-test, an ANOVA with repeated measures, and a chi-square with a 95% confdence interval.

Results
Te study's fndings were shown in three phases: descriptive, qualitative, and educational.

Descriptive Phase.
At this phase, data were analyzed on 80 nurses participating in the study.Te average age of the participants in this phase was 32.75 ± 6.14 years, with a work experience of 8.83 ± 4.67 years.Te majority of the study groups were female (76.3%) and single (56.3%) and had a bachelor's degree (87.5%).Table 1 displays the average knowledge, performance, and total score of oxygen therapy in the units studied.Based on percentile agreement, scores above 25% were deemed favorable, scores in the bottom 25% were unfavorable, and scores in the middle 50% were average.
Table 2 shows the degree of nurses' awareness about the person responsible for starting, determining the dose, type of oxygen therapy device, and oxygen consumption cessation.

Qualitative Phase.
A total of 13 participants were selected purpose-based for the qualitative phase of the study, including 2 emergency medicine specialists, 3 pulmonary and ICU specialists, four hospital supervisors and ICU head nurses, and four experienced nurses with more than ten years of work experience.Maximum variation sampling continued until data saturation.Te average age of the participants in the qualitative phase was 39.23 ± 2.20.Based on the content analysis, four main categories include lack of knowledge in the feld of oxygen therapy (with six subcategories), lack of sufcient monitoring of the oxygen therapy process (with fve subcategories), defects in the correct implementation of oxygen therapy at the patient's bedside (with fve subfoors), quantitative and qualitative defects of oxygen therapy devices (with four subcategories) were extracted as barriers to safe oxygen therapy (Table 3).
Also, the appropriate recommendations to solve these barriers were explained based on the interviews conducted (Figure 2).

Educational Phase.
In this phase, 80 nurses in the descriptive phase were divided into two groups (40 people in each intervention and control group).During this stage, one participant from the intervention group and two from the control group were removed from the study due to missed training sessions and incomplete questionnaires.Te data was analyzed on 39 nurses in the intervention group and 38 in the control group.
Demographic information is presented in Table 4. Te chi-square and independent t-test results indicated no signifcant diferences between the two groups regarding age, sex, work experience in ICU, work experience in COVID ICU, level of education, and completion of the oxygen therapy course.
Te interventional group showed signifcant diferences in all areas when comparing the average scores of knowledge and performance and the total score of oxygen therapy three times (before training, one month, and three months after intervention).However, the scores in three-time points showed no signifcant diference in the control group.Results are shown in Table 5. Te two-by-two comparison of measurement time points in the intervention group demonstrated a signifcant diference between the three times in knowledge and performance scores, as indicated by the Bonferroni post hoc test.Te control group did not report any signifcant diferences.
Te study's results show no statistically signifcant differences between the intervention and control groups' knowledge, performance, and total scores on oxygen therapy before the study.It was reported to be signifcant after the survey (one month and three months later).Te results are shown in Table 6.

Discussion
Our study revealed that ICU nurses need a better understanding and performance in oxygen therapy, with only 12.5% having adequate knowledge and 25% displaying favorable performance.Proper understanding and implementation of oxygen therapy were observed in only 11.25%.Most ICU nurses need more knowledge and performance status for oxygen therapy, which is unacceptable given its Critical Care Research and Practice importance in these departments.Tese fndings align with other studies in the knowledge and performance of nurses [1,17,19,20,[26][27][28].
Nurses should only administer oxygen therapy with a doctor's order, specifying the device, process, dose, and target oxygen saturation level [1,7,8].For deciding on a prescription, dose, device, and ending oxygen use, the percentages of nurses who were aware of the responsible person were 38.8%, 40%, 47.5%, and 52.2%, respectively.Tese fndings reveal that many nurses need more awareness in this domain.
Te study found that the primary barriers to safe oxygen therapy are insufcient knowledge and performance, inadequate monitoring, and defects in oxygen therapy equipment.Te present study is in agreement with previous studies [2,3,13,20,26] that identifed nurses and healthcare care professional's insufcient knowledge about oxygen therapy, absence of oxygen therapy protocol, and lack of oxygen therapy equipment as the primary challenges in ensuring safe oxygen therapy.Te study recommends continuous, shorter training to raise awareness and change attitudes towards oxygen therapy principles, properly monitoring oxygen therapy, fxing equipment defects, and motivating nurses to improve their performance.Te results of this research, along with other studies [3,29,30], highlight the necessity for more education for nurses on oxygen therapy and the knowledge defcit among nurses, physicians, and other healthcare professionals regarding O2 administration.
Tis study aimed to enhance the knowledge and practice of oxygen therapy in ICU nurses through training.Following the intervention, the group of nurses showed a substantial improvement in their knowledge and performance in oxygen therapy, which persisted in both the short term (one month) and long term (3 months).Oxygen therapy training positively afected the knowledge and performance of nurses, as evidenced by a statistically signifcant diference, which is in line with other studies [17,19].Te comparison between one month and three months revealed that although there was an improvement in knowledge and performance after the intervention, a noticeable gap was still observed in the third month in contrast to the frst month.Nurses' knowledge and performance decreased after three months compared to the frst month.Education is crucial to enhancing the knowledge and performance of nurses, but for its longterm sustainability, nurses need more frequent and concise training sessions.It is shown that the oxygen therapy training program has improved nurses' clinical competence in oxygen therapy.To attain the highest score, executing a continuous training program is crucial.Educational programs should be repeated to stay efective and updated with the latest changes in the clinical manual of oxygen therapy.Undergraduate nursing students and special nursing master's degrees should learn the clinical manual of oxygen therapy.Nursing managers should improve nursing services per the oxygen therapy clinical guide to ensure safe and proper oxygen therapy.It is proposed that a trained resident physician should be present to instruct ICU nurses.If not available, it is crucial to establish a particular protocol for oxygen therapy to avoid errors.

Limitations.
Te study faced limitations with adjusting the education plan and nurse schedules, but attempts were made to schedule classes on less busy working days.Contact between nurses from the interventional and control groups was outside the researcher's control.

Conclusion
ICU nurses need more favorable knowledge and optimal performance in oxygen therapy, and this is compounded by insufcient monitoring of the oxygen therapy process and quantitative and qualitative defects of oxygen therapy devices, which pose barriers to safe oxygen therapy.Knowing these components and working to eliminate any barriers is important to promote safe oxygen therapy for patients.Te impact of training was highlighted as a vital aspect in ameliorating nurses' understanding and profciency and safeguarding their standing in this domain.

Figure 1 :
Figure 1: Psychometric questionnaire knowledge and performance of nurses in oxygen therapy.

Figure 2 :
Figure 2: Appropriate recommendations to barriers to safe oxygen therapy.
Phase.At this phase, nurses in the study were selected based on the available sample size.

Table 2 :
Te level of awareness of the decision-maker for oxygen therapy in the studied units.

Table 1 :
Comparison of mean and standard deviation of knowledge, performance, and total score of oxygen therapy in the studied units.

Table 3 :
Extraction of main categories and subcategories of barriers to safe oxygen therapy from the point of view of the study units in the qualitative phase.

Table 4 :
Demographic characteristics of the studied units in the educational phase.

Table 5 :
Comparison of the mean scores of knowledge and performance and total score of oxygen therapy between two groups at diferent times of the study.
GroupsVariables Before mean ± SD After-1 month mean ± SD After-3 months mean ± SD F P value * P value * � ANOVA repeated measures test.

Table 6 :
Comparison of the average knowledge, performance, and total score of oxygen therapy between intervention and control groups in the three-time of the study.