Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based quidelines for the prevention of ventilator-associated pneumonia-A survey study

Paper details:
Follow the critique guidelines, critique the article in a narrative document written in APA 6th edition format by using the critique template and you can not change formatting from the template (critically appraise the article) be sure to respond to each of the critique guidelines. Minimum of 6 pages excluding title and reference page. Please evaluate my paper and make appropriate changes. Due by Oct 1, 2015

QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            2

Quantitative Research Article Critique
Introduction
Reference
Intensive and Critical care Nursing (2013) 29,216-222. Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia-A survey study. Journal homepage: www.elsevier.com/iccn
Authors Qualifications
MiiaJansso: Institute of Health Science, University of Oulu, Finland. Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
Tero Ala-Kokko: Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
PekkaYlipalosaar: Department of Infection Control, University Hospital, Oulu, Finland
HannuSyrjala: Department of Infection Control, University Hospital, Oulu, Finland
HelviKyngas: Institute of Health Science, University of Oulu, Finland. Oulu University Hospital, Oulu, Finland
Title
Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia-A survey study
Abstract
This paper is an academic critique of a nursing article written by Miia Janson, Tero Ala-Kokko, Pekka
Ylipalosaari, HannuSyrjala, and HelviKyngas (2013) titled: Critical care nurses’ knowledge of, adherence
to and barriers towards evidence-based guidelines for the prevention of ventilator-associated
pneumonia – A survey study. The authors undertook a survey study to explore critical care nurses’
knowledge of, adherence to and barriers to prevention of ventilator-associated pneumonia.The
rationale and the purpose of the study were clearly stated. My examination of the study
focuses on specific aspects of the article including evidence-based research of preventing
ventilator-associated pneumonia. I have attempted to explain the evidence-based survey study
which uses an independent-samples t-test to compare critical care nurses’ knowledge and
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                        3
adherence within different groups and principles of inductive content analysis used to analyze
the barriers towards evidence-based guidelines for prevention of ventilator-associated
pneumonia.The study was conducted in a single academic centre in Finland in a 22-bed mixed
adult general ICU. Participants were selected for the survey using convenience (accidental)
sampling. The spot testing questionnaires were distributed among all nursing staff by the
nurses in charge and completed anonymously in a 30 minute allotted time acquiring the
average knowledge level. The results of the knowledge test showed a mean scoreof 59.9%.

Problem
In this article, Critical care nurses’ knowledge of, adherence to and barriers towards evidence-
based guidelines for the prevention of ventilator-associated pneumonia-A survey study,the authors
notethrough research thatventilator-associated pneumonia (VAP) is the commonly encountered (12-
33.8%)nonsocomial infection in critical care situations (Karhu et al., 2011; Ylipalosarri et al., 2006).
Previous studies have shown that (VAP) is associated with high morbidity and mortality rates as
well as prolonged lengths in the intensive care units (ICU) and hospital stay (Babcock et al., 2004;
Ylipalosaari et al., 2006). Prevention of this nonsocomial infection could reduce costs and improve
patient-related outcomes and patient safety and the quality of care (Babcock et al., 2004; Marra et al.,
2009; Safdar et al., 2005).
The main barriers shown in Table 4 were inadequate resources, lack of time, knowledge, skills,
and forgetfulness. Due to these facts, it is imperative that we constantly monitor nurse’ education and
the barriers that play a role in patient care. It is realistic to believe that similar studies can be conducted
and analyzed to improve nurse’s knowledge of evidence-based guidelines (EBG) for the prevention of
ventilator-associated pneumonia.
Purpose
This article discusses previous studies, which show critical care nurses’ knowledge about EBGs
for preventing VAP is currently limited (Blot et al., 2007; Labeau et al., 2008). The lack of knowledge may
be a barrier towards adherence to EBGs (El-Khatib et al., 2010). The purpose of this study is to collect
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            4
data from critical care nurses of their knowledge of, adherence to and barriers towards EBGs for the
prevention of VAP. The results of these studies could be used to educate and stimulate further
discussions in order to implement new guidelinesand resources to improve infection control and break
the barriers towards EBGs for the prevention of VAP.

Literature Review
The authors drew on relevant previous studies to formulate the purpose of their own study and
variables were clear and precise. An independent-samples t-test was used to compare the knowledge
and adherence of critical care nurses with different levels of ICU experience ( < 5yrs vs > 5yrs),
education (registered nurses vs nursing assistants) and employment, permanent vs non-permanent. The
study was conducted in a single academiccentre in Finland in a 22 bed mixed adult general ICU. Two
multiple-choice questionnaires wereused to evaluate critical care nurses’ knowledge of (Labeau et al.,
2007), adherence to and barriers towards EBGs for prevention of VAP (Ricart et al., 2003).
The principles of inductive content analysis were used to analyze, categorize and qualify the
barriers towards EBG for prevention of VAP (Elo and Kyngas, 2008). This has helped me understand the
amount of research that had been done for this article.

Theoretical Framework
In organizing the framework, the authors identify therelevant nurse variables to include work
experience in the ICU, education, registered nurse vs nursing assistant, and employment, permanent vs
non-permanent. (Table 2). In this study, as in several other studies (Blot et al., 2007; Labeau et al., 2008),
more experienced nurses (ICU experience > 5 yrs) performed significantly better in the knowledge test
than their less experienced (ICU experience < 5 yrs) coleagues.

Research Questions, Objectives, or Hypothesis
During this study, the authors noted three key research questions: (1) What do critical care
nurses know about EBGs for prevention of VAP? (2) To what extent do critical care nurses adhere to
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            5
EBGs for prevention of VAP? (3) What are the carriers towards EBGs for prevention of VAP (p 217)?
When discussing barriers, questions arose regarding the use of sodium chloride with ventilator
patients. According to previous literature, the routine use of sodium chloride should be avoided (AARC,
2010; CHP, 2010). The self-reported adherence to sodium chloride instillation before tracheal suctioning
was68.3% (Table 4). The reasons for non-adherence were related to the lack of guidance, and time and
outcomeexpectancy. However, recent reports provided new information about the safety (Overend ET
AL., 2009; Paraz and Stockton, 2009) and efficancy (Caruso et al., 2009; Christensen et al., 2010) of
sodium chloride instillation, used also in bronchoalveolar lavages.

Study Variables/Concepts
Thedesign of this research study is indicated as being quasi-experimental. The survey was based
on two pre-validated multiple-choice questionnaires in order to explore the critical care nurses’
knowledge of, adherence to and barriers towards EBGs for prevention of VAP. The demographics of
this article of study show nurse variablesto include ICU nurses with experience varying from <1yr-
>10yrs, education of registered nurses vs nursing assistants, and employment whether it be permanent
or non-permanent (Table 2). There is no treatment or intervention discussed only questionnaires. The
majorityof participants (89.1%) were registered nurses, often with >10yrs ICU experience.
The population of this research article are considered to have inclusive criteria as follows (1)
informed consent was obtained, (2) participants were direct care providers at bedside.The
questionnaires were distributed to all nursing staff (n=173) by the head nurse in charge (p217). Nursing
assistants were included in the sampling of this study because they provide care for mechanically
ventilated adult patients. The final response rates ranged from 56.4% registered nurses to 100% nursing
assistants (p219).

Study Measures
After reading thisarticle, I interpret the measurement strategyto involve ameasurement of
statistics using the Likert scale (questionnaires) at a nominal level. The main strengths of this study are
the high response rate, which means the results closely represent the local target population, and of the
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            6
nurses in different departments with a range of ICU experience (Polit and Beck, 2011).

Data/Analysis Collection
For this article the authors used both descriptive statistics and inferential statistics. Descriptive
statisticsincluded frequency ratings and percentages to describe demographics, adherence and
perceived barriers of participants. The authors used inferential statistics to analyze other variables
which included an independent-sample t-test used to compare the knowledge and adherence of critical
care nurses with different levels of experience and education. A p value less than 0.05 was considered
statistically significant (p218).

Researchers’ Interpretations of Findings
After the calculations, the conclusions were average with a mean score in the knowledge test of
59.9%, whereas previous studies have reported mean scores ranging from 41.2% (Blot et al., 2007) to
78.1% (El-Khatib et al., 2010).

Study Limitations
Even though the sample size was small the questionnaire was for a specific group of nurses in
the ICU. Limitations were very little only three participants did not respond to the study. The nursing
assistants were included in the study but the sample size was less than 10% leaving the results to be
interpreted with caution.

Generalizability of Findings
This study showed in general, the most common self-reported adherences were adequate hand
washing. Hand hygiene, oral care and ETS practices were actually higher than in previous studies.

Implications for Further Studies

QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            7
The authors acknowledgefurther studies will be needed to assess the effect of new VAP
bundlesbeing put into place by the Centers for Disease Control and Prevention. These bundles are
designed to help reduce or eliminate VAP and promote adherence to EBG to improve patient care.

Conclusion
According to the study, the average knowledge level was low. It is important to evaluate critical
care nurses’ knowledge, attitudes and beliefs so that current practices can be improved (Ajzen, 2005).
With these studies they can be used to guide local practice and education and contribute to the nurses’
adherence and knowledge of methods in preventing VAP.

QUANTITATIVE RESEARCH ARTICLE CRITIQUE                                8
REFERENCES:
American Association for Respiratory Care (AARC). Critical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways. Respir Care 2010;55:758-64.
Ajzen I. Attitudes, personality and behavior. 2nd ed. Mcgraw Hill Education, Open University Press; 2005.
Babcock H, Zack J, Garrison T, Trovillion E, Jones M, Fraser V, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest 2004;125:2224-31.
Blot S, Labeau S, Vandijck D, Claes B. Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among intensive care nurses. Int Care Med 2007; 33: 1463-7.
Caruso P, Denari S, Ruiz S, Demarzo E, Deheinzelin D. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med 2009; 37: 32-8.
El-Khatib M, Zeineldine S, Ayoub C, Husari A, Bou-Khalil P. Critical care clinicians’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. AJCC 2010; 19: 272-7.
Elo S, Kyngas H. The qualitative content analysis process. Jan 2008; 62: 107-15.
Karhu J, Ala-KokkoTi, Ylipalosaari P, Ohtonen P, Laurila JJ, Syrjala H. Hospital and long-term outcomes of ICU-treated severe community and hospital-acquired, and ventilator-associated pneumonia patients. ActaAnaesthScand 2011; 55: 1254-60.
Labeau S, Vandijck B, Claes P, Van Aken P, Blot S. Critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: an evaluation questionnaire. AJCC 2007; 16: 371-7.
Overend TJ, Anderson CM, Brooks D, Cicutto L, Keim M, McAuslan D, et al. Updating the evidence base for suctioning adult patients: a systemic review. Can Respir J 2009; 16: e6-17.
Polit D, Beck C. Nursing research. Generating and assessing evidence for nursing practice. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2011.
Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med 2003; 31: 2693-6.

Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based quidelines for the prevention of ventilator-associated pneumonia-A survey study

Paper details:
Follow the critique guidelines, critique the article in a narrative document written in APA 6th edition format by using the critique template and you can not change formatting from the template (critically appraise the article) be sure to respond to each of the critique guidelines. Minimum of 6 pages excluding title and reference page. Please evaluate my paper and make appropriate changes. Due by Oct 1, 2015

QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            2

Quantitative Research Article Critique
Introduction
Reference
Intensive and Critical care Nursing (2013) 29,216-222. Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia-A survey study. Journal homepage: www.elsevier.com/iccn
Authors Qualifications
MiiaJansso: Institute of Health Science, University of Oulu, Finland. Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
Tero Ala-Kokko: Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
PekkaYlipalosaar: Department of Infection Control, University Hospital, Oulu, Finland
HannuSyrjala: Department of Infection Control, University Hospital, Oulu, Finland
HelviKyngas: Institute of Health Science, University of Oulu, Finland. Oulu University Hospital, Oulu, Finland
Title
Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia-A survey study
Abstract
This paper is an academic critique of a nursing article written by Miia Janson, Tero Ala-Kokko, Pekka
Ylipalosaari, HannuSyrjala, and HelviKyngas (2013) titled: Critical care nurses’ knowledge of, adherence
to and barriers towards evidence-based guidelines for the prevention of ventilator-associated
pneumonia – A survey study. The authors undertook a survey study to explore critical care nurses’
knowledge of, adherence to and barriers to prevention of ventilator-associated pneumonia.The
rationale and the purpose of the study were clearly stated. My examination of the study
focuses on specific aspects of the article including evidence-based research of preventing
ventilator-associated pneumonia. I have attempted to explain the evidence-based survey study
which uses an independent-samples t-test to compare critical care nurses’ knowledge and
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                        3
adherence within different groups and principles of inductive content analysis used to analyze
the barriers towards evidence-based guidelines for prevention of ventilator-associated
pneumonia.The study was conducted in a single academic centre in Finland in a 22-bed mixed
adult general ICU. Participants were selected for the survey using convenience (accidental)
sampling. The spot testing questionnaires were distributed among all nursing staff by the
nurses in charge and completed anonymously in a 30 minute allotted time acquiring the
average knowledge level. The results of the knowledge test showed a mean scoreof 59.9%.

Problem
In this article, Critical care nurses’ knowledge of, adherence to and barriers towards evidence-
based guidelines for the prevention of ventilator-associated pneumonia-A survey study,the authors
notethrough research thatventilator-associated pneumonia (VAP) is the commonly encountered (12-
33.8%)nonsocomial infection in critical care situations (Karhu et al., 2011; Ylipalosarri et al., 2006).
Previous studies have shown that (VAP) is associated with high morbidity and mortality rates as
well as prolonged lengths in the intensive care units (ICU) and hospital stay (Babcock et al., 2004;
Ylipalosaari et al., 2006). Prevention of this nonsocomial infection could reduce costs and improve
patient-related outcomes and patient safety and the quality of care (Babcock et al., 2004; Marra et al.,
2009; Safdar et al., 2005).
The main barriers shown in Table 4 were inadequate resources, lack of time, knowledge, skills,
and forgetfulness. Due to these facts, it is imperative that we constantly monitor nurse’ education and
the barriers that play a role in patient care. It is realistic to believe that similar studies can be conducted
and analyzed to improve nurse’s knowledge of evidence-based guidelines (EBG) for the prevention of
ventilator-associated pneumonia.
Purpose
This article discusses previous studies, which show critical care nurses’ knowledge about EBGs
for preventing VAP is currently limited (Blot et al., 2007; Labeau et al., 2008). The lack of knowledge may
be a barrier towards adherence to EBGs (El-Khatib et al., 2010). The purpose of this study is to collect
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            4
data from critical care nurses of their knowledge of, adherence to and barriers towards EBGs for the
prevention of VAP. The results of these studies could be used to educate and stimulate further
discussions in order to implement new guidelinesand resources to improve infection control and break
the barriers towards EBGs for the prevention of VAP.

Literature Review
The authors drew on relevant previous studies to formulate the purpose of their own study and
variables were clear and precise. An independent-samples t-test was used to compare the knowledge
and adherence of critical care nurses with different levels of ICU experience ( < 5yrs vs > 5yrs),
education (registered nurses vs nursing assistants) and employment, permanent vs non-permanent. The
study was conducted in a single academiccentre in Finland in a 22 bed mixed adult general ICU. Two
multiple-choice questionnaires wereused to evaluate critical care nurses’ knowledge of (Labeau et al.,
2007), adherence to and barriers towards EBGs for prevention of VAP (Ricart et al., 2003).
The principles of inductive content analysis were used to analyze, categorize and qualify the
barriers towards EBG for prevention of VAP (Elo and Kyngas, 2008). This has helped me understand the
amount of research that had been done for this article.

Theoretical Framework
In organizing the framework, the authors identify therelevant nurse variables to include work
experience in the ICU, education, registered nurse vs nursing assistant, and employment, permanent vs
non-permanent. (Table 2). In this study, as in several other studies (Blot et al., 2007; Labeau et al., 2008),
more experienced nurses (ICU experience > 5 yrs) performed significantly better in the knowledge test
than their less experienced (ICU experience < 5 yrs) coleagues.

Research Questions, Objectives, or Hypothesis
During this study, the authors noted three key research questions: (1) What do critical care
nurses know about EBGs for prevention of VAP? (2) To what extent do critical care nurses adhere to
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            5
EBGs for prevention of VAP? (3) What are the carriers towards EBGs for prevention of VAP (p 217)?
When discussing barriers, questions arose regarding the use of sodium chloride with ventilator
patients. According to previous literature, the routine use of sodium chloride should be avoided (AARC,
2010; CHP, 2010). The self-reported adherence to sodium chloride instillation before tracheal suctioning
was68.3% (Table 4). The reasons for non-adherence were related to the lack of guidance, and time and
outcomeexpectancy. However, recent reports provided new information about the safety (Overend ET
AL., 2009; Paraz and Stockton, 2009) and efficancy (Caruso et al., 2009; Christensen et al., 2010) of
sodium chloride instillation, used also in bronchoalveolar lavages.

Study Variables/Concepts
Thedesign of this research study is indicated as being quasi-experimental. The survey was based
on two pre-validated multiple-choice questionnaires in order to explore the critical care nurses’
knowledge of, adherence to and barriers towards EBGs for prevention of VAP. The demographics of
this article of study show nurse variablesto include ICU nurses with experience varying from <1yr-
>10yrs, education of registered nurses vs nursing assistants, and employment whether it be permanent
or non-permanent (Table 2). There is no treatment or intervention discussed only questionnaires. The
majorityof participants (89.1%) were registered nurses, often with >10yrs ICU experience.
The population of this research article are considered to have inclusive criteria as follows (1)
informed consent was obtained, (2) participants were direct care providers at bedside.The
questionnaires were distributed to all nursing staff (n=173) by the head nurse in charge (p217). Nursing
assistants were included in the sampling of this study because they provide care for mechanically
ventilated adult patients. The final response rates ranged from 56.4% registered nurses to 100% nursing
assistants (p219).

Study Measures
After reading thisarticle, I interpret the measurement strategyto involve ameasurement of
statistics using the Likert scale (questionnaires) at a nominal level. The main strengths of this study are
the high response rate, which means the results closely represent the local target population, and of the
QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            6
nurses in different departments with a range of ICU experience (Polit and Beck, 2011).

Data/Analysis Collection
For this article the authors used both descriptive statistics and inferential statistics. Descriptive
statisticsincluded frequency ratings and percentages to describe demographics, adherence and
perceived barriers of participants. The authors used inferential statistics to analyze other variables
which included an independent-sample t-test used to compare the knowledge and adherence of critical
care nurses with different levels of experience and education. A p value less than 0.05 was considered
statistically significant (p218).

Researchers’ Interpretations of Findings
After the calculations, the conclusions were average with a mean score in the knowledge test of
59.9%, whereas previous studies have reported mean scores ranging from 41.2% (Blot et al., 2007) to
78.1% (El-Khatib et al., 2010).

Study Limitations
Even though the sample size was small the questionnaire was for a specific group of nurses in
the ICU. Limitations were very little only three participants did not respond to the study. The nursing
assistants were included in the study but the sample size was less than 10% leaving the results to be
interpreted with caution.

Generalizability of Findings
This study showed in general, the most common self-reported adherences were adequate hand
washing. Hand hygiene, oral care and ETS practices were actually higher than in previous studies.

Implications for Further Studies

QUANTITATIVE RESEARCH ARTICLE CRITIQUE                            7
The authors acknowledgefurther studies will be needed to assess the effect of new VAP
bundlesbeing put into place by the Centers for Disease Control and Prevention. These bundles are
designed to help reduce or eliminate VAP and promote adherence to EBG to improve patient care.

Conclusion
According to the study, the average knowledge level was low. It is important to evaluate critical
care nurses’ knowledge, attitudes and beliefs so that current practices can be improved (Ajzen, 2005).
With these studies they can be used to guide local practice and education and contribute to the nurses’
adherence and knowledge of methods in preventing VAP.

QUANTITATIVE RESEARCH ARTICLE CRITIQUE                                8
REFERENCES:
American Association for Respiratory Care (AARC). Critical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways. Respir Care 2010;55:758-64.
Ajzen I. Attitudes, personality and behavior. 2nd ed. Mcgraw Hill Education, Open University Press; 2005.
Babcock H, Zack J, Garrison T, Trovillion E, Jones M, Fraser V, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest 2004;125:2224-31.
Blot S, Labeau S, Vandijck D, Claes B. Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among intensive care nurses. Int Care Med 2007; 33: 1463-7.
Caruso P, Denari S, Ruiz S, Demarzo E, Deheinzelin D. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med 2009; 37: 32-8.
El-Khatib M, Zeineldine S, Ayoub C, Husari A, Bou-Khalil P. Critical care clinicians’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. AJCC 2010; 19: 272-7.
Elo S, Kyngas H. The qualitative content analysis process. Jan 2008; 62: 107-15.
Karhu J, Ala-KokkoTi, Ylipalosaari P, Ohtonen P, Laurila JJ, Syrjala H. Hospital and long-term outcomes of ICU-treated severe community and hospital-acquired, and ventilator-associated pneumonia patients. ActaAnaesthScand 2011; 55: 1254-60.
Labeau S, Vandijck B, Claes P, Van Aken P, Blot S. Critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: an evaluation questionnaire. AJCC 2007; 16: 371-7.
Overend TJ, Anderson CM, Brooks D, Cicutto L, Keim M, McAuslan D, et al. Updating the evidence base for suctioning adult patients: a systemic review. Can Respir J 2009; 16: e6-17.
Polit D, Beck C. Nursing research. Generating and assessing evidence for nursing practice. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2011.
Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med 2003; 31: 2693-6.