Ventilator-Associated Pneumonia and Nursing - Term Paper Example

Evidence-Based Practice Full Ventilator-associated pneumonia is a type of hospital-acquired pneumonia that occurs with mechanically-ventilated patients. The knowledge of nurses about preventative measures also varied widely. Since the VAP is a leading cause of death in hospital-acquired infections, it is critical that nurses have awareness of the protocol and incorporate it into practice in order to reduce the chances of death in mechanically-ventilated patients due to respiratory infections. The paper examines the research conducted on ventilator bundles and the knowledge of critical care nurses regarding preventative measures. The question that has been formulated and researched is: for patients, who are on mechanical ventilation, does the use of ventilator bundle, with examination of critical care nurses’ knowledge on ventilator bundle, an effective prevention technique for VAP? The paper discusses how EBP can be incorporated into practice and leadership model drawn up to implement and supervise EBP. Keywords: ventilator-associated pneumonia, ventilator bundle, leadership Evidence-Based Practice Ventilator-associated pneumonia continues to be a major threat to patient safety. It is a huge challenge to critical care practitioners since it has become a leading cause of death among hospital-acquired infections. Ventilator-associated pneumonia is a type of hospital-acquired pneumonia that occurs with mechanically-ventilated patients. It has become one of the respiratory infections that have received a lot of attention by experts over the past years, and because of the high rate of mortality that it causes, studies have focused on preventative measures. However, despite the number of studies that has been conducted on VAP, the results of the studies vary widely. As a result, the knowledge of nurses about preventative measures also varied widely. The assessment of knowledge that critical care nurses had regarding preventative measures, particularly the use of ventilator bundles, is important since the better-informed the nurses are, the better their performance will be. Since the VAP is a leading cause of death in hospital-acquired infections, it is critical that nurses have awareness of the protocol and incorporate it into practice in order to reduce the chances of death in mechanically-ventilated patients due to respiratory infections. The problem arose in the intensive care units, where patients receive critical care. It is the patients who are directly affected by the problem; however it needs to be noted that if the mortality rate of the hospital is low, and there are proper measures being taken to prevent the patients from getting VAP, it would reflect positively on the practice of the nurses and the reputation of the hospital. Another reason that preventative measures need to be enforced and their knowledge given to nurses is because people who survive VAP spend more time in the hospital and have to bear the additional financial costs of staying on the ventilator and treatment for VAP. One of the ways that VAP can be prevented is through the ventilator bundle. In nursing practice, the use of the ventilator bundle has been adopted by many hospitals to prevent VAP. Therefore, the question arises that for patients, who are on mechanical ventilation, does the use of ventilator bundle, with examination of critical care nurses’ knowledge on ventilator bundle, an effective prevention technique for VAP? The PICO question that can be formulated is as follows: P (Population of Interest): Patients on mechanical ventilation I (Intervention of Interest): Use of ventilator bundle C (Comparison of Interest): Examination of critical care nurses’ knowledge on ventilator bundle O (Outcome of Interest): Prevention of ventilator-associated pneumonia. The journal article by Tolentino-DelosReyes, Ruppert and Shiao, titled Evidence-Based Practice: Use of the Ventilator Bundle to Prevent Ventilator-Associated Pneumonia, was aimed to examine the knowledge of critical care nurses about the use of the ventilator bundle to prevent ventilator-associated pneumonia. The ventilator bundle is a set of interventions for patients who are on mechanical ventilation. When these interventions are applied together, they result in better outcomes for the patients. The ventilator bundle has four main components: “elevation of the head of the bed to between 30 to 45 degrees, daily sedation vacation and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, deep venous thrombosis (DVT) prophylaxis (unless contraindicated)” (Lancashire and South Cumbria Critical Care Network, 2005). Elevation of the head reduces the chances for aspiration and on the same hand improves the ventilation of the patient. Daily sedation vacation helps to reduce the drowsiness experienced by patients; patients who were interrupted also showed early weaning. The occurrence of clots and pulmonary emboli was also decreased in patients with DVT prophylaxis. Patients on peptic ulcer disease prophylaxis showed less acid production in the stomach, which led to less chances of bleeding from gastric erosions and peptic ulcers (Aragao, 2008). In the research conducted by Tolentino-DelosReyes, Ruppert and Shiao to examine the knowledge of the nurses about the use of the ventilator bundle, published reports were assessed on the current use of ventilator bundles. Then education sessions were held to raise awareness amongst the nurses about the advantages of ventilator bundles. There were 61 nurses whose conduct was researched and the application of their knowledge into practice was investigated. A ten-item test was given to the nurses both before and after the educational sessions and their evidence-based conduct was assessed on the basis of the tests. 99 intubated patients were surveyed for ventilator bundles practices such as the elevation of the head etc. The results of the education sessions were that the nurses showed an improvement in their performance in 8 out of ten items that were being surveyed. Most of the nurses practiced elevation of the head, along with other preventative measures that they had learnt during the sessions like oral care, documenting the elevation of the head, maintaining hygiene conditions like washing hands, checking nasogastric tubes for residual volume, limiting the wearing of rings and nail polish. The Centers for Disease Control and Prevention (CDC) have suggested the aforementioned measures that nurses showed an improvement in; however, there have not been recommendations by the CDC about oral care, or how frequently subglottic secretions need to be removed. Tolentino-DelosReyes, Ruppert and Shiao (2007) state that research about what level of gastric residual volume increases aspiration risk and at what level feedings should it be withheld. Therefore, current practices of ventilator bundles have primarily been based on research findings. The findings of the research by Tolentino-DelosReyes, Ruppert and Shiao stated that nurses who were given educational sessions incorporated the evidence into practice and were able to increment their knowledge and enhance their evidence-based practice. The practice of the nurses also improved, since they became more professional by adopting techniques such as washing their hands and not wearing rings. The provision of high standards of health care service can be achieved through evidence-based practices. One of the limitations of the research was that although nurses shared information about the sessions with their colleagues who could not attend the sessions, the performance of nurses who did not attend the sessions was not tested; it could have provided better comparisons for implementation of evidence-based practice. Another limitation of the research was that since nurses were aware that they were being observed, they would have indulged in more meticulous work, and the number of patients who were being surveyed was limited. Tolentino-DelosReyes, Ruppert and Shiao suggest recommendations for the future such as more researches on oral care and nasogastric tube feedings. They also recommend the use of ventilator bundles for improving the knowledge of the nurses and their clinical practice. The transformation of evidence summaries into actual practice requires several basic elements. Evidence-based practice (EBP) has five basic steps. The first three steps require formulating a question, researching it and critically appraising the evidence to assess its validity. The later steps require application of the evidence and re-evaluating it to look for areas of improvement (University of Minnesota Libraries, 2009). As discussed above, evidence-based practice provides many advantages including lower costs, improved patient safety and better nursing practice. For translation of evidence into practice, factors such as if the patient are similar to the ones on whom the research had been conducted, how the evidence affects the treatment offered, are the evidences easy to apply and what strategies need to be adopted for implementation for these evidences. The actions for nursing practice as established by the American Association of Critical-Care Nurses (AACN) include that nurses always keep mechanically-ventilated patients HOB raised to 30 degrees or higher, unless medically contraindicated, assure that the critical care unit has written practice documents on practice alerts for nurses to consult, determine the unit’s rate of compliance with the HOB elevation directive and develop a plan to improve compliance. The methods that can be used to improve compliance include formation of an interprofessional team of nurses, clinical pharmacists and respiratory therapists to deal with the VAP changes and to raise awareness amongst the staff on the importance of hospital-acquired pneumonias in critically ill patients and the risks that they are subject to. The AACN also suggests measures for nursing practice like briefing nurses in orientation programs about usage of ventilator bundles, crafting a system of communications for spreading knowledge about preventative VAP protocol, making documentation standards that obligate the nurses to observe HOB elevation and to include HOB elevation monitoring in the critical care unit in scorecards, QI plans etc. to ensure that the nurses comply to the ventilator bundles. The ventilator bundles are aimed to improve patient safety and enhance the quality of health care service offered. Researches indicate that the foremost ideology to achieve high levels of patient care through ventilator bundles is to show commitment to the cause. Nurses should work in concert with each other to achieve shared goals. For evidence-based practice, the nurses must be educated on the significance of that particular topic and its advantages for the patients and themselves. Only then can they recognize the worth of that endeavor and incorporate it into practice. Improvements in the service can only be accomplished if a plan has been drafted upon at which the nurses can act. For every project, it is vital to have a team leader who can supervise the activities of the members and channel their efforts into the achievement of common goals. One model for providing a leadership framework for nurses to work with was proposed by Burns in 1978. This model of transformational leadership can enable nurses to develop themselves morally and to incorporate EBP into their professional conduct. the theory presents the assumptions that if subordianates are placed in a higher moral position then they will be more motivated and will be more willing to follow a leader who endorses higher moral positioning. The process of transformational leadership encourages both the leader and the followers to engage in a mutual process of raising each other to higher levels of morality and motivation (Changingminds.org, 2010). Transformational leadership is an effective tool EBP for nursing since it would encourage both the leaders and the followers to aspire to higher ideals of nursing practice, where the mortality rate of VAP is low. The leadership model calls upon the social values of the followers and so it is more selfless in nature than other models of leadership like transactional models. The transformational model offers leadership that is more “transcendent, uplifting, moral, and often charismatic” (Jackson, Clements, Averill, & Zimbro, 2009). The model provides a direction for the followers to follow. This is important in EBP for the usage of ventilator bundles since for the VAP rates to fall, the nurses need to work in collaboration for integrating evidence into practice. The transformational leadership theory offers commitment for the leader and the follower to relate to; thus encouraging them to achieve better performance. In EBP for the decrease in the incidence of VAP, nurses can be encouraged by the team leader to emulate the clinical practices of professionals who have relied on evidence to improve their performance and gain professional socialization by being more professional. The model is also instrumental in making the nurses feel more satisfied. The model for transformational leadership motivates followers to work for internal rewards and self-actualization (Jackson, Clements, Averill, & Zimbro, 2009). This is relevant to the nursing profession since the primary purpose of nursing is to provide the utmost care to the patients; if there are marked improvements in the quality of life of the patients as a result of application of evidence into practice, the nurses would feel rewarded. The plan of preventative VAP is to be enforced by both the administration of the hospital and the nursing heads. The formal channels will include the hospital administration but the informal channels of enforcing the plan will require the cooperation of technicians, respiratory therapists etc. EBP will enable nurses to improve their clinical practice and to provide more efficient nursing care. The effective implementation of EBP will require the collaboration of nurses, patients, and other health care professionals that are involved in the treatment of VAP. Nurses would require the support of the hospital administration to issue them documentation on preventative VAP and education sessions to enhance their knowledge. The nurses would need their group leaders to encourage and motivate them to adopt EBP and to appreciate them when they follow the guidelines that the hospital has issued regarding preventative VAP. The various stages involved would include educational sessions and training regarding preventative VAP. A time framework also needs to be construed in order to provide the nurses with an objective to achieve in a limited time period. The expected outcomes of EBP will help the nurses to improve their knowledge and subsequently their professional practice. This will also reduce mortality rate of patients on mechanical ventilation. Since the nurses show better performances this will reflect positively on the performance of the health care service. Patients would prefer coming to places that promote hygienic conditions and ensure a better survival rate. With increased harmony and collaboration amongst nurses and other interprofessional individuals, healthy relationships will be fostered, which will lead to smoother work flow and better interprofessional dynamics. Reduced mortality would lead to more satisfaction and self-internalization in the nurses, and they will be encouraged to adopt EBP for lifetime. Their job satisfaction can be assessed by questionnaires and surveys and will be mirrored in their performance and conduct with the patients. They will show more commitment to their job and will be more meticulous and thorough in their conduct. The effectiveness of EBP can be analyzed by conducting follow up after the allocated time period had elapsed. Formal measures such as questionnaires can be used to chart the progress. Interviews can be carried out with nurses to know about their responses and opinions on EBP. The effectiveness of EBP can be further incremented by taking into consideration the obstacles that nurses have faced and taking measures to remove them, such as difficulty understanding statistical data, and a feeling of inferiority from knowledgeable colleagues (Chang, 2010). A future RN needs to appreciate the role of EBP in nursing practice. It is obvious that EBP plays a significant part in nursing practice by improving the knowledge of the nurses and their practice. A nurse who is better informed about what practices encourage patient safety can also act as a role model for other colleagues to follow. The RN and his or her fellow colleagues can indulge in a process of mutual encouragement to adopt EBP into their professional conduct. If EBP is successful, the RN needs to appreciate the group members; the sense of accomplishment felt by the RN and group members would be shared amongst them and would help them connect to each other. Thus in conclusion the translation of evidence into practice would require charismatic and persuasive leadership as well as collaboration by all group members. Future recommendations for EBP include development of elements of EBP such as workplace culture (Thiel & Ghosh, 2010). Reference List Aragao, I. (2008). Importance of ventilator bundles compliance on the outcome of ventilator associated pneumonia (VAP). Retrieved from http://www.reamondor.aphp.fr/pdf/javaporto09/Ventilator_Bundles.pdf Chang, H. C. (2010). Implementing Evidence-Based Practice in Taiwanese Nursing Homes: Attitudes and Perceived Barriers and Facilitators. Journal of Gerontological Nursing, 36(1), doi: 10.3928/00989134-20091204-04. Changingminds.org (2010). Burns Transformational Leadership Theory. Retrieved from http://changingminds.org/disciplines/leadership/theories/burns_transformational.htm Jackson, J. P., Clements, P. T., Averill, J. B., & Zimbro, K. (2009). Patterns of knowing: proposing a theory for nursing leadership. Retrieved from http://findarticles.com/p/articles/mi_m0FSW/is_3_27/ai_n31974415/?tag=content;col1 Lancashire and South Cumbria Critical Care Network (2005). Ventilator Care Bundle. Retrieved from http://www.google.com/url?sa=t&source=web&cd=5&ved=0CCsQFjAE&url=http%3A%2F%2Fwww.cmccn.nhs.uk%2Fuploads%2FVentilator%2520Care%2520Bundle%2520Guidelines-lancsandsouthcumbria.doc&rct=j&q=ventilator+bundle+four+&ei=OToPTKb0G9mK4gaQ_-XIDA&usg=AFQjCNHlYT9Rx8DvYbwQyqXgjQFYhCTKmQ Thiel, L. & Ghosh, Y. (2010). Determining registered nurses’ readiness for evidence-based practice. Worldviews Evidence Based Nursing, 5(4), PMID: 19076919. University of Minnesota Libraries (2009). Evidence-Based Practice. Retrieved from http://www.biomed.lib.umn.edu/learn/ebp/mod01/index.html Tolentino-DelosReyes, A. F., Ruppert, S. D., & Shiao, S. P. K. (2007). Evidence-Based Practice: Use of the Ventilator Bundle to Prevent Ventilator-Associated Pneumonia. Retrieved from http://ajcc.aacnjournals.org/cgi/content/full/16/1/20 Read More