Med. J. Cairo Univ., Vol. 81, No.
2, September: 81-94, 2013
www.medicaljournalofcairouniversity.net
Knowledge and Performance of Critical Care Nurses Toward
Nebulizer Therapy in the Intensive Care Unit
at Assiut University Hospital
FARES A.A. KHODISH, B.Sc.N*; MONA A. MOHAMMED, D.N.Sc.*;
MERVAT ANWAR ABD EL-AZIZ, D.N.Sc.* and HANY AHMED IBRAHEM, M.D.**
The Departments of Critical Nursing* and Anesthesiology**, Faculties of Nursing* and Medicine**, Assiut University
Abstract
Background: A nebulizer is an important device used to
inhalant the drugs to treat some pulmonary diseases. The
examination of nurse's knowledge and performance regarding
the nebulizer therapy has not been conducted before at Assiut
University Hospital.
Aim of Study: Asses critical care nurse's knowledge and
performance related to nebulizer therapy.
Methods: Descriptive design was adapted for this study.
The sample of this study consisted of 80 nurses working in
three intensive care units (38 nurses in traumatic ICU, 20
nurses in postoperative ICU and 22 in general ICU). Two
tools were used to collect the required data; nurses' knowledge
assessment questionnaire and skills observation checklist
related to nebulizer therapy.
Results: The findings revealed that (56.2%) of nurses
have knowledge about nebulizer therapy at unsatisfactory
level (Mean±SD=27.44±12.09) also the findings revealed that
(88.8%) of nurses had performance about nebulizer therapy
at unsatisfactory level (Mean±SD=29.25±15.97). There was
a positive strong relationship between knowledge and perfor-
mance regarding nebulizer therapy (r=0.277, p=0.013).
Conclusions: Nurse's knowledge and performance about
nebulizer therapy were unsatisfactory so that the nurses should
be trained enough to give effective and safe care to such
patients.
Key Words: Nursing knowledge — Nursing performance —
Nebulizer therapy.
Introduction
AEROSOLIZED medications can greatly benefit
critically ill patients with respiratory disorders.
However, for an aerosol to be clinically useful, it
must be delivered effectively to the airways as
well as produce a desired therapeutic effect once
Correspondence to: Dr. Mona A. Mohammed, The Department
of Critical Nursing, Faculty of Nursing, Assiut University
81
delivered pi. A nebulizer is an electrically powered
machine that turns liquid medication into a mist
so that it can be breathed directly into the lungs
through a face mask or mouthpiece [21. It is gener-
ally believed that nebulizers are superior to MDIs
during mechanical ventilation. The delivery of
bronchodilators with MDI in mechanically venti-
lated patients has received considerable interest in
recent years. This is because the use of metered
dose inhalation (MDI) has several advantages over
the nebulizer, such as reduced cost, ease of admin-
istration, less personnel time, reliability of dosing
and a lower risk of contamination. The use of
nebulizers under certain circumstances may lead
to patient/ventilator dyssynchrony. Finally, nebu-
lizers may damage the expiratory transducer of
some ventilators, rendering the expiratory volume
measurement unreliable [31. Bronchodilators are
frequently used in ICU patients receiving invasive
mechanical ventilation (IMV) and commonly de-
livered through the inhalation route [4]. Medication
that is inhaled in the form of small droplets is
absorbed immediately into the mucosa and blood
stream and is available to the body within minutes.
This method of medication delivery is one of the
fastest, noninvasive methods of medications de-
signed to ease respiratory distress symptoms such
as those seen with asthma [51. Some studies reflect
that, there are advantages of nebulizertreatment
including: Patient coordination required, effective
with tidal breathing, high dose possible, dose
medication possible, can be used with supplemental
oxygen, systemic side effects are less frequent and
severe with inhalation compared to systemic deliv-
ery (injection, oral); e.g., less muscle tremor,
tachycardia, Can deliver combination therapies if
compatible and Ultrasonic nebulizer is quiet, and
has faster delivery are smaller and more portable
82
[6]. Aerosolized medication if not performed with
appropriate technique, will lead to several conse-
quences and perils such as mucosa irritation, bron-
chospasm, dyspnea, airway burns (when heating
elements are used), headaches, coughing, tachy-
cardia, palpitations, nausea and precipitation of
bronchoconstriction most common in asthmatic
and COPD patients and may result in hypoxemia
[7] . Aerosolized medication must be performed
according to right standards and codes in order to
reduce its side effects [8]. Diggory & Vallone [9],
demonstrated in a study that performing aerosolized
medication by well-educated nurses and after
checking patient's need has better effect and fewer
side effects than performing it routinely [10]. Also
revealed in a study that performing aerosolisolized
medication by themselves according to the codified
protocol will minimize its side effects. Despite the
existence of several studies, manual on the basis
of evidences about aerosolized medication by
nebulizer is not available in most units. There for
performing aerosolized medication by nebulizer
with the observance of such experimental evidences
by nurses is on question 1111. Day et al., [12] in two
separate studies in intensive and acute care units,
realized nurses' lacking knowledge which was
reflected in their performance Nurses are one of
the major components of manpower in the field of
healthcare. The skills and knowledge of nursing
personnel may be directed towards health promo-
tion, crisis intervention, maintenance, rehabilitation/
restoration or palliation in care of critically ill
patient [13] . Nursing rolebefore using Nebulizer;
assess the patient's respiratory status. Note if the
patient is using accessory muscles for respiration
or if there is flaring of the nares. Auscultate the
client's chest for wheezes and crackles. Respiratory
distress is the primary reason to administer nebu-
lized treatment, the nurse must Place the patient
in an upright position (40 to 90 degrees), which
allows deep ventilation and maximal diaphragmatic
movement Put the mouthpiece in the mouth, be-
tween teeth, and close the lips (if using a mask,
cover mouth and nose with the mask). Assess the
breath sound, pulse rate, respiratory status, oxygen
saturation; assess the heart rate during the treatment.
In pregnant patient, the fetal heart rate should also
be assessed, instruct the patients to take slow deep
breaths for 10 seconds through the mouth and hold
at end inspiration and wash face if using a mask
to prevent rash [1 4] . The nurse must follow the
following steps when preparing a medication by
a nebulizer machine; if you have the multiple dose
vial be; Squeeze the dropper to fill it to the line
that matches your prescribed dose, squeeze the
medicine into the medicine cup, most medicines
Knowledge & Performance of Critical Care Nurses
that comes in multiple dose vials needs to be diluted
with normal saline [5] . The nurse instructs the
patient to do breathing exercise for two or three
seconds to give the medication time to fully enter
the airways of The lungs. After this first breath
continue this cycle of exhalation and inhalation
until the dose of medication is finished. Typically,
treatment will take roughly five to 10 minutes [15].
During the nebulizing; therapy it may be necessary
for the nurse to suction the patient's tracheostomy
to enable removal of secretions. This should only
be carried out if necessary and if the patient is
unable to cough the secretions out of the tube
themselves. It should be remembered that suction-
ing is an invasive procedure, which may be uncom-
fortable and frightening for the patient. It should
only be carried out following careful assessment
of the need for suctioning and should only be
undertaken by practitioners who are competent.
Patient indications for suctioning may include:
Visible or audible secretions that patient are unable
to clear, patient distress, clammy skin or sweating,
increased heart rate/respiratory rate reduced oxygen
saturation [1 6] . The role of the nurse toward the
patient with nebulizer therapy for promoting res-
piratory care based. The nurse instructs the patient
to breathe through the mouth, taking slow, deep
breaths, and then to hold the breath for a few
seconds at the end of inspiration for increasing the
intrapleural pressure and reopen collapsed alveoli,
therapy increasing function residual capacity, the
nurse encourage the patient to cough and to monitor
the effectiveness of the therapy [17]. So, the signif-
icance of the study from an organizational perspec-
tive, the large and increasing number of noninvasive
procedures at intensive care unit may result in
capacity problems such as respiratory infection. A
possible solution for these problems might be a
reduction in length hospital stay. The number of
nebulizer therapy performed at Assiut University
ICU units in 2010-2011 more than 450 intervention
procedures Observation of nebulizer therapy at
ICU showed that most patient who performed
nebulizer therapy. Therefore the aim of this study
is to investigate Knowledge and practices levels
of nurses in ICU at Assiut University Hospital.
This study could be beneficial in many ways; first,
it will provide data-base that can be utilized by
health team members to raise nurse's awareness,
and initiate more active nurse's roles at intensive
care unit. Second, Health professionals can utilize
such information in the care plan for such group
of nurses in the future. Third, proper nursing as-
sessment and monitoring can improve patient's
outcome.
Fares A.A. Khodish, et al.
Subjects and Methods
Research design: Descriptive design was adapt-
ed for this study.
Studyaim: Investigate critical care nurses'
knowledge and performance related to nebulizer
therapy.
Research questions: What are nurses' knowledge
and performance of toward nebulizer therapy in
the intensive care unit at Assiut University Hospital.
Material:
Setting:
This study was conducted in three intensive
care units (general intensive care units, postoper-
ative intensive care units & traumatic intensive
care units) at Assiut University Hospital.
Subjects:
A sample of convenience included all the avail-
able nursing staff working at the general intensive
care units (22 nurses), postoperative intensive care
units (20 nurses) & traumatic intensive care units
I.C.0 (38 nurses) at Assiut University Hospital
(Total 80 nurses).
Tools:
Two tools were used to collect the required
data; nurses' knowledge assessment questionnaire
and skills observation checklist related to nebulizer
therapy.
Tool (1): Nurses' knowledge assessment Question-
naire:
Arabic interview questionnaire sheet was con-
structed after reviewing the relevant literature to
assess nurses' knowledge about a nebulizer ma-
chine. It was developed and translated into Arabic
language. Thequestionnaire was included three
parts. Part (1): Is for nurses' characteristics such
asage, marital status, years of experience, depart-
ment, qualifications and their attendance of related
course training about a nebulizer machine. Part
(2): Thispartassesses nurses' knowledge related to
nebulizer machine in general such as type, indica-
tions for applications, and complications of nebu-
lizer machine. Part (3): Assess nurses' knowledge
concerning nebulizer therapy related practices
including knowledge regarding assessment, prep-
aration, application, post nursing care, and docu-
mentation of nebulizer therapy.
The total score for this questioner tool was 24
points, the correct response answer was scored as
"1" and incorrect response or do not know as "o".
The Satisfactory level of knowledge equal or more
83
than 60% of the maximum score. Unsatisfactory
level of knowledge less than 60% of the maximum
Tool (2): Skills observation checklist tool:
This tool was adapted from Potter et al., it was
used to assess nursing performance while applying
and providing maintenance care of nebulizer ther-
apy. The check list items included 71 items. It
consists of three parts. Part (1): Includes type of
the ICU and the shift (morning, evening or night)
when the observation checklist was taken. Part (2):
Involves patients' characteristics, such as; age,
medical diagnosis and past history. Part (3): Was
used to observe nurses' practices while applying
and maintaining the nebulizer therapy. It contains
five main section covering the main steps of neb-
ulizer use and care; assessment, preparation, post-
care, maintenance and documentation. First section
was for assessment which involves items to be
assessed before the application of nebulizer therapy,
such as indication of nebulizertherapy, physician's
order and medications which used by nebulizer
therapy. Second section was concerned with the
preparation of equipment and patient. Third section
was for the application of the nebulizer therapy
including practices such as, breathexercises, vital-
singes, suction, mechanical ventilation, pulse oxim-
etry, oxygen therapy and arterial blood gas. Section
four involves post care practices such as; washing
hands and regular care while the nebulizer therapy
was maintained. Finally, section five was; docu-
mentation of the type of nebulizer, medications,
time, indications and unexpected outcomes for
nebulizer therapy. Satisfactory levelof performance
equal or more than 60% of the maximum score.
Unsatisfactory level of performance less than 60%
of the maximum score.
Methods:
Permission was obtained from the hospital
administrative authority to collect the necessary
data. Validation of the study tools was assessed by
presenting them to five experts from the critical
care nursing field. A pilot study was carried out in
march-July 2012 to test the tool. A pilot study was
conducted for purpose of testing clarity, complete-
ness, and validity, practicability of the study tools
of (5) nurses to determine the time involvement.
Also it was done to show the possibility and effec-
tiveness of using the observation checklist. Neces-
sary modification was done. Testing the questions
ware done to see if they are relevant and if they
elicit the type of information, which are thought
according to the answers and comments made by
nurse. Some details not required were omitted,
either to advance or reduce the tool lengthy test.
Also to show the possibility and the effectiveness
84 Knowledge & Performance of Critical Care Nurses

of using the observation checklist regarding the Statistical analysis:

policy of hospital performance
The observation checklist was carried out while
the nurses were working during their shifts in these
units. Each observation lasted for 20 minutes by
using the direct observation technique. At initial
interview the researcher explain the nature &
purpose of the study, prior to answering the ques-
tions to gain their oral consent & cooperation, and
fill out the questionnaire sheet by nurses were on
duty during morning,afternoon and night shifts.
Nurses were observed two hours for each nurse,
while they were performance nursing intervention
for their patient during this period. The whole
period for implementation of study was morning
shift.
Data entry was done using compatible personal
computer by the investigator. The statistical analysis
was done using SPSS-16 statistical software pack-
age. The content of each tool was analyzed, cate-
gorized and then coded by the investigator. Data
were presented using descriptive statistics in the
form of frequencies and percentages for qualitative
variables, Quantitative continuous data were com-
pared using student t-test in case of comparisons
between three groups. Pearson correlation analysis
was used for assessment of the inter-relationships
among quantitative variables. Statistical signifi-
cance was considered at p-value<0.05.
Results

Table (1): Presentation of study group at three units in intensive care units.
I.C.0 trauma Postoperative I.C.0 General I.C.0 DF=2
Characteristics (n=38) (n=20) (n=22)
No. % No. % No. % X2 p-value
Age in years:
<25 years 10 26.3 6 30.0 9 40.9 3.187
25-30 years 21 55.2 9 45.0 7 31.8
>30 years 7 18.4 5 25.0 6 27.2 0.527
Qualification:
Nursing Bachelor 10 26.3 4 20.0 2 9.0
Nursing Technical Institute 7 18.42 5 25.0 6 27.2 2.825 0.588
Nursing Diploma 21 55.2 11 55.0 14 63.6
Years of experience:
<5 years 4 10.5 7 35.0 4 18.1
5-10 years 25 65.7 5 25.5 7 31.8 13.219 0.010*
10 years and more 9 23.6 8 40.0 11 50.0
Training course:
Attended 0 00.0 0 00.0 0 00.0
Not attended. 38 10.0 20 10.0 22 10.0

(*) Statistical significant difference (p<0.05).

Table (1) showed that the total number of nurses

are (80) nurses from different of intensive care
units, (38) nurses from trauma intensive care unit,
(20) from post operative & (22) from general
intensive care unit. The majority of nurses (55.2%)
were between 25-30 years old in traumatic ICU,
The majority of the nurses were nursing diploma IN;Ll
(63.6%) in general ICU, and all nurses had no Unsatisfactory
56.2%
previous training courseabout nebulizer (100%).
Fig. (1): Illustrate nurses' knowledge
There was statistical significant difference about nebulizer.
related to years of experience (p-value=0.010) and
the majority of nurses (65.7%) were between 5-10 This figure shows that (56.2%) of nurses at
years in trauma ICU. unsatisfactory level of knowledge.
Fares A.A. Khodish, et al. 85

Table (2): Description of nurses' knowledge related to nebulizer therapy at three units.
Units
I.C.0 Postoperativ General
Nurses' knowledge p-value
Unsatisf. Satisfact. Unsatisf. Satisfact. Unsatisf. Satisfact.
No. % No. % No. % No. % No. % No. %
Define the nebulizer 20 52.6 18 47.4 10 50.0 10 50.0 17 77.3 5 22.7 0.115
Indications of nebulizer 3 7.9 35 92.1 1 5.0 19 95.0 2 9.1 20 90.9 0.874
Assessment:
Sings of hypoxemia 12 31.6 26 68.4 8 40.0 12 60.0 16 72.7 6 27.3 0.007*
The lung sound. 16 42.1 22 57.9 9 45.0 11 55.0 16 72.7 6 27.3 0.059
Chest secretions 34 89.4 4 10.5 18 90.0 2 10.0 21 95.4 1 4.5 0.542
The arterial blood gases 12 31.5 28 73.6 5 25.0 15 75.0 10 45.4 12 54.5 0.214
Pulse oximetry 7 18.4 31 81.6 5 25.0 15 75.0 12 54.5 10 45.5 0.011*
Pulmonary function test 7 18.4 31 81.6 3 15.0 17 85.0 10 45.5 12 54.5 0.033*
Prepare:
The equipment 12 31.5 26 68.4 9 45.0 11 55.0 17 77.2 5 22.7 0.003*
The medication 4 10.5 34 89.5 1 5.0 19 95.0 4 18.2 18 81.8 0.394
Checkthe connections 14 36.8 24 63.1 14 70.0 6 30.0 13 59.0 9 40.9 0.039*
Explain breathing exercises 22 57.9 16 42.1 10 50.0 10 50.0 17 77.3 5 22.7 0.163
Complications of nebulizer 28 73.6 10 26.3 16 80.0 4 20.0 19 86.3 3 13.6 0.048*

(*) Statistical significant difference (p<0.05).

Table (2) shows that there were significant
difference in nurses' knowledge about Sings of
hypoxemia patient (p-value=0.007), and the ma-
jority of nurses in General I.C.0 were at unsatis-
factory level (72.7%). Also, there was significant
difference in nurses' knowledge about pulse oxime-
tery (p-value=0.011) and the majority of nurses in
I.C.0 trauma were at satisfactory level (81.6%).
Shows there were significant difference in
nurses' knowledge aboutpulmonary function test
(p-value=0.033) and the majority of nurses in
postoperative I.C.0 were at satisfactory level
(85.0%). There was significant difference in nurses'
knowledge about prepare theequipment (p-value=
0.003) and the majority of nurses in general ICU
were at Unsatisfactory level (77.2%).
There was significant difference in nurses'
knowledge about Check all connections of nebulizer
(p-value=0.039) and the majority of nurses in
postoperative I.C.0 were at Unsatisfactory level
(70%).
There was significant difference in nurses'
knowledge about complications of nebulizer (p-
value=0.048) and the majority of nurses in general
I.C.0 were at unsatisfactory level (86.3%).

Table (3):Difference between nurses' knowledge related to nebulizer therapy according to qualification.
Qualification
Nursing Bachelor Technical Institute Nursing Diploma
Nurses' knowledge (n=16) (n=18) (n=46) p-value
Unsatis- Satis- Unsatis- Satis- Unsatis- Satis-
factory factory factory factory factory factory
No. % No. % No. % No. % No. % No. %
Define of nebulizer 3 18.8 13 81.3 12 66.7 6 33.3 36 78.3 10 21.7 0.000*
Indications nebulizer 2 12.5 14 87.5 4 22.2 14 77.8 4 8.7 42 91.3 0.194
Assessment:
Signs of hypoxemia 7 43.8 9 56.3 4 22.2 14 77.8 25 54.3 21 45.7 0.067
The lung sound. 13 81.2 3 18.7 16 88.8 2 11.1 46 100.0 0 0.00 0.026*
Thechest secretions. 16 100.0 0 0.0 16 88.9 2 11.1 44 95.7 2 4.3 0.317
Arterial blood gases 5 31.3 11 68.8 9 50.0 9 50.0 14 30.4 32 69.6 0.317
Pulse oximetry 4 25.0 12 75.0 4 22.2 14 77.8 16 34.8 30 65.2 0.546
Pulmonary function test 4 25.0 12 75.0 3 16.7 15 83.3 13 28.3 33 71.7 0.629
Prepare medication 2 12.5 14 87.5 1 5.6 17 94.4 6 13.0 40 87.0 0.685
Cleans the equipments 12 31.5 26 68.4 9 45.0 11 55.0 17 77.2 5 22.7 0.003*
Explain:
Breathing exercises. 3 81.8 13 18.2 2 11.1 16 88.9 4 8.7 42 91.3 0.548
Procedures of neubilizer 5 31.2 11 68.7 6 33.3 12 66.6 29 63.0 17 37.0 0.024*.
Complications of nebulizer 12 75.0 3 25.0 14 77.7 4 22.2 42 91.3 4 8.7 0.872
(*) Statistical significant difference (p<0.05).
86 Knowledge & Performance of Critical Care Nurses

Table (3) shows there were significant difference
in nurses' knowledge aboutdefine of nebulizer (p-
value=0.000) and the majority of nurses in Nursing
Bachelorwere at satisfactory level (81.3%), there
were significant difference in nurses' knowledge
aboutdefine of lung sound (p-value=0.026) and
the majority of nurses in Nursing Bachelorwere at
unsatisfactory level (81.2%), there were significant
difference in nurses' knowledge aboutdefine of
Cleans the equipment's (p-value=0.003) and the
majority of nurses in Nursing Bachelorwere at
satisfactory level (68.4%), there were significant
difference in nurses' knowledge aboutexplained
procedure of nebulizer (p-value=0.024) and the
majority of nurses in Nursing Bachelorwere at
satisfactory level (68.7%).

Table (4): Differences nurses' knowledge and nurses' charac- 95 F-7'100

teristics according to department, education, and 100
experience. 90
Level of Knowledge 80
Nurses'
characteristics Unsatisfactory Satisfactory p-value
70
No. % No. %
60
Department:
I.C.0 trauma 20 52.6 18 47.4 47.4 50
I.C.0 postoperative 10 50.0 10 50.0 50.0
General I.C.0 15 68.2 7 31.8 31.8 40
Education: 30
Nursing Bachelor 4 25.0 12 75.0 75.0
Nursing Diploma 32 69.6 14 30.4 30.4 20
Nursing Technical 9 50.0 9 50.0 50.0
Institute 10
Experience: 0 -=P- r,""
<5 years 12 80.0 3 20.0 20.0
5-10 years 22 59.5 15 40.5 40.5 ICU Trauma Post operation General ICU
10 years 11 39.3 17 60.7 60.7 ICU
(*) Statistical significant difference (p<0.05).
❑ Unsatisfactory
Table (4) shows that there was significant dif- • Satisfactory
ferences regarding to education (p-value=0.07)
and experiences (p-value=0.32). Fig. (2): Nurses' performance according to department.

Table (5): Relationship between nurses' performance and nurses' qualifications related to nebulizer therapy.

Qualification

Nurses' knowledge Nursing Bachelor Nursing Technical Nursing Diploma p-value

(n=16) Institute (n=18) (n=46)

No. No. No.

Hand washing:
Satisfactory 4 25.0 2 11.1 6 13.0
Unsatisfactory 12 75.0 16 89.0 40 87.0 0.019*
Flow rate of 02:
Satisfactory 13 81.3 15 83.3 40 87.0
0.838
Unsatisfactory 3 18.8 3 16.7 6 13.0
Arterial blood gases:
Satisfactory 13 81.3 13 72.2 22 47.8
Unsatisfactory 3 18.8 5 27.7 24 52.2 0.007*
Reassess lung sounds, pulse:
Satisfactory 3 18.8 7 38.9 5 10.9
0.036*
Unsatisfactory 13 81.3 11 61.1 41 89.1
Clean of equipment:
Satisfactory 7 43.7 12 66.6 8 17.3
Unsatisfactory 9 56.2 6 33.3 38 82.6 0.001**

(*) Statistical significant difference (p<0.05). 02 = Oxygen.

Fares A.A. Khodish, et al. 87

Table (5) shows significant difference in nurs-
es' performance about washing hands (p-value
=0.019) and the majority of nurses innursing
Technical Institute were at unsatisfactory level
(89.0%).
There was significant difference in nurses'
performance about Arterial blood gases (p-value=
0.007) and the majority of nurses in nursing bach-
elor were at satisfactory level (81.3%).
There was significant difference in nurses'
performance aboutreassessing breath sounds, pulse,
oxygen saturation, respiratory rate, (p-value=0.036)
and the majority of nurses in nursing diploma were
at unsatisfactory level (89.1%).
There was significant difference in nurses' per-
formance aboutwashing all parts of the nebulizer
(p-value=0.001) and the majority of nurses in nurs-
ing diploma were at unsatisfactory level (82.6%).

Table (6): Nurses performance related to nebulizer of MV (mechanical ventilation) according to qualifications.

Qualification

Nurses' knowledge Nursing Bachelor Nursing Technical Nursing Diploma p-value

(n=16) Institute (n=18) (n=46)

No. No. No.

Prepare suction equipment:

Satisfactory 14 87.5 14 77.77 33 71.73
Unsatisfactory 2 12.5 4 22.22 13 28.26 0.436
Reassess vital signs:
Satisfactory 11 68.7 11 61.11 22 47.82
0.035*
Unsatisfactory 5 31.25 7 38.88 24 52.17
Cleans the equipment:
Satisfactory 4 25.0 6 33.33 11 23.39
0.950
Unsatisfactory 12 75.0 12 66.66 35 76.08
Attach MV to endotracheal tube/tracheostomy tube:
Satisfactory 14 87.5 15 83.33 17 00.0
0.010*
Unsatisfactory 2 12.5 3 16.66 29 100.0
Secure ventilator tabling:
Satisfactory 12 75.0 11 61.11 0 00.0
0.010*
Unsatisfactory 4 25.5 7 38.88 46 100,0
Setup nebulizer which attached with MV:
Satisfactory 12 75.0 13 72.22 32 69.56
0.913
Unsatisfactory 4 25.0 5 27.77 14 30.43
Document all finding before & after therapy:
Satisfactory 12 75.0 15 83.33 34 73.91
0.817
Unsatisfactory 4 25.0 3 16.66 12 26.08

(*) Statistical significant difference (p<0.05).

Table (6) shows there were significant difference
in nurses' performance about Reassess vital signs
(p-value=0.035) and the majority of nurses in
Nursing Technical Institute were at satisfactory
level (77.7%).
There was significant difference in nurses'
performance about Attach mechanical ventilator
to endotracheal tube or tracheostomy tube (p-value
=0.10) and the majority of nurses in Nursing Bach-
elor were at satisfactory level (87.5%).
There was significant difference in nurses'
performance aboutsecure ventilator tabling (p-
value=0.010) and the majority of nurses in Nursing
Bachelor were at satisfactory level (75%).
88 Knowledge & Performance of Critical Care Nurses

Table (7): Nurses' performance related to nebulizer of mechanical ventilation according to units.
Units
Nurses' performance I.C.0 trauma Postoperative I.C.0 General I.C.0 p-value
(n=38) (n=20) (n=22)
No. % No. % No. %
Prepared suction equipment:
Satisfactory 30 78.9 14 70.0 15 68.2
Unsatisfactory 8 21.1 6 30.0 7 31.8 0.598
Lung sound:
Satisfactory 3 7.9 2 10.0 1 4.5
Unsatisfactory 35 92.1 18 90.0 21 95.5 0.792
Reassess vital signs:
Satisfactory 8 21.1 3 15.0 1 4.5
Unsatisfactory 30 78.9 17 85.0 21 95.5 0.226
Cleans the equipment at least once daily:
Satisfactory 11 28.9 6 30.0 4 18.1
Unsatisfactory 27 71.1 14 70.0 18 81.8 0.012*
Attach MV to endotracheal tube
or tracheostomy tube:
Satisfactory 33 86.8 16 30.0 0 0.0
Unsatisfactory 5 13.2 4 70.0 22 100.0 0.000*
Secure ventilator tabling:
Satisfactory 28 73.7 17 85.0 0 0.0
Unsatisfactory 10 26.3 3 15.0 22 100.0 0.000*
Documentation:
Satisfactory 33 86.8 17 85.0 18 81.8
Unsatisfactory 5 13.2 3 15.0 4 18.2 0.871

Table (7) shows that there was significant dif- =0.000) and the majority of the nurses in general
ference in nurses' performance about Cleans the I.C.0 were at unsatisfactory level (0.100%).
equipment at least once daily (p-value=0.012) and
the nurses of the majority in general I.C.0 were There was significant difference in nurses'
at unsatisfactory level (81.8%). performance about Secure ventilator tabling to
reduce pull on tracheostomy or endotracheal tube
There was significant difference in nurses' (p-value = 0.000) and the majority of nurses in
performance about Attach mechanical ventilator general I.C.0 were at unsatisfactory level
to endotracheal tube or tracheostomy tube (p-value (100%).
Table (8): Nurses performance related to nebulizer of mechanical ventilation (MV) according to experiences.
Year of experiences
Nurses' performance <5 years 5-10 years >10 years p-value
(n=15) (n=37) (n=28)
No. % No. % No. %
Prepared suction equipment readily available:
Satisfactory 12 80 28 75.67 18 64.28
Unsatisfactory 3 20 9 24.32 10 35.71 0.314
Reassess vital signs, breathing and lung sound:
Satisfactory 4 26.6 10 27.0 11 39.28
Unsatisfactory 11 73.3 27 73.0 17 60.71 0.048*
Cleans the equipment:
Satisfactory 5 33.33 10 27.0 16 57.14
Unsatisfactory 10 66.66 27 73.0 12 42.85 0.042*
Attach MV to endotracheal /tracheostomy tube:
Satisfactory 13 86.66 33 89.18 27 96.42
Unsatisfactory 2 13.33 4 10.81 1 3.57 0.465
Secure MV tabling:
Satisfactory 7 46.66 29 78.37 20 71.42
Unsatisfactory 8 53.33 8 21.62 8 28.57 0.076
Setup nebulizer which attached with MV:
Satisfactory 9 60.0 30 81.08 22 78.57
Unsatisfactory 6 40.0 7 18.91 6 13.04 0.253
Documentation:
Satisfactory 13 86.6 29 78.37 19 67.85
Unsatisfactory 2 13.33 8 21.62 9 3.57 0.353
(*) Statistical significant difference (p<0.05).
Fares A.A. Khodish, et al. 89

Table (8) shows there were significant difference Discussion

in nurses' performance about Reassess vital signs
(p-value=0.048) and the majority of the nurses at Nebulisers are commonly used in the manage-
the age less than 5 years old were at satisfactory ment of acute exacerbation airways disease. A
level (73.3%). study was therefore conducted to ascertain what
nurses knew about this form of therapy. Several
There was significant difference in nurses' areas of deficient knowledge were revealed, in-
performance about Cleans the equipments at least cluding how to clean the equipment properly, what
once daily (p-value=0.042) and the majority of the flow rate of gas should be and what type of
the nurses at the age between 5 to 10 years old gas to use. And nursing care for nebuliser therapy
(30.0%). is included [17] .

30.00 r=0.277 - - - - The results of the present study showed that

0
p=0.013* 0 the majority of nurses (55.2%) were between 25
0 00
0 0 0 -30 years old in traumatic ICU. the majority of
25.00 nurses were having nursing diploma (63.6%) in
o 0 000
0 0 0 0
0 0 general ICU, and all nurses had no previous training
0 0 0 0 0 0 0
20.00 - - - - - - --
0 - - - - - 00- - - -a about nebulizer (100%).
0 0 00 0
0 00
0 0 0 0
0 0 0
0 This study indicated that there was statistical
0
15.00 -o 0- 0-0- 0 a significant difference related to years of experi-
00
0 0 0 0 ence and the majority of nurses were between 5-
10 years in trauma ICU. These findings are con-
10.00 -
gruent with those of who [18] reported that; years
5.00 10.00 15.00 20.00 25.00 30.00 35.00 of experience in the hospital significantly correlated
(*) Statistical significant difference (p<0.05). to increased knowledge, attitudes and practices
Fig. (3): Correlation between nurses' among the various categories of staff but this did
knowledge and performance. not translate into good clinical practice in the ward
and stated that the education and training are two
There was a significant positive correlation components of staff development that occur after
between score of knowledge and score of perfor- employee indoctrination (which refers to planned,
mances (p-value=0.013). guided adjustment of employees' organization and
Table (9): Relationship between nurses' performance and work environment). The staff knowledge level and
nurses' characteristicsaccording to department, capabilities are a major factor in determining the
education, and experience number of staff required to carry out unit goals.
Nurses' performance The better trained and more competent the staff,
Nurses' Unsatis- Satis- the fewer staff required, which in turn saves the
characteristics p-value
factory factory organization money and rise reproductively.
No. % No. %
The findings revealed that total knowledge was
Department: at an unsatisfactory level. The reasons might be
I.C.0 trauma 30 78.9 8 21.1 due to education and training of the nurses, all
Postoperative I.C.0 19 95.0 1 5.0
General I.C.0 22 100.0 0 0.0 0.027*
nurses (100%) had not attended training courses
about nebulizer. The majority of the nurses in the
Education: three units (intensive care unit of trauma, postop-
Nursing Bachelor 10 62.5 6 37.5
Nursing Diploma 45 97.8 1 2.2 erative intensive care unit and general intensive
Nursing Technical 16 88.9 2 11.1 0.001* care unit) had gained a diploma in nursing), There-
Institute fore, these factors may affect the unsatisfactory
Experience: level of knowledge of nurses [19] . Stated that many
<5 years 13 86.7 2 13.3 medical personnel responsible for monitoring and
5-10 years 32 86.5 5 13.5 instructing patients in optimal inhaler use. Nurses
10 years 26 92.9 2 7.1 0.695 seldom receive formal training in the use of inhaling
(*) Statistical significant difference (p<0.05). devices, and newer inhaling devices designed to
obviate problems of technique are at present less
Table (9) shows that significant differences in likely to be used well by medical personnel soon
nursing performance regarding to department (p- after their introduction [20] . In another study also
v alue=0 .027) and education (p-value=0.001). discovered that knowledge is acquired primarily
90
through experience, usually observation of and
working withmentors and continuing education.
Tacit knowledge may also be described as practical
that is, derived from experience or practice [21].
Recommended that lack of knowledgeable nurses
leads to increased risks to patients and may influ-
ence patient's outcomes. Nursing shortage also
leads to increased workload as the nurse: Patient
ratio decreases and one nurse has to provide care
for more than one critically ill patient. Shift leaders
in both public and private sectors are working
under great pressure and a large number of them
are also not trained, but simply have the experience
of working in an ICU for a number of years.
The current study revealed that the majority of
the study sample (81.6%) werehaving satisfactory
in nurses' knowledge about pulse oximetery. These
finding is in accordance with the results of the
study conducted by [22] whomentioned that a pulse
oximetry (Sp02) knowledge survey was conducted
with 551 experienced critical care nurses at the
2002 American Association of Critical Care Two
hundred and seven questionnaires were completed
(a response rate of 74.5%). Mean pulse oximetry
knowledge, with ICU nurses having significantly
higher scores than anesthesia department nurses
and those with more than 10 years of experience
having significantly higher scores. Correct respons-
es did not exceed 50% for six questionnaire items,
five of which covered principles of pulse oximetry
function. ICU nurses had significantly more correct
responses in five items compared to nurses, and
in two of them compared to anesthesia department
nurses.
It was found in the present study that there was
significant difference in nurses' knowledge about
cleaning the equipments at least once daily These
results are in agreement with the study of Canadian
Committee on Antibiotic Resistance, [23], they
found that reusable medical equipment must be
thoroughly cleaned before disinfection or steriliza-
tion, factors that affect the ability to effectively
clean medical equipment must be considered prior
to cleaning, instruments should be cleaned as soon
as possible after use to prevent organic material
drying on instruments, place the instrument in a
pre-soak of water or an enzymatic solution, this
will prevent drying of organic material, organic
material must be removed before disinfection or
sterilization procedures are initiated and the process
for cleaning should include written protocols for
disassembly, sorting and soaking, physical removal
of organic material, rinsing, drying physical in-
spection and wrapping. In this regard Labrague,
et al., [24] found that age, gender, length of clinical
Knowledge & Performance of Critical Care Nurses
experience, and number of trainings attended are
not determinants of the knowledge on the principles
of sterile technique. This implies that nurses re-
gardless of their age, gender, length of clinical
experience, and numbers of trainings attended do
not differ in knowledge on sterile technique.
The present study of revealed that nurses'
knowledge about checking all connections of neb-
ulizer and the majority of nurses in postoperative
I.C.0 were at unsatisfactory level. McNeal, [25]
presented that There are lots of models of nebulizer
out there, and each one is a little different from
the others. This general guide to nebulizer parts
will give a basic idea of what makes a nebulizer
system function.
The current study revealed that of nurses' knowl-
edge about pulmonary function test were at satis-
factory level (85%). In this respect, (Encyclopedia
of Nursing) [26], reported that when the results of
pulmonary function testing are accurate, the most
frequent reason is adequate patient education and/or
technician training. It is recommended that person-
nel conducting pulmonary function testing have
one of the following credentials: Certified respira-
tory therapy technician (CRTT); registered respi-
ratory therapist (RRT); certified pulmonary function
technologist (CPFT); or registered pulmonary
function technologist (RPFT).
The results of the present study showed that
the majority of studied sample were having unsat-
isfactory level of knowledge about complications
of the nebulizer. according to (Hoyle, 2012) [27]
stated that nurses should have knowledge about
any complications that may occur during nebulizer
therapy, the patient may become dizzy,complainse
of headache or may become disoriented during the
course of treatment. If this happens, have patient
take off his or her mask or remove his mouthpiece
and take a break for a few minutes. Once his head
is clear, have him continue the treatment and focus
on breathing more slowly than before. In some
cases, slower breathing may not resolve dizziness
or disorientation. Kulas, [28] who also found that
the act of inhaling the medication through a nebu-
lizer can cause dry mouth, sore throat, a bad taste
in the mouth or hoarseness? Sometimes, nebulizers
can cause thrush, which is a yeast infection in the
mouth. Symptoms of thrush include white spots
in the mouth, bleeding and pain.
The current study results denoted that the ma-
jority of the studied nurse's were having a satisfac-
tory level of knowledge about the definition of the
nebulizer. The present study also showed that there
Fares A.A. Khodish, et al.
was significant difference in nurses' knowledge
about explaining procedures and the majority of
nurses in nursing Bachelor were at satisfactory
level of knowledge (68.7%). According to Ethan,
[29]the patient should be in a comfortable position
throughout the procedure. Once the patient puts
the face mask on, he or she can start taking slow,
deep breaths. He or she should continue to breathe
slowly and deeply until there is no medication left
in the Nebulizer cup. This generally takes anywhere
from ten to thirty minutes, depending on the pre-
scribed quantity of medication.
The current study revealed the majority of
nurses in nursing diploma were unsatisfactory
knowledge regarding hearing the lung sound
(0.00%). This result agrees with Layman, et al.,
[30]who emphasized that the assessment of the
breath sound, pulse rate, respiratory status, oxygen
saturation and assess the heart rate during the
treatment. In pregnant patient, the fetal heart rate
should also be assessed, instruct the patient to take
slow deep breaths for 10 seconds through the mouth
and hold at end inspiration and wash face if using
a mask to prevent rash.
For performance regarding nebulizer, the find-
ings showed that total practice was at an unsatis-
factory level. The reasons may be due to lack of
equipments, ignorance and the activities not in the
duties of nurses Plaza, et al., [31] found that a
shortage of equipment was identified as obstacle
to the facilitation of the nurses' performance in
clinical areas.
The present study showed that There was a
significant positive correlation between score of
knowledge and score of performances (p-value
=0.013). This result agreed with Whyte, [32] who
have reported that selection of a group of nurses
participants was classified as either novice or
experienced nurses on the basis of their years of
experience. There were 12 experienced nurses and
10 novice nurses. Using an experimental research
design based on the expert performance approach,
a simulated task environment was developed for
the study using a patient simulator and a fully
equipped true-to-life intensive care unit suite.
Nurses were required to control the physiologic
deterioration of the patient with respiratory com-
promise in 4 scenarios and were also tested on
their knowledge of the constructs present in the
scenarios.
The present study revealed significant differ-
ences in nursing knowledge regarding to department
(p-value=0.027) and education (p-value=0.001) &
91
there was no significant differences regarding to
experiences. Hassan & Aboulazm, [32] stated that
the highest mean scores of knowledge was found
among nurses' who have bachelor of Science in
nursing, and also found there were improvement
of nurses' knowledge related to nebulizer.
In the present study we found significant dif-
ference in nurses' performance of arterial blood
gases (p-value=0.007). Nurses having Bachelor of
Sciences in nursing had significantly higher scores
than those having technical institute of nursing
and those having nursing diploma. Coombs, [33]
found that the ABG analysis provides useful mon-
itoring, especially for carbon dioxide. In most
wards, taking arterial samples has traditionally
been a medical role, but some specialist nurses are
now taking samples and so need to be able to
interpret measurements. Nurses who are not taking
samples may be able to initiate earlier intervention
if they are able to interpret results. Understanding
results can help nurses to understand treatments
and interventions, so making nursing more inter-
esting.
The present study revealed a significant differ-
ence in nurses' performance about reassessing
breath sounds, pulse rate, oxygen saturation, res-
piratory rate, and peak (p-value=0.036) and the
majority of nurses in nursing diploma were at
unsatisfactory level (89.1%).
A report by Creed & Spiers, [34] entailed that
professional nurse must perform by assessing
patient status from breath sounds, respiratory status,
pulse rate and other significant respiratory functions
needed. Compare, record significant changes and
improvement. Refer if necessary and perform other
significant respiratory functions. The current study
revealed a great lack of performance as regarding
of hands washing as all nurses were having an
unsatisfactory performance score level and had
statistical significant (p-value=0.019). Hand hy-
giene is the most important single infection control
measure used in nursing [35] .
Pratt, et al., [36] presented that hand contami-
nation is one of the main contributing factors in
the current infection threat; contaminated hands
are responsible for transmitting infection. Effective
hand cleaning can significantly reduce infection
rates in high risk area. Unfortunately, the result of
the present study revealed that the majority of
nurses didn't carry out certain procedures in relation
to infection control precautions such as hands
washing, wearing gloves and cleaning equipments.
Lam, et al., [37] presented that hand hygiene has
92
been singled out as the most important measures
in preventing hospital acquired infection Ahmed,
[38] has found lack of knowledge related universal
precautions and infection control among nurses.
The current study revealed a great lack of per-
formance as regards to washing all parts of the
nebulizer. Scores of nurses' performance (p-value
=0.001) and the majority of nurses in nursing
diploma were at unsatisfactory level (82.6%).
According to Ahmed, [39] who found that the ma-
jority of nurses practices related to cleaning instru-
ments mechanical ventilation inadequately per-
formed by nurses having diploma of Science.
Robert, et al., [40] mentioned that ineffectual dis-
infection of inhalation equipment between therapy
sessions of different patients has been reported to
produce serious outbreaks of infection. The role
of properly disinfected equipment that becomes
colonized during use was assessed. In the Vancou-
ver General Hospital gram-negative bacilli in the
nebulizer water were demonstrated in 10.5% of
nebulizers being used for periods of 24 to 72 hours.
In at least 15% of patients exposed to contaminate
nebulizers the organism was recovered from the
respiratory tract 48 hours after removal of the
equipment. Only one out of 85 patients exposed
to contaminated nebulizers developed pneumonia,
and in this instance a clear history of aspiration of
vomitus was present. The low incidence of pneu-
monia may be related to the high percentage of
nebulizers contaminated by organisms of low vir-
ulence and might be much greater in hospitals
where more highly pathogenic organisms are com-
monly found as nebulizer contaminants.
The present study revealed that there was sig-
nificant difference in nurses' performance about
reassessing vital signs (p-value=0.035) and the
majority of nurses in Nursing Bachelor Were at
satisfactory level (68.7%). in this regard, Quino,
[41] reported that vital signs are necessary reassess-
ing patients status; breath sounds, respiratory status,
pulse rate and other significant respiratory functions
needed. Compare and record significant changes
and improvement. Refer if necessary after inhala-
tion therapy. Gamal, [42] found that highest mean
scores of knowledge and performance among
younger nurses' those who have least experience
and who have Bachelor of Science in nursing.
The current study revealed a great highof per-
formance as regards toattach mechanical ventilator
to endotracheal tube or tracheostomy tube (p-value
=0.10).
Knowledge & Performance of Critical Care Nurses
British Thoracic Society, [43] found that nebu-
lizers should not be connected directly to a cuffed
endotracheal or tracheostomy tube. This could
result in a pneumothorax, which occurs when there
is no expiratory route for exhaled gases When
nebulizing with endotracheal or tracheostomy tubes
check compatibility with the nebulizer machine.
In thepresent there was significant difference
in nurses' performance about flow rate of 02 de-
termined by the patient's condition (p-value=0.021)
this result agreed with Nationallnstitute for Health
& Clinical Excellence, [44] who reported that driv-
ing gas, either an air compressor or piped/cylinder
oxygen at 6-8Lt/min flow rate for most efficient
nebulization. And the patients with chronic obstruc-
tive pulmonary disease (COPD) should not rou-
tinely use oxygen driven nebulizers due to the risk
of carbon dioxide retention.
The current study showed that there was signif-
icant differences nurses' knowledge regarding to
education (p-value=0.07) and experiences (p-value
=0.32). The findings of the present study are in
accordance with Abolwafa, [45] who found that the
majority of score of nurses' knowledge who have
bachelor of Science in nursing had significant
higher score than those who have technical institute
and nursing diploma, scores of nurses' who have
work experience ranged from 5 to 10 years were
higher than those who have work experience less
than 5 years.
Conclusion:
Nurses' knowledge and performance about neb-
ulizer therapy were unsatisfactory with slightly
higher level of knowledge and this could explain
that the nurses acquired experience during their
nebulizer therapy.
Recommendations:
The nursingstaff in critical careunits are respon-
sible for giving care to the patients connected to
nebulizer machine should be trained enough to
give effective and safe care to such patients.
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