Evidence for nurses’ viewpoints to protective lung strategies implementation—a narrative review

Introduction

The protective lung strategies (PLS) include a tidal volume of 6-8ml/kg, plateau pressure limitation of less than or equal to 30 cmH₂O, and some degree of adjustment of hypercapnia and hypoxia (1). Pediatric recommendations are 3–6 mL/kg for poor and 5–8 mL/kg for preserved respiratory compliance, along with plateau pressure less than or equal to 28 cmH₂O (2). Lung protective mechanical ventilation (MV) is beneficial for patients with acute respiratory distress syndrome (ARDS) in terms of survival (3) and further protects the lung injury from the ventilator itself known as ventilation-induced lung injury (VILI) (4). However, despite the importance of PLS, persistent inconsistencies are observed in clinical practice among both adult patients (5-8) and pediatric patients (9-11). Identified barriers that limit guideline adherence are the under-recognition of ARDS by the physician, patient irritability, tachypnea, and hypercapnia (6,12).

The ongoing investigation looking at the providers’ perception of recommended guidelines revealed that deficient knowledge (13), communication barriers, and poor coordination among interdisciplinary teams (14) are major factors contributing to implementation failure (15). Efforts were being made to address these barriers through education, audit and feedback, interdisciplinary rounds, and the presence of ventilation protocols (12,16).

As a result, Improvement in physician’s knowledge was observed (17,18) and behavior modified (14), however, guidelines compliance is still challenging at the bedside. Weiss (14) reported that a clinician shows a positive attitude towards low tidal ventilation, easily diagnoses, and initiates PLS. However, it is worth noting that across a set of institutions, only 19.3% of ARDS patients received low tidal volume (LTV) ventilation, a remarkable discrepancy between perceptions and actual ventilatory management. Physicians know they should use low-tidal volume MV, but they fail to implement it practically as only 37% of eligible patients receive it (19). These studies indicated the need for an interprofessional and practice-based approach to understanding existing barriers that hinder the implementation of guidelines and affect patient outcomes. Nurses are best positioned to monitor problems, respond to iatrogenic patient risks, and undertake therapeutic measures to enhance patient parameters (20). The present review addresses nurses’ perspectives and barriers to deliver low-tidal volume ventilation. We present this article in accordance with the Narrative Review reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-44/rc).

Methods

After determining the population, intervention, comparison, and outcome of interest (PICO) criteria (Table S1) for searches, a comprehensive and systemic literature search was conducted to explore relevant literature. The databases PubMed, Google Scholar, Cumulated Index to Nursing and Allied Health Literature (CINAHL), ScienceDirect, and Cochrane Library were searched to retrieve data (Table 1). The search was restricted to a 10-year filter to retrieve the literature from 2015 to 2022. Furthermore, the full text was applied for comprehensive study, and the English language filter was applied for easy understanding. In the final stage, the primary investigator reviewed the bibliography of related search articles to search for this study comprehensively. The terms with Boolean operators and MeSH are used for the literature search in every database. The search was downloaded to a web-based bibliography and database manager, such as Endnote. The search results of four sources were combined, and duplicates were removed using an endnote. These articles were further assessed for eligibility.

The inclusion criteria were observational studies that investigated LTV strategies compared with traditional methods. The reported outcomes were actual ventilation practice at the bedside, practice variability from the physician’s point of view, the prognosis of the patients, and nurses’ barriers to implementing PLS. Articles were written in English language and published between 2015 to 2022.

By using MeSH terms, in PubMed, a total of 3,748 hits appeared, Google Scholar 17,700, CINAHL 15, Cochrane 4 reviews, ScienceDirect 52, and additional records (ProQuest) 2, a total of 21,521 hits appeared. After applying a filter and screening for relevancy, it was cut down to 286 articles. The reports assessed for eligibility criteria (PICO), and 246 articles were excluded. The titles of the selected articles were examined, retrieved articles scanned thoroughly, and marked only those that fit the topic and were researched. Further, the 40 articles were reassessed for relevancy, 16 were not found relatable to the research question, were disregarded, and 6 were not retrieved. Therefore, 18 articles were included in the review having theoretical and empirical knowledge relevant to the research question. These comprised 16 quantitative studies, 2 mixed methods, and 1 systemic review (Table 2).

Furthermore, both national and international data for ventilation variability and routine MV practices were included in the literature review. These details are presented through Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in Figure 1.

Figure 1 PRISMA flow of information for narrative review.

Clinical audit of PLS

The thematic approach for literature synthesis is presented in Table 3.

Patient audit

Adults

Following the development of guidelines, adherence to recommendations is compromised at the bedside. In practice, the vast majority of the patients do not receive volume compatible with recommendations. For example, the initial tidal volume of two-thirds of ARDS patients was greater than 6.5 mL/kg predicted body weight (PBW) (5), 35.1% of the ARDS patients received a tidal volume of more than 8 mL/kg, 86.2% received positive end-expiratory pressure (PEEP) less than 12 cmH₂O (6), and mean tidal volume 7.0 mL/kg PBW, 72 % PEEP compliance (7). Despite the fact that guidelines proved to have improved patient outcomes, these patients’ audit confirms the practice-guideline gap in MV management.

Pediatrics

Similarly, pediatric patients’ ventilation practices are not compatible with the recommendations. Only 30% of the pediatric acute respiratory distress syndrome (PARDS) patients were utilizing the LTV ventilation approach (9), high levels of fraction of inspired oxygen (FiO₂), low levels of PEEP (10), and 26.6% of the patients were managed with PEEP less than recommended (11). The reported adherence rate confirms underutilization of LTV ventilation. Therefore, the major concern is to find out the factors contributing to compromised adherence.

Physician audit

Physicians’ practices varied at the bed side for MV management. Reported practices in relation to LTV ventilation adoption are, tidal volumes calculation using visual height estimations (21,22), tidal volume estimation made with “eyeballs” movement (23), and unclear reasons for LTV ventilation nonadherence (24). These observed tidal volume calculation practices and behaviors to deliver artificial ventilation create questions on LTV delivery. Meanwhile, the LTV ventilation provider’s point of view is also important to the adoption of guidelines.

Factors affecting adherence to practice guidelines

Patient factors to non-adherence

Researchers strive to find out the barriers to implementing PLS. Both patient and physician factors are responsible for poor compliance with LTV recommendations. Patients associated factors are tachypnea, hypercapnia, and patient discomfort (16). Similarly, pediatric reported factors are overweight children (9). Patients’ response patterns and disease status influence providers’ behavior to follow the guidelines. However, continuous discrepancies negatively affect patient outcomes.

Physician factors to non-adherence

Physician-identified factors are under-recognition of ARDS, and system barriers (12,24) . Physicians’ perception, delayed recognition, and under-diagnosis prevent adoption and lead to the physicians’ consistently poor utilization of LTV ventilation.

In addition to perception, the attitude-behavior gap is also contributing to nonadherence to the guidelines. Observed physician attitudes are aligned with practice guidelines, but practically patients are not receiving tidal volume compatible with recommendation, attitude-behavior gap (17). Other behavioral barriers are the attitude-practice gap (14), personal behavioral factors, system barriers, and inertia of previous practice (18) were highlighted factors to the adoption of guidelines. Attitude-behavior-practice gap raises a need to understand barriers among other healthcare professionals to implement evidence-based practice as a team. Existing barriers should be identified via a multidisciplinary lens to align practice with recommendations.

Nurses' barriers to adoption of practice guidelines concerning behavior change

While practice guidelines give direction to work, nurses’ responsibility is to implement them effectively. Intensive care unit (ICU) nurses should have an in-depth understanding of its mechanics and clinical application to safely deliver this intervention to patients. However, a severe lack of knowledge (25), and limited nurses’ understanding (17) express a lack of awareness and unfamiliarity with practice guidelines resulting in acting on personal experiences. Conversely, Cornish (26) reported that nurses are well aware of the guidelines and ARDS protocol being used with practice guidelines. These diverse findings raise a question to further evaluate nurses’ knowledge.

In addition to knowledge, nurses’ attitude, such as previous practice patterns or lack of motivation toward practice guidelines, affects their bedside practice. Sixty-one percent of the nurses believed they delivered LTV ventilation to all their patients, with only 7.4% receiving recommended ventilation (14). Similarly, Hynes (18) indicated an increased tendency in the barriers toward lung protective ventilation (LPV) usage among nurses. Nurses work twenty-four-seven at the bedside, directly monitoring the patients and being in the best position to ensure the implementation of the guidelines. More research is needed to identify the barriers to using PLS among nurses and to design interventions accordingly.

Discussion

In this review, various articles regarding barriers to PLS were explored and antecedents of nurses’ barriers were determined to clarify and define the concepts for wider practical application in nursing practice (Figure 2).

Figure 2 Antecedents of nurses barrier concepts toward the PLS use in the ICU. MV, mechanical ventilation; PLS, protective lung strategies; ICU, intensive care unit.

Implementation of PLS is still challenging within the ICU. The guidelines are not implemented within the ICU despite strong evidence-based recommendations and dedicated professionals (5-7,9,10). Several interventions to overcome the factors responsible for non-adherence to LTV ventilation have been identified (16), but still, there is a gap between actual and recommended practice.

Evidence-based practice is the future of medical sciences, yet the western world is still struggling with behavior change. Limited literature is available to understand the behaviors of LTV providers. Few studies highlighted implementation barriers (17) and positive attitudes (14). Other identified behaviors are personal behavioral factors, along with the system and inertia of previous practice (18) to the application of LPV among all providers. PLS are beneficial to decrease mortality, but unfortunately, common ventilation practices are based on personal experience. It is required to understand the factors responsible for non-adherence and behavior change among all healthcare professionals.

In the literature, most work was focused on clinicians and respiratory therapists (Figure 3). Although a positive attitude and adequate knowledge were observed, they seem to be still struggling with the implementation of guidelines at the bedside. For example, in a study by Weiss (14), clinicians had a positive attitude toward the use of LTV, and they reported 92.5% of patient-initiated LTVs, but in actual practice, only 19.3% of the patients received LTV. Excellence in clinical practice can only be achieved by the involvement of every ICU team member. When we all take silos approach to implement evidence-based practice, major attitude practice gaps are more likely the result.

Figure 3 Nurses barriers towards PLS use. (A) Multidisciplinary studies evaluate PLS use by role; (B) trends of nurses barriers to the implementation of PLS in these studies. Tick mark shows the variable/outcome have been assessed in the similar study, cross mark illustrates the variable/outcome have not been assessed in the study. PLS, protective lung strategies; RT, respiratory therapist; ICU, intensive care unit; ER, emergency.

The science that supports clinical practice often occurs in disciplines that lack interprofessional practice. For example, Knighton (17) initially assessed nurses, respiratory therapists, and physicians for barrier identification. However, due to the repeated statement by the nurses that they had no barriers or facilitators for using LPV and that it was not their responsibility, the researcher later focused on respiratory therapist and physicians only. Nurses’ involvement is mandatory to incorporate evidence-based recommendations from the literature into daily practice. Nurses work twenty-four-seven at the bedside, directly monitoring the patients and being in the best position to ensure the implementation of the guidelines.

Nurses’ adherence to PLS is essential in translating guidelines into practice and improving patient outcomes. However, several barriers hinder the process of adopting evidence-based practice. For instance, lack of awareness and unfamiliarity with practice guidelines result in acting on personal experiences. Nurses have a severe lack of knowledge, only 11.8% of participants correctly answered the knowledge part of the questionnaire; however, they rated themselves as knowledgeable persons (25). Nurses’ knowledge and understanding are limited to PLS and ventilation management activities due to less exposure (17). Thus, the knowledge deficit can be a significant barrier to implementing evidence-based practice. More studies are required to identify nurses’ knowledge regarding recommended MV practices.

Besides knowledge, nurses’ attitude, such as previous practice patterns or lack of motivation toward practice guidelines, affects their behavior. For instance, Weiss (14) reported that nurses showed positive attitudes toward PLS. Although this attitude is lesser in them than in the clinicians, 61.1% of the nurses believed they delivered LTV ventilation to all their patients. However, it is worth noting that despite the positive attitudes of clinicians, they initiated low tidal ventilation for only 7.4% of eligible patients. A positive attitude only cannot cause behavior compliance to evidence-based practice, standardized education is mandatory to translate recommendations into action. Hence, it is anticipated that finding the factors among providers, understanding them, and addressing them accordingly will lead to increased compliance with recommended guidelines.

Nurses’ barriers to the implementation of PLS are not identified rigorously in the literature. The evaluation of knowledge, attitude, and behavior as a barrier was observed in a 2007 survey and a significant knowledge deficit was identified among nursing professionals in the achievement of the LTV delivery goal. However, even after 13 years, Hynes (18) reported them as barriers again and found a trend toward nurses. The question is how we can guarantee that nurses apply LTV in daily practice, as it is known that knowledge is the basic requirement for behavior modification. More research is needed to identify the barriers to using PLS among nurses and to design interventions accordingly.

ICU settings require prompt action for the survival benefit of the patient. Nurses’ twenty-four-seven presence makes them more vulnerable to delivering the required amount of tidal volume to the patient. However, Knighton (17) reported that, according to nurses, the physician and respiratory therapist are responsible for ventilation control. Nursing scope of practice is considered more toward patient care, causing compromised learning, and decreased autonomy for decision-making about tidal volume delivery compatible with guidelines. Nursing is an implementation science, their understanding and involvement in MV management may have a positive impact on delivering PLS.

Inactive participation of nurses in MV management results in ineffective decision-making about the situation. Nurses may not agree with specific concepts or all the guidelines. According to Weiss (14), nurses refuse to initiate LTV ventilation despite physician orders to ensure the patient’s comfort. There is a possibility that nurses may prefer the patient’s comfort, over the survival benefit of the guidelines, due to some degree of adjustment of hypoxia and hypercapnia (3). Active nurses’ participation and collaborative approach are needed to overcome the gap between actual and recommended practice. Thus, identification of nurses’ barriers, and addressing them accordingly can lead to better adherence to recommendations.

Meanwhile, nurses’ behavioral compatibility with practice guidelines can improve the chances of delivering tidal volume according to lung capacity. For example, Cornish (26) reported that nurses are well aware of the ARDS protocol and tidal volume being delivered with practice guidelines. Nurses are the basic workforce and service delivery, they can warn the physician/respiratory therapist that the patient is not receiving low tidal ventilation while documenting or charting MV settings and act according to recommendations. Nurses’ familiarity can bridge the gap between actual and recommended practice. Thus, more research is required to understand nurses’ role in the implementation of PLS.

To the best of the author’s knowledge, this is the first review that summarizes current studies by providing an overview and comprehensive set of antecedents for nurses’ perspectives on the implementation of PLS. Most of the evidence explores barriers to the implementation of PLS among adult patients. Further, the researcher had tried their best to find out studies from all available sources, but the effect of unaccessed reports may lead to an unknown conclusion.

Conclusions

Nurses’ involvement can improve compliance with recommended practice, but poor understanding of nurses’ barriers negatively affects adherence to MV clinical practice guidelines. Lack of knowledge and compromised attitude are identified nurses’ barriers to the implementation of LTV. Future research is necessary to understand nurses’ nonadherence factors to practice guidelines. Continual inconsistency in clinical practice raises a need for a collaborative approach to deliver air volume compatible with recommendations. Nursing is an implementation science; the importance of the nurse’s role cannot be denied in evidence-based practice. It is recommended to consider nurses’ involvement in MV management for example in tidal volume delivery goals and PEEP adjustments, to bridge the gap of implementation failure.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-44/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-44/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-44/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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