To our knowledge, this is the first national and regional observational study to investigate critical care nurses’ compliance with CLABSI prevention guidelines and identify gaps in knowledge, attitudes, and perceived barriers. Furthermore, this study offers new insights into CLABSI prevention by highlighting the discrepancies between evidence-based recommendations and current practices among critical care nurses. The findings underscore the importance of knowledge, positive attitudes, and the need to overcome perceived barriers to promoting compliance with CLABSI prevention guidelines among critical care nurses. The overall mean score of Yemeni critical care nurses’ compliance with CLABSI prevention guidelines barely reached an acceptable level (12.54 out of 20). Compliance with several critical measures was low. This may be linked to perceived barriers by nurses, according to the study’s findings, such as staffing shortages, high workloads, lack of written protocols and in-service workshops/training programs in most hospitals, and unfamiliarity with guidelines. This is further compounded by the current state of Yemen’s healthcare system, which is characterized by poor working conditions and overcrowded hospitals.
Critical care nurses in this study demonstrated a concerning gap in their knowledge (5.38 out of 10) regarding CLABSI prevention guidelines. These gaps put patients at increase the risk of developing CLABSIs. Some awareness existed in knowledge, such as recommendations for replacing CVCs routinely (64.9%), replacing the administration set when neither lipid emulsions nor blood products were administered (64.7%), and applying an antibiotic ointment at the insertion site of the CVC (60.2%). However, knowledge gaps were identified in recommendations regarding covering insertion sites, using CVC coated or impregnated with an antiseptic agent, and disinfecting the catheter insertion site. These findings contrast with a Malaysian study by Sham et al. (2023). This study found a lower mean score for knowledge (5.85) and lower scores in the same specific aspects (ranging from 19.7% to 23.2%), but also reported a higher percentage in other areas [13]. A comparison with studies by Chi et al. (2020) (16.29%, 10.90%, 21.32%, and 28.38%, respectively) also revealed a lower percentage [14]. Low knowledge was observed in items related to the time to change the IV set, using catheters impregnated with disinfectants, changing, cleaning, drying, and healthy dressing, and the best solution to disinfect the catheter entry site [11]. Incorrect answers were often provided for changes in administration sets, changes in pressure transducers and tubing, changes in transparent catheter dressings, and use of > 0.5% chlorhexidine [10]. Studies across China [14], 25 European countries [8], Jordan[15], Egypt [16], and Greece [17] point to a lack of knowledge regarding CLABSI prevention among ICU nurses. These findings are consistent with those of the present study. Conversely, studies from Poland, Italy, and Belgium reported higher knowledge levels [8, 18, 19]. Azlan et al. (2021) found that ICU nurses exhibit a high level of knowledge, attitudes, and practices regarding CLABSI prevention. The study also revealed a positive association between these three factors [20]. These discrepancies in studies on nurses’ knowledge arise from several factors, including regional variations, hospital policies, tools used, national regulations, and nurse populations.
The study results revealed CLABSI prevention compliance gaps (12.54 out of 20). Critical care nurses exhibited low compliance with specific elements, such as using sterile gloves and maintaining clean dressings. Most critically, they frequently omitted two crucial steps: the dressing was maintained clean and dry, the catheter was flushed with normal saline, and the port was swabbed with antiseptic solution. This discrepancy in adherence can be attributed to two potential causes. One possibility is a knowledge gap regarding the critical nature of these steps. Moreover, nurses reported several contributing factors. These barriers to compliance include high workloads, staffing shortages, and limited access to necessary equipment. Deficiencies in compliance and reporting factors also contribute to an increased risk of CLABSIs. A similar result has been observed in nurses with handwashing, wearing sterile gloves, daily assessment of catheter insertion, and checking dressing change dates [12]. A low mean score for nurses’ practice has been reported by 4.19 in Malaysia, [13]. While (43%) of the nurses always followed the maximum barrier precautions, a concerning number (14%) never used chlorhexidine gluconate 2%. Additionally, only 40% of catheters were removed when no longer needed, and a third (33%) routinely changed catheters, even if there was no potential risk of infection [14]. A similar barrier factor was reported among Iranian nurses, with high workload, shortage of necessary equipment, and lack of workshops being the most common barriers [11]. A shortage of nurses, unfamiliarity with guidelines, and excessive workload are the main barriers for ICU nurses in China [10].
Nurses with higher education and access to prevention training and protocols exhibited higher knowledge, compliance, and positive attitudes toward CLABSI prevention. Conversely, they also reported fewer perceived barriers. This finding suggests that advanced education, experience, training, and clear policies play a role in enhancing nurses’ understanding, compliance, attitudes, and ability to overcome barriers to the implementation of CLABSI prevention guidelines in CVC care. This is supported by the finding that training, written policies, and experience contribute to an increase in knowledge, practice, and positive attitudes toward CLABSI prevention [9]. Nurses’ experiences were associated with their knowledge and practices. No association was found between nurses’ characteristics and their attitudes [13]. Age, sex, educational level, experience, and previous workshops associated with knowledge [11]. Experience and educational level are associated with knowledge [10]. Nurses’ knowledge differed according to age, ICU experience, and nurse-to-patient ratio. Moreover, nurse-to-patient ratio and hospital were associated with nurses’ compliance, whereas educational level and training were not associated with knowledge [21].
Interestingly, nurses working in teaching hospitals displayed higher levels of knowledge, compliance, and attitude. However, these barriers remain unchanged. This suggests that, while a teaching environment fosters positive learning and practice, it may not directly address perceived barriers in implementing CLABSI prevention. Our findings align with the study by Matlab (2022), which demonstrates an association between the type of hospital and nurses’ compliance with implementing CLABSI prevention guidelines [21].
Nurses caring for one patient in the ICU demonstrated higher knowledge and compliance, and lower barrier scores than those caring for three patients. This finding suggests that a lower patient-to-nurse ratio facilitates more focused care, potentially enhancing knowledge acquisition, adherence to protocols, and overcoming barriers to implementing CLABSI preventive measures. Consequently, this approach may reduce the incidence of CLABSI, thereby highlighting the potential benefits of lower nurse-to-patient ratios. In addition, nurses facing higher barriers had lower compliance rates. Our multilayer neural network analysis identified knowledge as the most significant factor that influences nurse compliance. This suggests that the model prioritizes knowledge when evaluating and improving factors affecting nurses’ compliance. This is consistent with a study in Saudi Arabia, which stated that previous education and nurses working in a 1:1 nurse-patient ratio environment were more likely to comply with CLABSI prevention guidelines than those working in a 1:2 ratio environment [12]. Moreover, the nurse-to-patient ratio is associated with nurses’ knowledge and compliance [21]. A low nurse-to-patient ratio reduces the incidence of CLABSIs [22]. Yemen’s constant political violence, instability, and worsening economic situation are the root causes for everything. This has ultimately resulted in poor quality healthcare services and the daily stress and frustrations faced by the Yemeni people. These findings highlight the importance of education, patient care ratio, experience, availability of protocols, hospital type, attitudes, and barriers to influencing critical care nurses knowledge and compliance.
To effectively prevent hospital-acquired infections, especially CLABSI, it is essential to regularly assess the knowledge and compliance of critical care nurses and to address barriers. This evaluation can be effortlessly integrated into the existing competency assessments for critical care nurses. Moreover, ongoing monitoring of nurses’ adherence to the latest evidence-based CVC care bundles can provide useful feedback for identifying areas where further education is needed. This feedback loop can inform the development and implementation of targeted educational interventions, such as workshops or training sessions, to improve the ability of critical care nurses to prevent CLABSI or other hospital-acquired infections.
Add Comment