Prevention of ventilator-associated pneumonia: intensive care nurses’ perspectives and solution-oriented recommendations—a qualitative study

Abstract

Objective

This study aimed to explore the barriers intensive care nurses face in preventing ventilator-associated pneumonia (VAP) and to identify their proposed solutions.

Methods

The qualitative study used a descriptive-phenomenological design. Intensive care nurses working in Atatürk University Research Hospital were recruited using maximum variation purposive sampling. Eleven nurses participated. Data were collected using a Demographic Information Form and a Semi-structured Interview Form. Interviews were conducted in the ICU meeting rooms at times preferred by participants, lasted approximately 30–45 min, and were audio-recorded with permission. Data were analyzed using Colaizzi’s descriptive phenomenological method. The study was reported in accordance with the COREQ checklist.

Results

Three themes and fourteen sub-themes were identified: (1) VAP Prevention Practices (aspiration procedures, oral care, positioning, cuff pressure control, respiratory circuit management, hand hygiene), (2) Obstacles Encountered (technical inadequacies, emergency situations, workload, lack of education, communication problems), and (3) Solution Suggestions (technical improvements, training needs, protocol development).

Conclusion

Intensive care nurses reported high awareness of evidence-based VAP prevention practices; however, they faced systemic barriers, particularly inadequate equipment (e.g., cuff pressure monitoring devices) and insufficient standardized protocols. Their suggestions highlight priority areas for improving VAP prevention at the unit level.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04766-x.

Introduction

Ventilator-associated pneumonia is defined as pneumonia developing ≥ 48 h after endotracheal intubation and initiation of mechanical ventilation [1]. VAP is a nosocomial infection observed in patients hospitalized in intensive care units and is associated with increased morbidity and mortality [2, 3]. The reported incidence of VAP ranges from 2.5% to 51% worldwide [4–6]. Studies conducted in Turkey have reported that VAP incidence ranges from 21.7% to 51.36% [7, 8]. Overall, VAP remains a substantial burden both globally and in Turkey, highlighting the importance of prevention to reduce mortality and morbidity. Nurses play a critical role in implementing nonpharmacological interventions to prevent VAP [9]. Identifying nurses’ prevention practices, the barriers they encounter, and feasible solutions may help lower VAP incidence, reduce healthcare costs, shorten hospital stays, and decrease adverse events [10, 11].

Background

Nurses play a critical role in preventing VAP by implementing evidence-based nursing interventions [9]. The literature indicates that nurses contribute to VAP prevention by maintaining hand hygiene, providing regular oral care, performing open or closed suctioning, ensuring appropriate patient positioning, monitoring cuff pressure, managing respiratory circuits, and controlling water accumulation within ventilator circuits [12, 13].

Existing research on VAP has primarily focused on nurses’ compliance with VAP prevention guidelines [14–16], the incidence and risk factors associated with VAP [4, 7, 17, 18], the effectiveness of VAP prevention interventions [12, 19–21], oral care practices and solutions [2, 22], and the impact of educational interventions on nurses’ knowledge and practices [23].

Although previous studies have examined VAP prevention practices and guideline adherence, limited research has qualitatively explored intensive care nurses’ lived experiences by integrating both perceived barriers and solution-oriented recommendations within a single analytical framework. This study provides a comprehensive, context-specific understanding by simultaneously examining nurses’ daily practices, encountered challenges, and practical solutions, thereby offering a novel contribution to the existing literature. Understanding nurses’ lived experiences, perceived challenges, and proposed solutions may provide valuable, context-specific insights to strengthen VAP prevention strategies in intensive care settings. Therefore, this study aimed to explore intensive care nurses’ experiences with VAP prevention, the barriers they encounter in clinical practice, and their proposed solution-oriented recommendations. Unlike prior studies that primarily focus on guideline adherence or isolated aspects of VAP prevention, this study uniquely integrates nurses’ lived experiences, perceived barriers, and solution-oriented recommendations within a single qualitative framework, thereby providing a more comprehensive and practice-oriented contribution to the literature.

Research questions

Q1. What are the methods used by intensive care nurses to prevent VAP?

Q2. What difficulties do intensive care nurses face in the process of VAP prevention?

Q3. What are the solution strategies suggested by nurses to overcome the difficulties encountered in the process of VAP prevention?

Method

Research design

This study employed a descriptive phenomenological design, a qualitative research approach that focuses on providing an in-depth description of phenomena and elucidating participants’ lived experiences. Data were analyzed using Colaizzi’s descriptive phenomenological method [24]. This design was chosen to enable a comprehensive exploration of intensive care nurses’ experiences, challenges, perceived barriers to preventing VAP, and proposed solutions. Descriptive phenomenology enables a clear, holistic understanding of complex, deeply personal clinical experiences.

The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [25]. Interviews were conducted by a researcher trained in qualitative interviewing and experienced in intensive care nursing and qualitative research. Before data collection, the researcher explained the study’s purpose and established rapport with participants. Reflexive notes were maintained throughout data collection and analysis to minimize potential researcher bias and enhance confirmability. The interviewer had no supervisory or hierarchical relationship with the participants, and no incentives were provided for participation.

Place and time of the study

The study was conducted between July and December 2024 in the intensive care units of a university hospital in Turkey’s eastern region.

Study population and sample

The study’s population consisted of intensive care nurses working in the relevant hospital. Maximum diversity sampling, a purposive sampling method, was used to select the sample. This method included nurses working in different intensive care units with varying lengths of experience. Sampling continued until data saturation was reached (i.e., no new codes or themes emerged in consecutive interviews), and 11 nurses were included.

Sample selection criteria

Inclusion criteria:

• Having at least one year of intensive care experience.

• Actively working in the intensive care unit.

• Acceptance of voluntary participation in the study.

Exclusion criteria:

• Having less than one year of experience in intensive care.

• Working in a managerial position.

Data collection tools

The data were collected with a two-part data collection form developed by the researchers in line with the literature:

Demographic information form

This form consists of 10 questions and collects information on participants’ characteristics, including age, gender, educational status, professional experience, and intensive care certification.

Semi-structured interview form

An interview guide consisting of open-ended, exploratory questions designed to elicit intensive care nurses’ experiences with VAP prevention, perceived obstacles, and solution-oriented recommendations. The semi-structured interview guide was developed by the researchers specifically for this study based on a review of the relevant literature and the study objectives. The English version of the interview guide is provided as Supplementary File 1.

Data collection process

In this study, semi-structured, in-depth interviews were conducted to understand the difficulties intensive care nurses face in preventing VAP and their suggestions for solutions. Semi-structured interviews are a data-collection method frequently used in qualitative research that allows participants to express their experiences in detail. The interviews were conducted using a semi-structured guide that enabled participants to freely share their thoughts while addressing the research questions in depth. This method enabled the collection of rich, detailed data reflecting the participants’ unique perspectives and experiences.

The interviews were conducted in the intensive care unit meeting rooms, in a quiet, comfortable environment. The dates and times were planned according to the participants’ availability. Before each interview, the study’s purpose was explained in detail. It was emphasized that participation was voluntary, and written informed consent was obtained from the participants prior to data collection.

Each interview lasted approximately 30–45 min and was audio-recorded with the participant’s permission. These recordings were used to ensure accurate transcription of the data and to prevent information loss. Audio recordings were transcribed verbatim shortly after each interview to ensure data integrity. Ultimately, the transcripts were prepared to reflect the participants’ statements.

In the findings section, participants’ statements are directly quoted, presented in quotation marks, and italicized. At the end of each quotation, a number indicating the relevant interview is provided. This method allowed the researcher to analyze the data collected systematically while the participants conveyed their experiences in their own words.

The semi-structured, in-depth interview method effectively met the study’s objectives. Given nurses’ challenging and stressful working conditions in the intensive care environment, the interviews were conducted in a manner that was sensitive to participants’ time and workload. The researcher created a respectful, supportive atmosphere in which participants could comfortably share their experiences.

This approach is critical to ensuring the study findings are reliable and verifiable. By examining the detailed perspectives of intensive care nurses, this study provides a deeper understanding of the barriers and solutions to preventing VAP.

Data analysis

Data analysis: structuring with colaizzi’s descriptive phenomenological method

This study adopted Colaizzi’s descriptive phenomenological method to analyse the participants’ experience [24]. This method is well known for systematically analyzing the essence of participants’ lived experiences. The steps of the process are structured as follows:

1. Familiarisation: The audio recordings from the interviews were fully transcribed. Two researchers independently reviewed the transcripts. Codes and themes were developed iteratively through constant comparison, and discrepancies were resolved through discussion until consensus was reached. The researchers analysed the data by reading the texts several times to thoroughly master the data and understand the participants’ lived experiences.

2. Extracting Significant Statements: Significant and relevant statements related to the phenomenon under investigation were identified from each transcript. This process ensured that all critical perspectives were fully addressed.

3. Formulating Meanings: Meaningful statements were carefully analysed to formulate meanings that reflect the participants’ unique perspectives. At this stage, researchers used reflexive notes and peer debriefing to minimise the influence of preconceptions and to remain grounded in participants’ accounts.

4. Organising Into Themes: The formulated meanings were grouped into themes that represented the participants’ shared experiences. Themes were developed through induction to ensure they emerged naturally from the data.

5. Developing a Comprehensive Description: The themes were integrated into a comprehensive description of the phenomenon, creating a narrative that details and holistically reflects the participants’ experiences.

6. Producing the Fundamental Structure: The phenomenon’s concise, fundamental structure is developed by reducing it to the essential elements of the comprehensive definition.

7. Validating With Participants: To ensure the reliability and accuracy of the findings, member checking was conducted by sharing the preliminary findings with selected participants, who confirmed that the results reflected their experiences. Participants confirmed that the results accurately represented their own experiences.

Reason for choosing the colaizzi method.

The Colaizzi method was chosen for its robustness and effectiveness in structurally capturing participants’ lived experiences. This method offers an appropriate approach to exploring nurses’ experiences and barriers to preventing VAP. It was used to authentically reflect the participants’ voices, especially when addressing sensitive and critical issues such as intensive care.

Ethical aspects of the research

For this study, ethics committee approval was obtained from the Atatürk University Faculty of Medicine Non-Interventional Clinical Research Ethics Committee (Date: 07.06.2024, Number: B.30.2.ATA.0.01.00/408), and institutional approval was obtained from the hospital where the research was conducted. Additionally, informed consent was obtained from participants who agreed to participate. The study was conducted in accordance with the Declaration of Helsinki. The study purpose was explained to the participants, and their written informed consent was obtained.

Validity and reliability of the study

To ensure the study’s trustworthiness, the criteria proposed by Lincoln and Guba (1985) were applied, including credibility, transferability, dependability, and confirmability [26]. Credibility was ensured through prolonged engagement with the data, member checking, and peer debriefing [27]. Participants were given the opportunity to review the findings, and their feedback confirmed that the results accurately reflected their experiences.

Transferability was supported by providing a detailed description of the research setting, participant characteristics, and data collection process, enabling readers to assess the applicability of the findings to similar contexts.

Dependability was ensured by maintaining a clear audit trail throughout the research process, including data collection, coding, and analysis procedures. In addition, intercoder agreement was achieved through independent coding by researchers and consensus discussions.

Confirmability was achieved through the use of reflexive notes and the systematic documentation of analytical decisions, ensuring that the findings were grounded in participants’ experiences rather than researcher bias [26, 27].

Findings

The study’s findings aim to identify the difficulties encountered in the VAP prevention process, and nurses’ solution-oriented recommendations are presented. Most of the nurses participating in the study were female (72.7%, n = 8). The mean age of the participants was 29.1 ± 3.3 years, and 90.9% (n = 10) were undergraduate graduates. Regarding professional experience, the mean ICU working time was 7.0 ± 4.3 years, and the mean working time in the intensive care unit was 7.0 ± 4.3 years. Most participants (63.6%, n = 7) worked in surgical intensive care units. Regarding shift organisation, 63.6% (n = 7) worked in rotating shifts. The proportion of nurses with intensive care certificates was 45.5% (n = 5) (Table 1).

Table 1.

Demographic characteristics of participants (n = 11)

Variables		n	%
Gender	Female	8	72.7
	Male	3	27.3
Education Status	Bachelor’s degree	10	90.9
	Master’s degree	1	9.1
Intensive Care Area	Internal	4	36.4
	Surgery	7	63.6
Intensive Care Unit	Chest Diseases	4	36.4
	Anaesthesia	3	27.3
	Brain Surgery	2	18.2
	Orthopaedics	1	9.1
Shift Type	Rotating shifts	7	63.6
	Fixed day shift	4	36.4
Intensive Care Certificate	Yes	5	45.5
	No	6	54.5
Age (years)	Min-Max	24–35
	Mean ± SD	29.1 ± 3.3
Years of ICU experience	Min-Max	1–16
	Mean ± SD	7.0 ± 4.3

As a result of the thematic analysis, three main themes and fourteen sub-themes were identified.

Theme 1: VAP prevention practices

This central theme covers nurses’ daily clinical practices for preventing VAP. The data show that nurses try to integrate evidence-based practices into their clinical routines. This theme consists of six sub-themes:

Proper aspiration practices

According to the research findings, participant nurses placed great importance on proper aspiration practices, particularly infection-control measures. Practices such as adherence to sterile technique, regular replacement of irrigation solutions, appropriate management of aspiration equipment, and prevention of contamination were among the most frequently emphasized components. Most participants identified the sterile aspiration technique as a fundamental requirement.

Nurses reported that they consistently prioritized aseptic practices during aspiration (n = 9):

When we remove the packaging, we try to send it directly into the tube without any contact (I1)

I pay great attention to aseptic technique during aspiration. First, I wash my hands, put on sterile gloves, and then remove the catheter. I take care not to contaminate even when opening the packaging. (I4)

In addition, participants emphasized the importance of regular replacement of irrigation solutions (n = 8), typically every 24 h:

We change the aspiration bag daily. We also renew the irrigation solutions every 24 hours. These are very important because they increase the risk of microbial growth. We also make sure they are patient-specific; we never use them in common. (I9)

Irrigation solutions are renewed every 24 hours and for each new patient. (I2)

These findings highlight that proper aspiration practices extend beyond task performance to include adherence to evidence-based techniques, strict infection-control measures, and a strong focus on patient safety.

Oral care

The participants’ statements reveal that oral care is a critical practice in VAP prevention. The use of antiseptic solutions and regular maintenance are among the standard practices. Nurses especially prefer the use of chlorhexidine gluconate and sodium bicarbonate:

Chlorhexidine gluconate (n = 8) and sodium bicarbonate (n = 5) were the most frequently used solutions for oral care:

We do oral care with chlorhexidine solution three times a day. We clean the old secretions in every care unit and then wipe them with a new solution. We try not to neglect the area on the tongue and inside the cheeks because bacteria accumulate there. (I9)

We have oral care sets, we use them. We usually do it with sodium bicarbonate. But sometimes the sets may run out, so we must find alternative methods. Unfortunately, this disrupts standardization. (I8)

Positioning

The study results show that the semi-recumbent position is adopted as a basic practice in VAP prevention. Almost all of the participants stated that they keep the head position of the patients in an elevated position to prevent aspiration:

The majority of the participants (n = 10) stated that they kept the head position of the patients at 30–45 degrees:

We always keep our patients in a 30–45 degree position. I adjust the head of the bed for this; then, I support the patient so they do not slip. I pay attention to this position, especially during and after feeding, because the risk of aspiration increases. (I10)

Sometimes we cannot give the exact position due to the patient’s condition; then I try to give at least the highest angle possible. I constantly check and correct because the position deteriorates as the patient moves. (I4)

Cuff pressure control

The findings reveal that nurses recognize the importance of cuff pressure control well, but objective measurement methods are lacking. Most of the participants use manual control methods based on experience:

Most of the nurses (n = 9) stated that they checked the cuff pressure manually:

Since we do not have a device that measures cuff pressure, we control it by hand. We look at the tension in the balloon; we make sure it is not too tight. With experience, we now understand approximately how much it should be. (I3)

Cuff pressure is a very sensitive issue. If it is too little, there is a risk of aspiration; if it is too much, there is a risk of tracheal damage. We cannot be sure when we check manually, but we do our best. It is better to say by eye judgment; it will not be too swollen, it will not be too little (I7)

Respiratory circuit management

The research findings indicate that respiratory circuit maintenance is managed systematically. Standardized practices were adopted for circuit replacement and active heat and humidity inhalation set usage management:

Regular circuit replacement (n = 6) and puddle control (n = 7) were reported as important practices:

We change the circuits routinely, but sometimes early replacement may be necessary. For example, if there is visible contamination or mechanical problems, we change them without waiting. We pay attention to sterile technique in every change. (I5)

We constantly check the water accumulated in the circuits. When water accumulates, I drain it immediately to prevent it from harboring microorganisms. It is essential to drain the accumulated water without leaking it to the patient. (I9)

Hand hygiene

Hand hygiene is one of the fundamental practices nurses emphasize in preventing VAP. Participants stressed the importance of hand hygiene, especially before and after patient contact, and considered it integral to their routine practice.

Hand washing (n = 4) and glove use (n = 3) were stated as prioritized practices:

Hand hygiene is a must for us. I always wash my hands before and after touching the patient. Even if I wear gloves, I ensure hand hygiene first because gloves can give a false sense of security. (I3)

I pay great attention to hand hygiene, especially before and after aspiration. It is important not only to wash hands but also to wash with the right technique. I especially try not to neglect the fingers, thumbs, and wrists. (I5)

Theme 2: Barriers encountered

This theme reflects nurses’ challenges and systemic problems in VAP prevention practices. The findings reveal technical, operational, and educational barriers.

Technical inadequacies

The study’s findings reveal that the lack of objective assessment, especially in cuff pressure measurement, is an important technical deficiency. The majority of the participants emphasized that this deficiency affected their clinical practice:

The most frequently mentioned technical inadequacy was the lack of a cuff pressure measuring device (n = 8):

We don’t have a cuff pressure gauge, which is a big deficiency. We have to assess it manually by palpation. Sometimes, I think we inflate it too much; sometimes, I worry it is insufficient. We do not feel safe because we cannot make objective measurements. (I10).

The quality of the humidifier filters is essential, but sometimes we have difficulties supplying materials. We have to make do with the material we have. If there is quality material, we can prevent complications better. (I2)

Emergency situations

The findings indicate that full compliance with sterilization rules becomes difficult, especially in emergency intubation cases. This was identified as an important obstacle in the implementation of infection control measures:

The inability to comply with sterilization rules in emergencies (n = 5) was stated as an important barrier:

In cases where emergency intubation is required, sometimes we cannot fully comply with sterilization rules. Saving the patient is the priority. But we take the necessary precautions immediately afterward; we pay extra attention to reduce the risk of infection. (I8)

Emergencies in intensive care make it difficult to apply many techniques. We managed with what we had at that moment. Then we complete the deficiencies as soon as possible and try to provide optimal care. (I2)

Workload

The research results reveal that increasing patient density and workload affect optimal care practices. Nurses stated that this situation especially made it difficult to implement comprehensive care protocols:

Difficulties experienced due to patient density (n = 4) were expressed:

The number of nurses per patient is significant. In some cases, because there are not enough nurses for the patients, there may be a mentality of “let me do it right away and move on to the next one” when the patient is finished. This leads to sloppy work. (I8)

Sometimes there are too many patients for one nurse. It becomes difficult to check all patients’ positions regularly and perform oral care on time. We have to prioritize, but this is not ideal. (I4)

Lack of education

The participants’ statements emphasize the difficulties in accessing up-to-date information and practices, as well as the need for continuous training. Lack of training was found to be an important obstacle, especially in the standardization of practices:

Lack of up-to-date information (n = 5) is seen as an important barrier:

New protocols are emerging, but we do not learn about them in time. For example, there are updates to VAP prevention packages, but we continue to use outdated information. It would be beneficial if there were regular update training. (I9)

Especially the orientation process of recruits may be insufficient. They need more detailed training on VAP prevention. They learn from experienced nurses, but this is not always enough. (I10)

Communication problems

One of the most frequently mentioned barriers by nurses was interdisciplinary communication problems.

Communication problems (n = 5) are seen as an important barrier in preventing VAP:

Sometimes there can be a communication gap between doctors and nurses. For example, there may be different approaches to patient positioning. It would be better if there were a common protocol and everyone followed it. (I3)

Sometimes important information cannot be transferred during shift changes. Especially on busy days, deliveries are fast, and some details may be missed. This affects the continuity of maintenance. (I8)

Theme 3: Solution suggestions

The study’s findings show that nurses offered a range of solutions to improve VAP prevention practices. These suggestions include technical improvements, the need for standardized training, and the development of protocols. Participants emphasized eliminating technical equipment deficiencies and standardizing training programs and care packages. These solution-oriented suggestions further illustrate how nurses actively make sense of their experiences and propose practical strategies grounded in their everyday clinical realities.

Technical improvements

The most frequently mentioned suggestion by the participants was the provision of cuff pressure-measuring devices. This finding reveals that eliminating the lack of technical equipment is seen as a priority need in improving clinical practices:

Provision of a cuff pressure measuring device (n = 7) was the most frequently mentioned suggestion:

Our top priority need is a cuff pressure monitor. There should be at least one in every intensive care unit. Continuous manual control is both time-consuming and unreliable. It would be much better if devices could make digital measurements. (I5)

Quality standards should be set for suction products and oral care products. If quality materials are used, it will reduce the cost in the long run. (I2)

Training needs

Research findings emphasize the need for continuous and structured training programs. In particular, it is seen that the face-to-face training model is preferred, and training formats that enable experience sharing come to the fore:

Regular training programmes (n = 6) and the demand for face-to-face training (n = 4) stood out:

There must be regular and structured training programs. There should be not only theoretical but also practical training. For example, practical training can be done in a simulation laboratory. Experienced nurses can be mentors for beginners. (I9)

Digital training is provided, but it may not be enough. There should be practical and supportive training. (I8)

Protocol development

Participants’ statements reveal the need for standardized practice protocols and care packages. This finding reflects the importance attached to the standardization of clinical practice:

It was suggested to develop standardized implementation protocols (n = 5):

VAP prevention package must be updated and standardized in all intensive care units. Minimum standards that everyone must comply with should be determined. Checklists should be created and regularly monitored. (I8)

While developing protocols and guidelines, the opinions of nurses working in the field must be taken. Because we know the difficulties experienced best in practice. There should be realistic and applicable protocols and also care packages. (I8) (Table 2).

Table 2.

Themes and sub-themes identified from the analysis

Theme	Sub-Theme
VAP Prevention Practices	Proper Aspiration Practices
	Oral Care
	Positioning
	Cuff Pressure Control
	Respiratory Circuit Management
	Hand Hygiene
Barriers Encountered	Technical Inadequacies
	Emergency Situations
	Workload
	Lack of Education
	Communication Problems
Solution Suggestions	Technical Improvements
	Training Needs
	Protocol Development

Discussion

This study contributes to the literature by providing a phenomenologically grounded and integrated qualitative perspective on VAP prevention, capturing nurses’ practices, barriers, and solution-oriented recommendations. Unlike previous studies that primarily focus on compliance or isolated aspects of care, this study offers a holistic and context-specific understanding of how these elements interact in real clinical settings. This distinction highlights the study’s originality by moving beyond description to generate actionable, context-based insights. From a phenomenological perspective, these findings reflect the lived experiences of intensive care nurses, capturing how they perceive, interpret, and navigate VAP prevention practices within complex clinical environments.

This study’s VAP Prevention Practices theme includes aspiration procedures, oral care, patient positioning, cuff pressure control, respiratory circuit management, and hand hygiene. These practices are consistent with commonly recommended VAP prevention measures and infection prevention resources [28]. Nurses play a critical role in implementing nonpharmacological interventions to prevent VAP [9]. Previous studies have shown that nurses are aware of the importance of hand hygiene, commonly use sodium bicarbonate during oral care, monitor cuff pressure, adhere to appropriate suctioning practices, ensure proper patient positioning, change ventilator filters regularly, and replace ventilator circuits when contamination occurs [12–14, 16, 20, 29, 30]. Overall, the sub-themes identified in the present study are consistent with existing literature on nursing practices for VAP prevention. Although intensive care nurses generally comply with recommended VAP prevention practices, sustaining this compliance requires continuous updating of knowledge and the elimination of existing structural and organisational barriers. The development of standardised protocols and improvements in resources—particularly in key areas such as hand hygiene, oral care, and respiratory circuit management—may reduce infection risk and enhance patient safety in intensive care settings. This integrative approach represents a key strength of the study, as it moves beyond describing practices alone and provides actionable insights grounded in nurses’ real-world experiences. These findings suggest that awareness of evidence-based practices alone may not be sufficient to ensure optimal implementation, and that structural, organizational, and contextual factors play a critical role in shaping clinical behavior. This highlights how nurses’ lived experiences are shaped not only by clinical knowledge but also by contextual constraints, influencing how evidence-based practices are interpreted and enacted in everyday care.

The strong emphasis on sterile technique during aspiration may reflect nurses’ awareness of infection risk; however, this awareness alone may not ensure consistent practice under demanding clinical conditions. Consistent with previous research, nurses were reported to apply open or closed suctioning systems and adhere to sterile techniques as key components of VAP prevention [29, 31]. However, the findings indicate that maintaining strict adherence to sterile technique can be challenging during emergency situations and under high-workload conditions, potentially compromising optimal VAP prevention practices. Beyond individual awareness, regular equipment replacement and the standardization of sterilization procedures are essential to reducing infection risk. Continuous education, access to up-to-date protocols, and adequate equipment support the sustainability of safe practices. Additionally, workload management and appropriate staffing arrangements directly contribute to patient safety and the overall quality of care in intensive care settings.

The frequent use of oral care practices, particularly chlorhexidine, suggests a high level of awareness; however, variability in materials and workload-related constraints may limit the consistency and effectiveness of these interventions. Existing evidence highlights oral care as a critical component of VAP prevention, and several studies have examined the effectiveness of different oral care practices and solutions [12, 13, 32]. Although there is no consensus on the most effective agent, previous research suggests that chlorhexidine may be more effective at reducing VAP-related outcomes [2, 22]. This alignment supports the consistency of oral care practices; however, contextual constraints may limit their effective implementation. However, despite strong evidence supporting oral care, factors such as high workload, limited availability of materials, and knowledge gaps may hinder optimal implementation. Therefore, standardizing oral care practices, enhancing training programs, and ensuring adequate resource availability are essential to improving patient safety.

Appropriate patient positioning appears to be a well-established practice; however, its sustainability may be influenced by patient condition, workload, and environmental constraints. Patient positioning, particularly the semi-recumbent position, has been shown to effectively reduce the incidence of VAP [33], and bedside head elevation is widely recognised as a key preventive measure [12]. Previous studies have reported that nurses commonly maintain head-of-bed elevation between 15° and 30° as part of VAP prevention strategies [13, 32]. Proper positioning not only helps reduce VAP incidence but also facilitates the clearance of pulmonary secretions. While the high level of nurses’ awareness of patient positioning is a significant strength, ensuring consistent, appropriate positioning tailored to patients’ clinical conditions and addressing practical limitations remains critical for patient safety.

Although nurses recognize the importance of cuff pressure monitoring, reliance on subjective assessment may introduce variability and increase the risk of suboptimal clinical outcomes. Previous studies similarly report that nurses recognize the importance of cuff pressure monitoring in preventing VAP [16, 32], and that appropriate cuff pressure measurement contributes to reducing VAP risk (Jadot et al., 2018). Evidence suggests that maintaining cuff pressure within the range of 20–30 cm H₂O is recommended to prevent both aspiration-related VAP and tracheal tissue injury [13].

Given the critical role of cuff pressure management, nursing care practices should be grounded in evidence-based, valid, reliable, and objective measurement methods. Accurate adjustment of cuff pressure is essential not only for VAP prevention but also for minimizing tracheal damage. Therefore, the availability of appropriate monitoring devices, the identification of technical barriers, the development of targeted solution strategies, and the provision of focused training on cuff pressure management are necessary to enhance patient safety and the quality of care. From an organizational perspective, ensuring the availability of cuff pressure monitoring devices and establishing routine monitoring protocols may directly improve the accuracy of clinical practice and reduce preventable complications.

The structured approach to respiratory circuit management suggests procedural awareness; however, maintaining consistency in practice may depend on resource availability and workload conditions. Consistent with previous findings, nurses have been reported to change ventilator circuits and humidifier filters to reduce infection risk [13]. Regular inspection and prompt drainage of condensate within respiratory circuits are essential to prevent microbial growth and subsequent infection. Ensuring adequate resources, standardized procedures, and continuous training may further strengthen patient safety by enhancing nurses’ awareness and adherence to best practices.

Hand hygiene is a fundamental component in preventing VAP and other healthcare-associated infections (HAIs) among patients hospitalized in intensive care units. Although awareness of hand hygiene is high, translating this knowledge into consistent practice may be challenged by time constraints, workload, and clinical urgency. Consistent with previous evidence, hand hygiene has been recognized as an effective and essential measure in reducing the risk of VAP [34, 35]. Özdemir and Türk (2022) reported that 97.4% of nurses believed hand hygiene to be effective in preventing VAP, while Darawad et al. (2018) found that 94.2% of intensive care nurses adhered to hand hygiene practices for this purpose [13, 16]. Despite high awareness, workload, time constraints, and stress may limit consistent hand hygiene. These challenges are inherent to the demanding nature of intensive care settings and have been similarly highlighted in the literature. Therefore, reducing workload and improving time management are critical to enhancing compliance with hand hygiene practices and ensuring patient safety.

The study also revealed that nurses experienced technical inadequacies, particularly in cuff pressure measurement, as well as occasional difficulties with the availability and quality of medical supplies. Previous studies have demonstrated that effective cuff pressure management is crucial for preventing VAP [16, 32]. Furthermore, appropriate cuff pressure monitoring techniques and regular evaluation of medical device performance have been identified as essential components of VAP prevention [21]. Deficiencies in hospital infrastructure, insufficient training, and inadequate routine maintenance of technical equipment may contribute to these challenges. In high-risk environments such as intensive care units, inadequate technical support can compromise device performance and hinder infection control practices. Strengthening technical infrastructure and supporting nurses through continuous education are therefore essential to improving the effectiveness of VAP prevention strategies.

Nurses also reported difficulty fully adhering to sterilization and infection-control measures during emergency situations. Maintaining hygiene, ensuring sterile intubation practices, and adhering to hand hygiene are critical for preventing VAP [29, 31]. However, high workload, time pressure, and the urgency of interventions during emergencies may limit strict adherence to established protocols. The dynamic and unpredictable environment of intensive care units further complicates adherence to standard procedures. These findings are supported by the literature, which emphasizes the need for emergency-specific protocols and practical solutions. Providing nurses with targeted training and adequate resources is therefore vital to improving infection control during emergency situations. Importantly, these challenges are not merely procedural but are embedded in nurses’ lived experiences, reflecting the tension between ideal care standards and real-world clinical demands.

In addition, nurses indicated that patient density and excessive workload negatively affected the quality of care and made it difficult to implement comprehensive care protocols. Workload is a critical determinant of nursing care quality, and insufficient nurse staffing in intensive care units has been associated with poorer patient outcomes [36]. Moreover, increased nursing workload has been identified as a significant risk factor for healthcare-associated infections, including VAP [17]. Nurse shortages, low nurse-to-patient ratios, and imbalanced workload distribution may reduce the time available for essential preventive interventions, thereby increasing infection risk. Addressing these challenges through adequate staffing, balanced workload distribution, and organizational-level strategies—including optimizing nurse-to-patient ratios and implementing workload management systems—is essential to improving patient outcomes and infection prevention.

The findings further revealed that nurses experienced difficulties in accessing up-to-date information and reported a need for continuous education. Inadequate orientation processes for newly recruited nurses were also highlighted. Previous studies have shown that improving nurses’ knowledge, providing updated guidelines, and implementing structured training programs effectively contribute to VAP prevention [15, 19]. Guilhermino et al. (2018) similarly reported that educational programs on mechanical ventilation for nurses are often limited in scope, underscoring the need for comprehensive, ongoing training. Restricted access to current information, insufficient educational resources, and gaps in institutional training policies may underlie these challenges [23]. Regular, standardized, and continuous training programs are therefore essential to strengthen nurses’ competencies in VAP prevention. Embedding these programs within institutional policies and ensuring protected training time may further enhance their effectiveness and sustainability in clinical practice.

Another barrier identified in this study was inadequate interdisciplinary communication and insufficient information transfer during shift changes. Although empirical studies addressing this issue are limited, these challenges may stem from high workload, time pressure, and poorly structured communication protocols. Given that nurses spend extensive time with patients, communication gaps between nurses and physicians may lead to inconsistencies in care processes. Implementing structured communication guidelines and standardized handover protocols may improve continuity of care and reduce preventable complications such as VAP. These communication gaps may compromise patient safety by leading to inconsistencies in VAP prevention practices. Strengthening structured communication strategies, such as standardized handover protocols and interdisciplinary collaboration, may enhance care continuity and ultimately improve patient safety outcomes in intensive care settings. Organizational interventions, such as standardized communication protocols and structured handover systems, may improve interdisciplinary coordination and reduce care-related inconsistencies.

Finally, nurses emphasized the need for standardized application protocols and for developing comprehensive care bundles for VAP prevention. Previous research has demonstrated that structured programs and care bundles are effective in reducing the incidence of VAP [10, 19, 37]. Standardized protocols help define minimum care standards, reduce practice variability, and minimize communication problems. Importantly, incorporating nurses’ perspectives into the development of these protocols is essential, as they are primarily responsible for implementing preventive interventions in clinical practice. Flexible, practical, and context-appropriate protocols—particularly those designed for emergency situations—can support nurses’ decision-making processes and enhance the overall quality and safety of patient care.

Although this study was conducted in a single intensive care unit, the identified barriers—such as workload, equipment limitations, and lack of standardized protocols—are commonly reported in various intensive care settings. Therefore, the findings may be transferable to similar clinical environments with comparable organizational and structural conditions, particularly in settings with similar resource constraints. However, caution should be exercised when generalizing the results to different healthcare systems or settings with distinct resources and policies.

Clinical relevance

From an institutional perspective, these findings highlight the need for adequate resource allocation, including the provision of essential equipment such as cuff pressure monitoring devices and oral care materials. In addition, the development and implementation of standardized, evidence-based protocols should be prioritized to reduce practice variability and enhance patient safety. Policymakers and healthcare administrators play a critical role in translating these findings into practice by ensuring adequate resource allocation, supporting continuous professional training, optimizing nurse-to-patient ratios, and implementing standardized, evidence-based protocols at the institutional level.

Strengths and limitations

This study provides important insights into the challenges nurses face in VAP prevention and their proposed solutions. The use of semi-structured interviews enabled the collection of rich, in-depth data, and the inclusion of experienced intensive care nurses ensured that the findings reflect real-world clinical practice. These strengths contribute to the literature by highlighting the importance of structured protocols, technical support, and ongoing education in preventing VAP.

However, several limitations should be considered when interpreting the findings. First, the study was conducted in a single institution, which may limit the transferability of the results to other settings with different organizational structures and resources. Second, the study focused solely on nurses’ perspectives, which may restrict the comprehensiveness of the findings. Given that VAP prevention is inherently an interprofessional process involving collaboration among nurses, physicians, respiratory therapists, and other healthcare professionals, future research should incorporate multidisciplinary perspectives to provide a more comprehensive understanding.

In addition, data were collected solely through interviews, and no methodological triangulation (such as observations or document analysis) was employed. This may limit the depth and confirmability of the findings. Future studies may benefit from incorporating multiple data sources to enhance the robustness and credibility of results.

Finally, the qualitative design, relatively small sample size, and cross-sectional nature of the study may limit the range of perspectives and preclude evaluation of changes over time. Despite these limitations, the study offers valuable insights to improve VAP prevention practices and guide future research. These limitations do not undermine the value of the study; however, they should be considered when interpreting the findings.

These barriers, including workload, technical limitations, and communication challenges, are consistent with findings from international studies, indicating that these issues are not unique to this setting but are common challenges across intensive care environments globally.

Conclusion and recommendations

Intensive care nurses show high awareness of VAP prevention but face structural barriers, including equipment limitations, inadequate protocols, and staffing constraints. The solutions nurses offer provide valuable clues for overcoming these problems and improving practices. These findings have important implications for institutional policy and management, particularly regarding resource allocation, including ensuring the availability of cuff pressure monitoring devices, adequate staffing levels, and standardized care protocols. The findings emphasize the need for a multidisciplinary approach and holistic solutions to successfully implement VAP prevention strategies. By integrating nurses’ experiential insights with practical solution strategies, this study offers a contextually grounded contribution that may inform the development of more feasible and sustainable VAP prevention interventions. These findings highlight the need for coordinated organizational strategies that integrate resource management, staff training, and protocol standardization to effectively translate evidence-based recommendations into routine clinical practice. From a phenomenological standpoint, the study underscores the importance of understanding nurses’ lived experiences as a foundation for developing context-sensitive and sustainable VAP prevention strategies.

Standard protocols for preventing VAP should be developed with input from nurses, and compliance with these protocols during implementation should be increased. Deficiencies in cuff pressure-measuring devices, oral care kits, and other technical equipment should be eliminated, and nurses’ knowledge and skills should be improved through the organization of face-to-face and practical training programs. The workload should be balanced, and the quality of care should be improved by increasing the number of nurses. Flexible protocols suitable for rapid intervention should be established for emergencies, and harmonization of care processes should be strengthened by improving communication between nurses and other health professionals. In addition, research on VAP prevention strategies should be encouraged, and new information should be integrated into practices.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

VAP

Ventilator-associated pneumonia

ICU

Intensive Care Unit

COREQ

Consolidated Criteria for Reporting Qualitative Research

Author contributions

1. Study conception and design: ÇB, KG 2. Data collection: ÇB, KG 3. Data analysis and interpretation: ÇB, BY, KG, YGN 4. Drafting of the article: ÇB, KG, BY, YGN, YBHD, KD 5. Manuscript writing: ÇB, KG, BY, YGN, YBHD, KD 6 . Critical revision of the article: ÇB, KG, BY, YGN, YBHD, KD.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to confidentiality and ethical restrictions but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethics committee approval for this study was obtained from the Atatürk University Faculty of Medicine Non-Interventional Clinical Research Ethics Committee (Date: 07.06.2024, Decision No: B.30.2.ATA.0.01.00/408). Institutional permission was also obtained from the hospital where the study was conducted. Written informed consent was obtained from all participants prior to data collection. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.