ABSTRACT
Ventilator‐associated pneumonia (VAP) remains a prevalent and costly healthcare‐associated infection in intensive care units (ICUs). This study aimed to translate the Ventilator‐Associated Pneumonia Prevention Knowledge and Attitudes Scale (VAPPKAS), conduct cross‐cultural adaptation and test its psychometric properties. A cross‐sectional survey was performed, enrolling 322 ICU nurses from one tertiary hospital in Jiangxi Province. The Chinese VAPPKAS consists of two dimensions containing 15 items. The Cronbach's α coefficient was 0.937, split‐half reliability was 0.928, and test–retest reliability was 0.907 (95% CI: 0.887–0.924). The item‐level content validity index (I‐CVI) ranged from 0.867 to 1.000, and the average scale‐level content validity index (S‐CVI/Ave) reached 0.906. Exploratory factor analysis (EFA) extracted two factors that jointly explained 76.382% of the total variance. Confirmatory factor analysis (CFA) yielded satisfactory model fit indices: χ2/df = 2.326, RMSEA = 0.052, SRMR = 0.026, NFI = 0.927, TLI = 0.918, CFI = 0.922, GFI = 0.903. The Chinese version of the VAPPKAS demonstrates excellent reliability and validity.
Keywords: attitude, knowledge, nursing, reliability, validity, ventilator‐associated pneumonia
Impact Statements
- What is known about the topic
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○VAP prevention relies on nurses' knowledge and attitudes, yet no psychometrically validated Chinese scale is available for ICU nurses.
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- What this paper adds
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○The Chinese version of the VAPPKAS is a 15‐item scale with sound reliability and validity. It enables standardized assessment of ICU nurses' VAP prevention knowledge and attitudes, supporting standardized training and clinical practice improvement in Chinese ICUs.
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1. Introduction
Ventilator‐associated pneumonia (VAP) is defined as pneumonia developing in patients who received mechanical ventilation for ≥ 48 h or within 48 h following extubation [1, 2]. It is one of the most frequent and severe hospital‐acquired infections in critical care, affecting 25%–30% of mechanically ventilated patients in intensive care units (ICUs) and contributing to prolonged ventilation, increased ICU stay and higher mortality [3].
The VAPPKAS was developed by Savci et al. [4] comprehensively evaluates nurses' mastery of VAP prevention knowledge and their cognitive attitudes towards infection control. In China, most existing assessment tools for nurses' VAP prevention knowledge are self‐designed questionnaires with insufficient psychometric verification, resulting in poor standardization and limited cross‐hospital comparability [5, 6].
2. Aim
To translate the VAPPKAS and validate the reliability and validity among nurses in Chinese ICUs.
3. Methods
A cross‐sectional study was conducted from April to May 2026 in three tertiary hospitals in Jiangxi Province, China. Participants were registered ICU nurses with at least 3 years of work experience, excluding interns, trainees and nurses on leave. Based on recommended sample size guidelines for factor analysis, a minimum of 75 participants was required for exploratory factor analysis (EFA) and over 200 participants for confirmatory factor analysis (CFA) [7, 8]. A total of 322 nurses were recruited.
3.1. Scale Translation and Cultural Adaptation
Permission was obtained from the original developer. The Brislin translation model was used [9].
3.1.1. Forward Translation and Reconciliation
Two independent translators separately produced two Chinese forward translations (A1 and A2). A four‐member research team compared the two drafts, resolved discrepancies and generated the integrated Chinese draft A3.
3.1.2. Back‐Translation
Two translators blind to the original scale independently back‐translated draft A3 into English to produce two back‐translated drafts (B1 and B2). The research team compared B1 and B2 against the original scale to identify and correct semantic inconsistencies and ambiguous expressions arising from forward translation, yielding the final back‐translated version B3.
3.1.3. Expert Committee Review
Ten specialists in critical care nursing and hospital infection control assessed the scale for semantic equivalence, cultural adaptability and content integrity, based on which a pre‐test Chinese draft (Version A) was developed.
3.1.4. Pre‐Testing
Thirty ICU nurses completed the draft scale to evaluate item clarity and response duration. Minor wording revisions were implemented according to feedback, forming the official Chinese VAPPKAS for formal investigation.
3.2. Data Collection
Data were collected via an online platform. The survey included demographic questions and the Chinese version of the VAPPKAS. Ethical approval was obtained, and informed consent was provided electronically. Quality control measures included IP restriction, mandatory responses and exclusion of inconsistent or identical responses.
3.3. Statistical Analysis
Analyses were performed using SPSS 27.0 and AMOS 26.0. Item analysis used critical ratio and correlation coefficient method [10]. Content validity was assessed via item‐level (I‐CVI) and scale‐level (S‐CVI/Ave) indices. Construct validity was evaluated using EFA (principal component analysis and maximum variance orthogonal rotation methods) and CFA (the maximum likelihood method). Reliability was evaluated by the Cronbach's α coefficient and the split‐half reliability. Reliability of test–retest refers to the stability of a scale over time [11]. After 2 weeks, test–retest reliability reflects the temporal stability of the scale. After a 2‐week interval, 30 randomly selected ICU nurses completed the scale again, and the intraclass correlation coefficient (ICC) was calculated to quantify test–retest consistency [12].
4. Results
4.1. Participant Characteristics
Participants' demographic characteristics are presented in Table 1.
TABLE 1.
General information of the participants (n = 322).
| Item | n (%) | Item | n (%) |
|---|---|---|---|
| Gender | Education | ||
| Male | 66 (20.50) | Associate degree | 11 (3.42) |
| Female | 256 (79.50) | Undergraduate | 295 (91.61) |
| Age | Master's degree and above | 16 (4.97) | |
| < 30 | 176 (54.66) | Marital status | |
| 30–40 | 98 (30.43) | Married | 242 (75.16) |
| > 40 | 48 (14.91) | Unmarried/divorced/widowed | 80 (24.84) |
| Departments | Years of experience | ||
| Internal Medicine ICU | 91 (28.26) | 1–5 years | 119 (36.96) |
| Surgical ICU | 76 (23.60) | 6–10 years | 94 (29.19) |
| Emergency ICU | 61 (18.95) | 11–15 year | 88 (27.33) |
| Transplantation Department ICU | 73 (22.67) | > 15 years | 21 (6.52) |
| Gynaecological ICU | 21 (6.52) | — |
4.2. Item Analysis
The results showed that the critical ratio (CR) range of all items of the scale was 7.036–26.935 (> 3). The Pearson correlation coefficients between each item and the total score of the scale ranged from 0.637 to 0.807 (> 0.4). All the entries meet the criteria. No items were deleted.
4.3. Validity
Content validity: I‐CVI ranged from 0.867 to 1.000, and S‐CVI/Ave was 0.906, indicating excellent content validity.
4.3.1. Construct Validity
The sample of 322 nurses was randomly divided into two subgroups for factor analysis: one for exploratory factor analysis (EFA, N1 = 122) and the other for confirmatory factor analysis (CFA, N2 = 200).
4.3.2. EFA
Conducted on the first subsample (N1 = 122) using principal component analysis with Varimax rotation methods. The KMO value was 0.908, and Bartlett's test was significant (χ2 = 2609.425, p < 0.001). Extracted two factors with eigenvalues > 1, which collectively explained 76.382% (Factor 1 accounts for 28.763 of the total variance, whereas Factor 2 accounts for 47.619 of the total variance) of the total variance. The factor loadings of all items were > 0.4 (Table 2).
TABLE 2.
Factor loadings of EFA for Chinese VAPPKAS.
| Items | Factor 1 (standard preventive measures) | Factor 2 (nursing measures for tracheal intubation) |
|---|---|---|
| 1 | 0.762 | 0.366 |
| 2 | 0.834 | 0.348 |
| 3 | 0.856 | 0.308 |
| 4 | 0.832 | 0.327 |
| 5 | 0.828 | 0.377 |
| 6 | 0.798 | 0.321 |
| 7 | 0.823 | 0.344 |
| 8 | 0.864 | 0.396 |
| 9 | 0.802 | 0.295 |
| 10 | 0.786 | 0.329 |
| 11 | 0.426 | 0.764 |
| 12 | 0.395 | 0.788 |
| 13 | 0.451 | 0.826 |
| 14 | 0.384 | 0.861 |
| 15 | 0.382 | 0.837 |
CFA based on the second subsample (N2 = 200) was performed via AMOS 26.0 using maximum likelihood estimation, which verified the stable two‐factor structure with satisfactory model fit indices (χ2/df = 2.326, RMSEA = 0.052, SRMR = 0.026, NFI = 0.927, TLI = 0.918, CFI = 0.922, GFI = 0.903). All the model fitting index parameters were within the acceptable range (Figure 1).
FIGURE 1.
Diagram of the standardized two‐factor structural validity model of the VAPPKAS.
4.4. Reliability
The Cronbach's α of the Chinese VAPPKAS was 0.898. The Cronbach's α coefficients of the two dimensions were 0.879 and 0.917, respectively, and the split‐half reliability of the scale was 0.933. After 2 weeks, 30 ICU nurses were randomly selected for the retest reliability evaluation. The test–retest ICC was 0.907 (95% CI: 0.887–0.924), indicating excellent temporal stability.
5. Discussion
This cross‐sectional study verified that the Chinese VAPPKAS is a psychometrically sound instrument to evaluate ICU nurses' knowledge and attitudes towards VAP prevention. The two‐factor structure identified in this study corresponds to core clinical VAP prevention workflows, including standard universal preventive measures and specialized endotracheal intubation care [13].
The two‐factor structure aligns with core VAP prevention practices: standard preventive measures and endotracheal intubation‐related nursing care. These domains reflect routine ICU nursing tasks, making the scale clinically relevant and easy to implement. The high content validity confirms that items are culturally appropriate and aligned with Chinese critical care guidelines.
Accurate assessment of nurses' knowledge and attitudes supports targeted education and practice improvement. The Chinese version of the VAPPKAS can identify knowledge gaps, evaluate training effectiveness and facilitate multicentre comparisons. This is particularly important given the lack of standardized assessment tools in China.
6. Limitations
This study used convenience sampling from one province, which may limit generalizability. Future multicentre studies across different regions and hospital levels are recommended.
7. Conclusion
The Chinese version of the VAPPKAS has excellent reliability and validity. It is a brief, practical tool for assessing VAP prevention knowledge and attitudes among Chinese ICU nurses. Its use can support standardized education, quality improvement and research in critical care infection prevention.
Author Contributions
Zhiqiang Cheng: conceptualization, methodology, formal analysis, data curation, validation, writing – original draft, writing – review and editing. Jiaoyun Xia: conceptualization, methodology, validation, writing – original draft, writing – review and editing. Yuxuan Zeng: supervision, validation, writing – review and editing. Jing Li and Xueyan Wei: software, methodology, formal analysis, visualization, writing – review and editing. Baozhen Zhang: supervision, methodology, validation, funding acquisition, writing – review and editing.
Funding
This study did not receive any funding.
Disclosure
We declare no AI has been used in this study or in the writing of this manuscript.
Ethics Statement
This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participants gave informed consent. Ethical approval was obtained (no. IIT2026‐493).
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
The authors sincerely thanks the staff who participated in this research and made significant contributions to this study.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.