Nurses’ practices and associated factors in the prevention of ventilator-associated pneumonia in adult and pediatric ICUs in Tigray, Ethiopia: a mixed-methods study

Abstract

Background

Ventilator-associated pneumonia (VAP), which increases morbidity, mortality, and healthcare costs, is a major challenge in ICUs worldwide. Nurses are crucial in preventing VAP, but there are limited data on VAP prevention practices in Tigray’s adult and pediatric ICUs. This study aims to assess practices and identify factors associated with the prevention of ventilator-associated pneumonia among nurses in Tigray.

Methods

A hospital-based cross-sectional study with a sequential explanatory mixed method was conducted among 216 nurses working in adult and pediatric intensive care units from January 15 to February 15, 2025. A pretested, structured questionnaire was used to collect data from all ICU nurses in Tigray public hospitals. The data were entered into Epi-Data version 4.2 and exported to SPSS version 24 for analysis. Thematic analysis was used for the interpretation of qualitative findings. Logistic regression analyses identified factors associated with VAP prevention practices. Variables with a p-value < 0.25 in binary regression were included in the multivariable analysis. Variables with a p-value < 0.05 were considered statistically significant, and multicollinearity was assessed via tolerance and variance inflation factors.

Results

The percentage of good practices for VAP prevention was 38.89% (95% CI: 32.35%–45.74%). Age (AOR = 3.02, 95% CI: 1.058–8.65), ICU working experience (AOR = 3.19, 95% CI:1.163–8.784), educational level (AOR = 3.205, 95% CI: 1.45–8.971), special training on VAP prevention (AOR = 4.29, 95% CI: 1.94–9.48), staffing levels in the ICU (AOR = 0.157, CI: 0.064–0.386) and knowledge of VAP prevention (AOR = 3.41, 95% CI: 1.542–7.553) were statistically significant factors associated with a good level of practice in VAP prevention. The qualitative interviews identified inadequate training, staffing shortages, high workloads, and a lack of team collaboration and management support as factors influencing nurses’ VAP prevention practices.

Conclusion

Fewer than four out of ten ICU nurses had good practices toward VAP prevention. Adherence to VAP prevention practices was significantly associated with nurses’ age, ICU work experience, educational level, specialized training, and knowledge. These findings emphasize the importance of strengthening regular in-service training, continuous professional education, adequate staffing, teamwork, and managerial support to improve compliance with VAP prevention guidelines and enhance patient safety in ICU settings.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-04922-3.

Background

Ventilator-associated pneumonia is an infection acquired during hospitalization that occurs 48 h or more after mechanical ventilation via endotracheal intubation [1]. It is the most severe healthcare-associated illness for people on artificial breathing in intensive care units [2]. Ventilator-associated pneumonia (VAP) can be classified as either early-onset (within 48–96 h) or late-onset (> 96 h) of mechanical ventilation [3]. VAP develops from the aspiration of oropharyngeal secretions or gastric contents into the lower respiratory tract due to intubation [4]. Mechanical ventilation weakens defense mechanisms such as coughing and mucociliary clearance, allowing bacterial colonization of the tracheal tube and leading to infection, inflammation, and pneumonia [5]. VAP patients exhibit new or developing infiltrates, systemic infection, alterations in sputum characteristics, and the identification of a causal agent [6].

Ventilator-associated pneumonia is generally caused by a single bacterial organism, but cases involving multiple pathogens are becoming more common. The most frequently identified bacteria were Staphylococcus aureus (28.4%), Pseudomonas aeruginosa (25.2%), and other gram-negative bacteria (26.6%) [7, 8]. The ability to diagnose VAP necessitates strong clinical suspicion, along with thorough bedside examinations, radiographic assessments, and microbiologic analysis of respiratory secretions [9].

The incidence of VAP ranges from 5% to 67% of the population at risk worldwide [10]. Nursing care is central to the prevention of VAP. Some of the measures that nurses have a direct say in the application include hand washing, proper positioning of patients, oral prostaglandin solutions on patients, and correct use of ventilator care bundles. These interventions have been shown to reduce VAP incidence, providing implications for nurses’ practice compliance with guidelines as well as protocols [11]. However, the implementation of such preventive measures depends on many factors, such as the knowledge, attitudes and practices of nurses, the resources available, their working pressure and the overall working environment in health care facilities [12]. For example, a lack of training or information among nurses may result in substandard practices for VAP prevention measures [13]. Similarly, high nurse’s turnover and particularly increased duties assigned to a nurse reduce the possibility of executing VAP preventive measures with due diligence [14].

Globally, VAP is the second most common hospital-acquired infection in intensive care unit patients [15]. VAP is a widespread hospital-acquired issue in intensive care units, representing 47% of infections among ICU patients [16]. In developing countries, the incidence of VAP is particularly high, with rates of 40.1 infections per 1,000 days of ventilation in India, 44.3 in Costa Rica, and 21.6 in Iran [17]. In South African study, VAP developed in 25% of ventilated patients [18]. The incidence of VAP is greater in developing countries, primarily because of a lack of experienced healthcare workers, limited knowledge and understanding of the pathophysiology and prevention of VAP, and insufficient implementation of VAP prevention bundles [19]. In Ethiopia, the incidence of VAP is 45.7 per 1,000 ventilator days [20].

The nature of the work setting and organizational culture of ICUs also significantly influence the ability of nursing practices to prevent VAP. In addition, aspects such as staff volume, antiseptic solutions and functional medical equipment are important resources that impact nursing practices [21]. Some barriers, such as staff shortages, the absence of basic stock and poor physical facilities, significantly affect the constant implementation of VAP preventive measures in low-income countries [22].

In Ethiopia, the prevention of VAP in ICUs is particularly challenging due to resource constraints, workforce shortages, and limited access to ongoing training. Nurses play a critical role in VAP prevention, but their efforts are often hindered by inadequate supplies, high patient-to-nurse ratios, and insufficient knowledge of evidence-based practices [23].

Mortality from VAP ranges from 24% to 50% to 70% in high-risk patients [24, 25]. VAP weakens the immune system, increasing the risk of multiorgan complications, including sepsis and death the risk of developing VAP after two days on mechanical ventilation ranges from 5% to 40% among patients receiving invasive mechanical ventilation for more than two days. This variation depends significantly on the country, type of ICU, and criteria used to diagnose VAP [26]. Patients with VAP are prone to numerous complications, including severe sepsis, septic shock, acute respiratory distress syndrome (ARDS), atelectasis, and infections with multidrug-resistant organisms. These complications lead to increased costs, increased morbidity, and elevated mortality rates [27].

Several factors contribute to the increased incidence of VAP, including prolonged ICU stays, advanced age (≥ 60 years), emergency intubation, coma, reintubation, tracheostomy, prior antibiotic use, bronchoscopy, blood transfusions, and patient movement outside the ICU [6]. Specific VAP risk factors include oropharyngeal and gastric colonization, thermal injuries, and posttraumatic or postsurgical interventions such as emergency intubation, reintubation, tracheostomy, bronchoscopy, and nasogastric tube insertion. Additionally, patients’ body position, level of consciousness, stress ulcer prophylaxis, and use of medications such as sedatives, immune-suppressants, and antibiotics further increase the risk [28, 29].

VAPs can make it challenging for patients to wean off the ventilator, often resulting in prolonged hospital stays. This not only adds a significant financial burden on patients but also increases the demand for advanced medical equipment and resources [30]. It can extend the duration of mechanical ventilation, lengthen both ICU and hospital stays, and increase hospitalization costs, which are reported to reach $10 billion annually [31]. VAP also increases antimicrobial use and increases the risk of mortality in intensive care units [32, 33].

The Ventilator Bundle is a proven strategy for reducing VAP rates in ICUs. To enhance its effectiveness, the bundle should be adapted and expanded to include specific care processes that have been definitively shown to reduce VAP rates. Alternatively, a tailored VAP bundle could be developed specifically for VAP prevention [34]. Nursing practice plays a critical role in effectively implementing the Ventilator Bundle, as nurses are key in adhering to protocols, monitoring patients, and making necessary adjustments to reduce VAP and improve ICU outcomes.

This study is guided by the Donabedian Model of Quality of Care, which explains healthcare quality through three interrelated components: structure, process, and outcomes [35]. Structural components include organizational and resource-related factors such as nurses’ educational level, ICU work experience, availability of training, staffing levels, and access to essential medical supplies. These structural elements influence the process of care, which in this study refers to nurses’ practices in implementing VAP prevention measures, including adherence to ventilator care bundles and infection prevention protocols. Effective implementation of these practices can lead to improved outcomes, particularly the reduction of ventilator-associated pneumonia among mechanically ventilated patients.

Despite the critical role nurses play in implementing ventilator care bundles and infection prevention protocols, evidence on the relationship between organizational factors, nursing practices, and VAP prevention outcomes remains scarce in the Tigray context. Therefore, this study aims to asses nursing care practices and factors associated with the prevention of ventilator-associated pneumonia among ICU nurses, aiming to fill this research gap and offer insights for improving practice.

Methods and materials

Study area and period

The study was conducted in public hospitals in the Tigray region of Ethiopia: Ayder Comprehensive Specialized Hospital (ACSH) and Aksum Comprehensive Specialized Hospital (ACSH) are the only comprehensive specialized hospitals in the region, and 14 general hospitals, 24 primary hospitals, 230 health centers, and 741 health posts are located in the region. Tigray, located in northern Ethiopia, with its capital in Mekelle, is known for its diverse topography and climate. All hospitals offer extensive health services, including surgical, gynecological, obstetric, medical, pediatric, minor and major operations and ophthalmologic and diagnostic facilities. The Ayder Comprehensive Specialized Hospital has 2,185 staff, including 750 nurses, whereas the Aksum Comprehensive Specialized Hospital has 300 beds and employs over 210 nurses with various qualifications [36, 37]. The study was performed from January 15 to February 15, 2025.

Study design

A hospital-based cross-sectional study with a sequential explanatory mixed method was performed among adult and pediatric ICU nurses at public hospitals in Tigray, Ethiopia, in 2024 [38, 39].

Population

Source population

All adult and pediatric ICU nurses who work in public hospitals in the Tigray region.

Study population

All adult and pediatric ICU nurses who work in public hospitals in the Tigray region during the data collection period.

Eligibility criteria

Inclusion criteria

All adult and pediatric ICU nurses working in public hospitals in the Tigray region were included in the study.

Exclusion criteria

Nurses who were on annual leave during the study period were excluded from the study.

Sample size determination

The sample size was determined by single population proportion formula by considering 53.1% of good level of practice toward prevention of VAP in previous study done in Addis Ababa [40]. Z α/2 = Z score of 95% CI = 1.96, d= Margin of error (5%).

However, Currently there are a small number of nurses working in the functional public hospitals in the region (ACSH, Ayder CHS, Aksum St. marry, Sihul, and Adigrat general hospitals) so, studying all the source populations is feasible in terms of limited man power, the size of the study population was the size of the source population. Hence, all nurses (N = 216) working in adult and pediatrics ICUs in those hospitals during the study period was included in the study for the sake of fair sampling through the census sampling technique.

The sample size for qualitative analysis was determined on the basis of data saturation.

Sampling technique and procedures

The total number of nurses working in the adult and pediatric ICUs of public hospitals is 216. Therefore, all nurses were included via the convenience sampling method.

Study variables

Dependent variable

Nurses’ practices in the prevention of ventilator-associated pneumonia (VAP).

Independent variables

Demographic factors

Age, sex, and marital status.

Personal factors

Educational Level, ICU Training Courses, Years of Work Experience, Special Training on VAP Prevention, Substantial ICU Experience, Diplomas in Respiratory Therapy.

Organizational factors

Excessive Workload, Insufficient Supplies, Inadequate Experience in Intensive Care Settings.

Knowledge level

Knowledge regarding the prevention of VAP.

Operational definitions

Good practice

This refers to study participants who demonstrate 60–100% of the recommended VAP prevention practices.

Poor practice

Refers to study participants who demonstrate less than 60% of the recommended VAP prevention practices [41].

Good knowledge

was defined as a score above the mean on the knowledge questions. Participants who correctly answered ≥ 6 out of 10 questions on the prevention of ventilator-associated pneumonia were classified as having good knowledge.

Poor knowledge

Refers to study participants who score less than or equal to the mean on knowledge questions [14].

Good staffing level

when one nurse cares for 1–2 patients (1:1 to 1:2 ratio) during a shift, indicating adequate staffing for ICU care delivery.

Fair staffing level

when one nurse cares for 3 patients (1:3 ratio), indicating moderate workload but still manageable care provision.

Insufficient staffing level

when one nurse cares for more than 3 patients (> 1:3 ratio), indicating high workload and inadequate staffing for safe ICU care.

Data collection tools and procedures

The checklist, interviewer-administered questionnaire, and interview guide were adapted in English from different literature sources [42–44]. The checklist was administered to all study participants. the observations were conducted in a non-participant and unobtrusive manner, without informing nurses of the exact timing of observation. (See supplementary/Annex Questionnaire) These questionnaires included five main sections: Part I collected information on basic sociodemographic variables; Part II gathered data related to personal factors; Part III assessed organizational factors; Part IV evaluated the knowledge level regarding the prevention of ventilator-associated pneumonia (VAP); and Part V focused on the practices of nurses concerning VAP prevention.

Quantitative data were collected using the structured questionnaire through face to face interviews with all eligible ICU nurses. Participants were approached individually during their shifts and the study objectives were explained. Four BSc nurses, trained for one day on the study tools and procedures, conducted the interviews under the supervision of two senior supervisors to ensure completeness and accuracy.

For the qualitative component, in-depth interviews were conducted for five nurses with a purposively selected nurses to explore factors influencing VAP prevention practices. Interviews were scheduled at convenient times for participants, conducted in a private setting within the hospital, and lasted approximately 30–45 min. All interviews were audio-recorded with participants’ consent, then transcribed verbatim and translated into English for analysis.

Data quality assurances

Data quality was ensured by designing a rigorous and appropriate tool. The adapted questionnaire was evaluated by experienced researchers in the field. A pretest was conducted on 5% of the sample size at Mekelle General Hospital two weeks before the actual data collection. Based on the findings of the pretest, modifications were made on rephrasing unclear questions, correcting ambiguous wording, improving the sequence of questions for better flow, and removing or adjusting items that were difficult for respondents to understand or interpret consistently. The reliability of the interviewer-administered questionnaire was assessed using Cronbach’s alpha for the knowledge and practice-related items (α = 0.87). Data collectors and supervisors received one-day training on the data collection tool and process. To maintain data quality, close supervision and monitoring were carried out by supervisors and investigators during data collection. The principal investigator evaluated the data extraction tool at the end of each data collection day. Additionally, the collected data were checked for completeness and consistency by the principal investigator.

Data processing and analysis

The data were entered into EpiData V.4.2 software and exported to SPSS 24 for further statistical analysis. Descriptive statistics, including means, frequencies, and percentages, were used to analyze the independent variables. The findings are presented in tables and graphs. VAP practice scores were recorded as a continuous variable in SPSS 24. ATLAS.ti7 software was used for coding the qualitative data. Binary logistic regression was performed to identify candidate variables for multivariable logistic regression. Variables with a p value less than 0.25 in the binary logistic regression were included in the multivariable logistic regression. Variables with a p value less than 0.05 in the multivariable logistic regression were considered statistically significant in relation to VAP prevention practices. The strength of associations between independent and dependent variables was assessed via AORs and 95% confidence intervals. Model fit was also assessed via the Hosmer–Lemeshow test, which yielded a p value > 0.1 (> 0.05), indicating that the model was a good fit.

For the qualitative part, three steps were taken in the data analysis process. The transcribed data were entered into Atlas software as a new interpreted unit. The first step, familiarization, involved carefully reading the transcripts to understand the facts. The second step involved coding and organizing the data. The coding was based on the quantitative results and the specified objectives to better comprehend how the quantitative findings were manifested and to provide further explanation. The third step involved grouping the codes into various categories. Each category’s data were analyzed and condensed to ensure internal consistency and reduce the word count without losing essential ideas. The developed themes were then used for data triangulation and thematic analysis.

Results

Demographic and professional characteristics

A total of 216 nurses were included in this study. The mean age of the participants was 39 years (± 9.77 SD). Among the participants, 69.91% were female, with the majority (50.46%) falling within the 30–39 years of age. A significant portion (65.28%) had more than 3 years of intensive care unit (ICU) experience, and 35.1% had cared for 12 mechanically ventilated patients in the past two weeks. In terms of education, 15.7% held a bachelor’s degree. In terms of training, 71.76% had completed ICU-specific training, whereas only 30.09% had received special training on VAP prevention (Table 1).

Table 1.

Demographic and professional characteristics of nurses working in ICUs of Tigray Public Hospitals, Ethiopia, 2024

Variable	Category	Frequency	Percentage
Sex	Male	65	30.09%
	Female	151	69.91%
Age	20–29 years	63	29.17%
	30–39 years	109	50.46%
	40 and above year	44	20.37%
ICU working experience	< 1 years	36	16.67%
	1–2 years	39	18.06%
	3 and above years	141	65.28%
How many MVP have you cared in the past 2 weeks?	1–2 patients	76	35.1%
	3–5 patients	112	51.8%
	≥ 6 patients	28	12.9%
Educational level	Diploma	99	45.8%
	Bachelor	34	15.7%
	Master	83	38.4%
ICU training	No	61	28.24%
	Yes	155	71.76%
Special training on VAP prevention?	No	151	69.91%
	Yes	65	30.09%

Hospital-related characteristics in ICU settings

The highest percentage of respondents (42.5%) reported that the number of staff was insufficient. Shortages of essential supplies specifically equipment required for effective VAP prevention were always encountered by 27.78% of the respondents, whereas 37.04% reported sometimes encountering such shortages. A significant proportion of nurses (59.72%) reported that the current VAP prevention protocol was ineffective, and 68.06% rarely received VAP prevention training. Among the participants (25%), resources for maintaining proper hygiene and infection control were inadequate, whereas 75.93% found infection control protocols poorly accessible in their ICUs (Table 2).

Table 2.

Hospital-related characteristics in ICU settings: frequency and percentage distribution of nurses’ responses

Question	Options	Frequency	Percentage
How would you rate sufficiency of staffs?	Sufficient	67	31%
	Fair	57	26.3%
	Insufficient	92	42.5%
How often do you encounter insufficient supplies?	Rarely	76	25.19%
	Sometimes	80	37.04%
	Always	60	27.78%
How would you rate your experience in intensive care settings?	Poor	62	28.70%
	Good	76	35.19%
	Excellent	78	36.11%
How effective is the current protocol for VAP prevention in your ICU?	Ineffective	129	59.72%
	Neutral	50	23.15%
	Effective	37	17.13%
How often do you receive training on VAP prevention?	Rarely	147	68.06%
	Sometimes	34	15.74%
	Always	35	16.20%
Are there adequate resources for maintaining proper hygiene and infection control in your ICU?	Inadequate	54	25%
	Neutral	65	30.09%
	Adequate	97	44.9%
How would you rate the support from hospital management in implementing VAP prevention strategies?	Poor	179	82.87%
	Fair	21	9.72%
	Excellent	16	7.41%
How sufficient is the current staffing level in your ICU for VAP prevention efforts?	Insufficient	151	69.91%
	Neutral	26	12.04%
	Sufficient	39	18.04%
How accessible are infection control protocols and resources for staff in your ICU?	Poorly Accessible	164	75.93%
	Moderately Accessible	31	14.35%
	Highly Accessible	21	9.72%

Nurses’ practice and knowledge levels regarding VAP prevention

Among nurses working in pediatric and adult ICUs, 38.89% (95% CI: 32.35%-45.74%) reported good practices in VAP prevention, whereas 61.11% (132) reported poor practices. Similarly, 52.78% (114) exhibited good knowledge levels, whereas 47.22% (102) had poor knowledge levels (Fig. 1).

Fig. 1.

Nurses’ practice levels in VAP prevention among those working in adult and pediatric intensive care units in Tigray Public Hospitals, Ethiopia, 2024

Factors associated with the practice of VAP prevention

In the bivariate logistic regression analysis, ten variables were identified as potentially associated with the practice of VAP prevention. This information included sex, age, ICU working experience, the number of mechanically ventilated patients cared for in the past two weeks, educational level, ICU training, special training on VAP prevention, availability of resources for proper hygiene and infection control, current staffing levels in the ICU, and knowledge of VAP prevention. These associations were determined using a significance threshold of p ≤ 0.25. These variables were subsequently included in a multivariable logistic regression model to identify independent predictors. The analysis revealed that six factors, namely, age, ICU working experience, educational level, special training on VAP prevention, staffing level and knowledge of VAP prevention, were statistically significant predictors of a good level of practice in VAP prevention, with a significance level of p ≤ 0.05.

The odds of having good VAP prevention practices were 3.02 times greater (AOR = 3.02, 95% CI: 1.058–8.65) among those aged 40 years and above than among those aged 20–29 years, and nurses with three or more years of experience were 3.19 times more likely to have good practices in VAP prevention (AOR = 3.19, 95% CI: 1.163–8.784). The odds of good VAP prevention practices were 3.205 times greater (AOR = 3.205, 95% CI: 1.145–8.971) for bachelor’s degree holders than for diploma holders. Nurses who received special training related to VAP prevention were 4.29 times more likely to have good VAP prevention practices than those who did not (AOR = 4.29, 95% CI: 1.94–9.48). The odds of good practices for VAP prevention were 3.41 times greater among nurses with a good level of knowledge of VAP prevention (AOR = 3.41, 95% CI: 1.542–7.553). Compared with ICUs with sufficient staffing, ICUs with fair staffing had 58% lower odds of practicing good VAP prevention (AOR = 0.421, 95% CI: 0.179–0.990). Similarly, ICUs with insufficient staffing had 84% lower odds of good VAP prevention practices (AOR = 0.157, 95% CI: 0.064–0.386) (Table 3).

Table 3.

Bivariate and multivariable logistic regression analysis of associated factors influencing the practice of VAP prevention

Variable	Category	Practice of prevention of VAP		COR (95CI)	AOR (95CI)
		Poor	Good
Sex	Male	44	21	1	1
	Female	88	63	1.50(0.81–2.77)	1.233(0.57–265)
Age	20–29 years	45	18	1	1
	30–39 years	66	43	1.63(0.84–3.18)	1.39(0.589–3.29)
	40 and above year	21	23	2.74(1.22–6.13)	3.02(1.058–8.65) *
ICU working experience	< 1 years	28	8	1	1
	1–2 years	27	12	1.55(0.55–4.39)	2.321(0.675–7.98)
	3 and above years	77	64	2.90(1.24–6.83)	3.19(1.163–8.784) *
Educational level	Diploma	55	44	1	1
	Bachelor	16	18	1.41(0.64–3.07)	3.205(1.145–8.971) *
	Masters	61	22	0.45(0.24–0.85)	0.919(0.408–2.072)
How many MVP have you cared in the past 2 weeks?	1–2 patients	58	18	1	1
	3–5 patients	59	53	2.89(1.52–5.52)	1.526(0.67–3.463)
	≥ 6 patients	15	13	2.79(1.12–6.95)	1.122(0.339–3.71)
ICU training	No	45	16	1	1
	Yes	87	68	2.19(1.14–4.22)	2.013(0.859–4.718)
Special training on VAP prevention?	No	106	45	1	1
	Yes	26	39	3.53(1.93–6.48)	4.29(1.94–9.48) ***
Resources for proper hygiene and infection control	Adequate	26	28	1	1
	Fair	41	24	0.54(0.26–1.13)	0.355(0.135–1.021)
	Inadequate	65	32	0.46(0.23–0.85)	0.346(0.140–1.011)
Current staffing level in your ICU	Sufficient	29	38	1	1
	Fair	33	24	0.56(0.27–1.13)	0.421(0.179–0.990)*
	Insufficient	70	22	0.24(0.12–0.47)	0.157(0.064–0.386)*
Knowledge on Prevention of VAP	Poor	77	25	1	1
	Good	55	59	3.30(1.85–5.91)	3.41(1.542–7.553) **

NB: *, **, and *** denote significance levels at p-values of 0.05, 0.01, and 0.001, respectively

Qualitative interview results

This thematic analysis explored key factors influencing nurses’ practices toward VAP in adult and pediatric intensive care units (ICUs). Data were collected using in-depth interviews. A purposive sampling technique was employed to recruit ICU nurses who had direct experience in the care of mechanically ventilated patients. In-depth interviews were conducted sequentially, and data collection continued until data saturation was achieved. To ensure adequate depth and confirmation of emerging findings, a minimum of two in-depth interviews were conducted for each significant variable/theme. A total of five in-depth interviews were conducted.

Data were transcribed verbatim and translated into English by the trained data collectors, after which the principal investigator and two experienced qualitative researchers independently coded the transcripts. Codes were then discussed among the team to reach consensus, and themes were derived through iterative thematic analysis. Reflexivity was maintained throughout the process ensuring that interpretations were grounded in the participants’ experiences rather than the researchers’ preconceptions.

The analysis identified five primary themes: knowledge and awareness of VAP prevention, ICU training and specialized VAP prevention training, institutional support and resources, attitudes and perceived responsibility, and organizational culture and policies. Each theme highlights the barriers, facilitators, and knowledge gaps affecting VAP prevention practices among ICU nurses.

1. Knowledge and awareness of VAP prevention

Subthemes

• 1.1Comprehensive understanding of VAP: Nurses emphasized the importance of having a solid foundation of knowledge about VAP, including its risks, clinical presentation, and preventive measures. They noted that a lack of awareness regarding the long-term consequences of VAP and its impact on patient outcomes serves as a barrier to effective prevention.
• 1.2.Educational gaps: Many nurses reported limited training or a lack of updated knowledge regarding VAP prevention strategies. Some participants expressed concerns that the education received during initial nursing programs was insufficient to address the specific needs of ICU care, especially for pediatric patients.

Illustrative verbatim quote

I know VAP is a serious issue, but sometimes we don’t receive the kind of updates or refresher training that help us implement better practices in prevention. The information we obtain often feels outdated or generalized and is not tailored for the complex cases we manage daily. Without regular training sessions, we cannot keep up with the latest evidence-based practices for preventing VAP, which affects how we approach our care. It is frustrating because we want to provide the best care, but we’re not always equipped with the most current knowledge. (IDI: Female, 25 years, Pediatric ICU nurse)

• 2. ICU training and specialized VAP prevention training

Subthemes

1. Formal ICU training: Nurses with more experience in ICU settings mentioned that formal ICU training significantly improved their ability to prevent VAP. However, several nurses highlighted that their initial training was generic and did not focus on intensive care specifics.

2. Specialized training on VAP prevention: Some nurses expressed that specialized training focused on VAP prevention techniques (e.g., oral hygiene, head-of-bed positioning, sedation protocols) was lacking. For those who had received this training, it was seen as invaluable in preventing VAP and improving care quality.

Illustrative verbatim quote

We need specialized courses that focus specifically on VAP prevention. It is too crucial to be overlooked in our regular training. Even in ICU training, we cover a broad range of topics, but we do not consider the nitty-gritty of infection control practices such as oral care, head-of-bed positioning, and sedation practices—things that are critical to VAP prevention. When I had the chance to attend VAP-focused training, I learned techniques I never would have thought of. It truly changed how I approach patient care, but unfortunately, not all of us get that opportunity. (IDI: Male, 32 years old, Adult ICU nurse)

1. Institutional support and resources

Subthemes

• 3.1Availability of resources: Nurses reported that the availability of adequate resources, such as antiseptic oral care products, suction equipment, and ventilator maintenance tools, directly impacted their ability to prevent VAP. Shortages of these resources were identified as a significant barrier to proper practice.
• 3.2Staffing and workload: High nurse-to-patient ratios are frequently cited as a factor that hinders the ability to focus on preventive measures for VAP. With more patients to manage, nurses felt that they could not consistently implement all best practices for VAP prevention.

Illustrative verbatim quote

We try our best, but when we have too many patients and too few supplies, it becomes harder to maintain the quality of care that VAP prevention demands. For example, there are times when we run out of necessary supplies such as antiseptic mouthwash or suction devices, which are essential in preventing VAP. These shortages make it difficult to adhere to the recommended protocols. Furthermore, staffing levels are often limited, and we do not have the time or energy to give every patient the kind of attention needed to prevent infections such as VAP. It’s a daily challenge. (IDI: Female, 40 years old, ICU nurse)

1. Attitudes and perceived responsibility

Subthemes

• 4.1Personal commitment to prevention: Many nurses reported that their personal commitment to VAP prevention drove their actions, but this varied significantly. Nurses who perceived VAP prevention as part of their professional identity were more likely to adhere to guidelines and best practices.
• 4.2Team collaboration and accountability: Collaboration with other healthcare team members, including physicians and respiratory therapists, was highlighted as a positive influence. However, some nurses expressed concerns about the lack of multidisciplinary communication and accountability in implementing prevention protocols.

Illustrative verbatim quote

It truly depends on how committed each nurse is. Some of us feel a strong personal responsibility to prevent VAP and are constantly vigilant, but others do not seem to be invested. Sometimes there’s a lack of teamwork, and that affects how well we can implement VAP prevention. For example, when the specialist does not follow through with the head-of-bed protocol or if physicians are not consistent with their orders for sedation practices, it makes it harder for us to do our part. VAP prevention truly should be a team effort, but at times, it feels like we’re working in silos. (IDI: Male, 36 years, Pediatric ICU nurse)

• 5. Organizational culture and policies

Subthemes

• 5.1Institutional policies and protocols: The existence and enforcement of institutional protocols for VAP prevention were cited as key factors affecting practice. Nurses emphasized the importance of clear, well-communicated policies and regular audits to ensure compliance with VAP prevention practices.
• 5.2Management support: Nurses noted that strong leadership and support from ICU management were crucial for fostering an environment that prioritized infection prevention. Leadership that emphasizes patient safety and provides adequate training resources was linked to better implementation of VAP prevention strategies.

Illustrative verbatim quote

When the management supports these efforts and sets clear rules, it’s much easier for all of us to stay on track. I’ve seen a big difference in units where leadership takes infection control seriously—they make sure everyone knows the protocols and checks that we’re following them. They also provide us with the resources and ongoing training we need. In those environments, there is less ambiguity, and everyone feels accountable. On the other hand, in places where leadership is not as engaged, it feels that there is no urgency, and the protocols become optional. That lack of oversight leads to inconsistencies in how VAP prevention is handled.” (IDI: Female, 45 years old, Adult ICU nurse)

Discussion

The findings of this study revealed that 38.89% (95% CI: 32.35%-45.74%) of nurses working in the ICU demonstrated a good level of practice toward VAP prevention. Age, ICU working experience, educational level, special training on VAP prevention, and knowledge of VAP prevention were statistically significant factors associated with a good level of practice in VAP prevention.

In this study, 38.89% of the nurses demonstrated a good level of VAP prevention practice. This finding is lower than those of studies conducted in Yemen (48%) [45], Iran (56.32%) [46], India (74%) [47], Pakistan (83%) [48], and Rwanda (60.78%) [49]. This is due to Countries with higher levels of practice, such as Iran, India, Pakistan, and Rwanda, may benefit from more robust healthcare systems, better availability of resources, and more frequent or intensive training programs for ICU nurses.

Similarly, The reported proportion of nurses demonstrating good VAP prevention practice (38.89%) is lower than findings from previous studies in Ethiopia (54.5%) [50]. This might be due to the recent war in Tigray has severely affected the health system infrastructure, leading to destruction of health facilities, shortages of essential medical supplies, and disrupted supply chains. These conditions directly limit the ability of ICU nurses to consistently implement standard VAP prevention measures.

However, this percentage is higher than that reported in a study conducted in Egypt (26.7%) [42]. This difference may be attributed to variations in study settings, Methodological differences, including measurement tools and operational definitions of good practice, differences in sample characteristics, training exposure, and availability of guidelines. Additionally, the findings are quite similar to those of a previous study conducted in Addis Ababa, Ethiopia (41.1%) [43]. The variation in findings regarding VAP prevention practices can be attributed to several factors. This might be due to in Egypt’s lower level of practice may stem from differences in the definitions of good and bad practices, as well as variations in the study’s cutoff point for determining practice levels. The similarity between the findings of the current study and those of the Addis Ababa study suggests regional consistency in healthcare infrastructure, training opportunities, and resource availability within Ethiopia. These differences highlight the influence of healthcare policies, staff education, and available resources on VAP prevention practices. This indicates that Future research should focus on evaluating the effectiveness of training interventions, mentorship programs, and organizational support mechanisms in improving adherence to VAP prevention practices among ICU nurses.

This study revealed that nurses with more years of experience were more likely to demonstrate good practices in VAP prevention. This finding aligns with studies from Saudi Arabia [51], Egypt [42], and India [47]. The finding that nurses with more years of experience are more likely to demonstrate good practices in VAP prevention can be explained by several factors.

This is due to First, experienced nurses have a deeper understanding of the clinical environment, as they have encountered a wide range of patient cases and scenarios over time. This exposure enables them to develop comprehensive knowledge of ICU protocols and infection control measures, which are critical in preventing VAP. Additionally, with more experience, nurses are more likely to have received ongoing education, training, and exposure to the latest research and evidence-based guidelines, allowing them to stay updated on best practices for preventing ventilator-associated pneumonia. This is due to Experienced nurses also tend to have a greater level of confidence in their ability to implement VAP prevention strategies effectively [23]. They have had more opportunities to apply these practices in real-world settings and can identify potential risks and take proactive measures to mitigate them.

Educational level is also an associated factor influencing nurses’ practice levels toward VAP prevention. Nurses with a master’s or bachelor’s degree are more likely to demonstrate good practices than those with a diploma. This finding is consistent with studies from Yemen [45] and Ethiopia [52]. The finding that nurses with higher educational levels (Bachelor’s or Master’s degrees) are more likely to demonstrate good practices in VAP prevention can be explained by the advanced knowledge and skills acquired through their education.

This might be due to the fact that higher education provides nurses with a deeper understanding of infection control, clinical guidelines, and evidence-based practices. Nurses with advanced education are better equipped to apply these practices and make informed decisions regarding patient care. These nurses also tend to have stronger critical thinking and problem-solving skills, which help them evaluate and implement protocols effectively. Additionally, they may be more involved in research or leadership roles, influencing the adoption of best practices. These findings suggest that enhancing the educational level of nurses, particularly diploma holders, could be an effective strategy to improve VAP prevention practices. Healthcare institutions should prioritize continuing education and professional development to ensure that all nurses are equipped with the necessary knowledge and skills.

Nurses who receive special training on VAP prevention are more likely to demonstrate good practices. Similarly, this finding aligns with a study from India [47]. Additionally, the qualitative findings provide further insight: “We need specialized courses that focus specifically on VAP prevention. It is too crucial to be overlooked in our regular training.” This highlights the critical role that continuous education plays in maintaining high standards of care. The reason why nurses who receive special training on VAP prevention are more likely to demonstrate good practices lies in the acquisition of specific, evidence-based knowledge and skills related to infection control. Training programs enhance nurses’ understanding of VAP risk factors, prevention strategies, and the importance of strict adherence to protocols, thus directly influencing their clinical behavior. By focusing on the specific mechanisms of VAP prevention, such training addresses gaps in knowledge and reinforces the critical role nurses play in preventing healthcare-associated infections. The implications of these findings are significant. This highlights the necessity of integrating specialized, regular training into healthcare systems, especially in intensive care units where the risk of VAP is high. Institutions should prioritize this type of education to ensure that nurses are well prepared to implement best practices, ultimately leading to improved patient outcomes, reduced infection rates, and lower healthcare costs.

These findings suggest that staffing levels in ICUs are significantly associated with the effectiveness of VAP prevention practices. ICUs with insufficient staffing are particularly at greater risk of poor VAP prevention, with a sharp decline in effectiveness as staffing levels decrease. This finding is in agreement with a study from Pakistan [53].

This may be due to fatigue and burnout from overwork further hinder the consistent practice of preventive measures. Limited access to training and resources in understaffed settings also contributes to poor VAP prevention. This highlights the importance of adequate staffing to ensure optimal infection control practices and better patient outcomes. Improving staffing in critical care units could be key to enhancing the prevention of VAP and reducing related complications.

Furthermore, nurses who have good knowledge of VAP prevention are more likely to demonstrate a high level of VAP prevention practices. This finding is supported by studies conducted in India [54] and previous research from Ethiopia [50], which also showed that improved knowledge directly correlates with better adherence to VAP prevention protocols. The qualitative interviews support this idea, with the following statement: “The information we get often feels outdated or generalized, not tailored for the complex cases we manage daily. Without regular training sessions, we cannot keep up with the latest evidence-based practices for preventing VAP.”

The finding that nurses with good knowledge of VAP prevention are more likely to demonstrate high levels of VAP prevention practices is grounded in the understanding that knowledge empowers healthcare professionals to apply evidence-based practices.

This could be due to the fact that when nurses are well versed in VAP prevention guidelines, they are more confident and capable of implementing strategies such as elevating the head of the bed, performing oral care, and minimizing sedation—all critical steps in preventing ventilator-associated pneumonia. Knowledge acts as a tool that drives motivation and informs decision-making, ensuring that nurses adhere to best practices and protocols designed to minimize patient risk. The implications of these findings are important for healthcare practice and policy. These findings emphasize the need for effective educational programs and training for nurses, particularly in intensive care units, where the incidence of VAP is high. By ensuring that nurses possess up-to-date and comprehensive knowledge of infection prevention, healthcare institutions can significantly reduce the occurrence of VAP, leading to better patient outcomes, fewer complications, and lower healthcare costs.

In addition, the results from the qualitative interviews highlighted several other factors influencing VAP prevention practices, including staffing and workload, team collaboration and accountability, and management support. Previous studies also support these findings [55, 56], suggesting that adequate staffing and manageable workloads are crucial for ensuring that nurses have the time and capacity to follow infection prevention protocols effectively. Furthermore, team collaboration and accountability were identified as key elements for ensuring that all healthcare professionals adhere to best practices collectively, whereas management support was emphasized as a critical factor in providing the necessary resources and leadership to sustain effective VAP prevention efforts.

These findings have significant implications for healthcare practice. Healthcare institutions must not only focus on training and education but also address these systemic factors. Ensuring adequate staffing levels, fostering a culture of teamwork and accountability, and securing strong management support are critical to enabling nurses to consistently implement VAP prevention strategies.

The study has several strengths. The mixed-methods design provides both quantitative data and qualitative data on VAP prevention practices and qualitative insights into the challenges nurses face, offering a comprehensive view. The context-specific focus on Tigray makes the findings particularly relevant to local healthcare settings. Additionally, the inclusion of both adult and pediatric ICUs offers a broader understanding of VAP prevention across different patient populations. The inclusion of multiple hospitals in the Tigray region enhances the study’s external validity, providing a broader understanding of factors influencing VAP prevention practices in a context impacted by local healthcare challenges. However, there are limitations. As a cross-sectional study, it captures data at one point in time, limiting the ability to assess long-term changes. Self-reporting in qualitative interviews may lead to socially desirable responses, and the study’s design restricts the ability to establish causal relationships between various factors and VAP prevention practices.

Conclusion and recommendations

Conclusion

This study revealed that only 38.89% of ICU nurses had good practices toward VAP prevention. Adherence to VAP prevention practices was significantly associated with nurses’ age, ICU work experience, educational level, specialized training, and knowledge. These findings emphasize the importance of strengthening regular in-service training, continuous professional education, adequate staffing, teamwork, and managerial support to improve compliance with VAP prevention guidelines and enhance patient safety in ICU settings.

The qualitative findings also highlighted additional challenges, such as inadequate training opportunities, insufficient staffing, high workloads, and the need for better team collaboration and management support. Future research should focus on longitudinal and interventional studies may also help identify sustainable strategies to strengthen infection prevention practices and reduce the burden of ventilator-associated pneumonia in resource-limited ICU settings.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ACSH

Aksum Comprehensive Specialized Hospital

ACSH

Ayder Comprehensive Specialized Hospital

AOD

Adjusted Odds Ratio

ARDS

Acute Respiratory Distress Syndrome

CI

Confidence Interval

COR

Crude Odds

ICU

Intensive Care Unit

NICU

Neonatal Intensive Care Unit

SPSS

Statistical Package for Social Sciences

VAP

Ventilator-Associated Pneumonia

VIF

Variance Inflation Factor

Author contributions

The MA was made substantial contributions to the conception, design of the work, methodology, analysis, data interpretation and wrote the final manuscript. EB, DS, and WA have made substantial contribution in reviewing overall the study in analysis, interpretation of data, have drafted the manuscript and substantively revised the work. All authors read and approved the final manuscript.

Funding

There is no funding for this research. All cost of data collection and analysis were covered by the authors.

Data availability

All data is available via this manuscript.

Declarations

Ethical approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. Formal letter of ethical clearance and approval were obtained from Ethical Review Board of Aksum University College of health sciences [096/2024]. Official support letter was obtained from Tigray regional health bureau. The respondents were informed about the purpose of the study and they have full right to withdraw or refuse at any time from the process. Respondents were ensured about the confidentiality of information obtained. The respondents were not requested to write their name, to answer the questions alone and assuring individual response wasn’t reported. Beneficence of the participants was maintained throughout the study.

Consent for publication

Not applicable.

Informed consent

Written informed consent was obtained from all participants before data collection.

Competing interests

The authors declare no competing interests.