Establishing a course to train ICU nurses on prone position mechanical ventilation: A Delphi study
Abstract
Aim
To develop a comprehensive training course for training ICU nurses in prone positioning.
Design
A mixed study combining semi-structured interviews and two rounds of Delphi surveys.
Methods
We constructed a questionnaire after collecting data through a literature review and semi-structured interviews. We used the Delphi expert correspondence method to conduct two rounds of research among 17 experts in the field of critical illness. Data collection took place between May and August 2022.
Results
The effective questionnaire recovery rate was 88.2%. The expert authority coefficient was 0.876; the Kendall coordination coefficient was 0.402; the average importance score for each index ranged from 4.00 to 4.93; and the coefficient of variation for each index ranged from 0.05 to 0.19. We established 13 second-level indicators and 41 third-level indicators on prone position ventilation training according to three aspects: training contents, training methods and training assessment. The training system of prone mechanical ventilation for ICU nurses established in this study will provide an effective framework for training and evaluating the practical ability of prone mechanical ventilation for ICU nurses.
1 INTRODUCTION
Mechanical ventilation (MV) is a type of ventilation mode that provides respiratory support for patients with respiratory dysfunction. It uses a ventilator mechanical device to establish the principle of pressure difference between the air passage and the alveoli and replaces, regulates, or changes the abnormal spontaneous respiratory movement. It also helps patients to restore effective ventilation and improve oxygenation (Cronin et al., 2022). MV, as a means of life support, is the most effective treatment for patients with various respiratory failures (Rackley, 2020). It is reported that about 800,000 patients in the United States receive MV each year, accounting for 2.8% of total hospitalisations. In intensive care units (ICU), the proportion of patients receiving MV was as high as 73.3% (Wunsch et al., 2010). While maintaining respiratory support, MV may also bring a series of complications to patients, including ventilator-associated pneumonia, ventilator-associated lung injury, pressure injury, difficulty in extubation and tracheal intubation displacement, etc., resulting in prolonged hospital stay and increased costs and even higher mortality of patients (Kollef et al., 2012; Melsen et al., 2013). However, these complications can be avoided and managed by adopting reasonable nursing measures (Al-Mugheed et al., 2022; Osti et al., 2017).
2 BACKGROUND
The position change is one of the most commonly used nursing measures to prevent complications in patients with MV, which is of great significance for preventing pressure sores, clearing respiratory secretions and ventilator-associated pneumonia (Alderden et al., 2020; Mastrogianni et al., 2023). Among them, prone MV can also promote the re-expansion of collapsed alveoli, improve the blood flow ratio of ventilators, enhance respiratory system compliance, increase oxygenation and reduce the potential for lung injuries that are associated with mechanical ventilators (Cornejo et al., 2013), which has been carried out in clinical practice and accompanied by novel coronavirus pneumonia and has received considerate attention from scholars around the world (Wang et al., 2021). At the same time, many studies have demonstrated the effectiveness and safety of MV in the prone position. For example, a meta-analysis reported that prone ventilation could improve oxygenation and reduce mortality rates in patients with novel coronavirus pneumonia (Behesht Aeen et al., 2021). In 2017, the European Society of Intensive Care Medicine and the American Thoracic Society recommended prone ventilation for patients with severe acute respiratory distress syndrome (Fan et al., 2017), given that such applications significantly reduce patient mortality rates.
Although numerous studies have shown that prone ventilation is more effective in the treatment of patients with respiratory failure of all causes, survey data show that the use of prone ventilation in the treatment of respiratory failure is still relatively low globally (Bellani et al., 2016); in fact, one study reported a rate of less than 10% in China (Liu et al., 2018). The low rate of clinical practice of prone MV may be due to a lack of awareness among medical personnel, insufficient attention to the importance of prone MV in treating critically ill patients and unclear benefits of prone MV (Bruni et al., 2021). Meanwhile, several investigations by Li (2021) Yang et al. (2019) have shown that ICU nurses lack knowledge about prone MV and do not know how to properly carry out prone MV. In addition, the concerns of ICU nurses about complications such as extubation and facial pressure injury during prone MV also limit its clinical application (Lu & Wang, 2018).
Nurses are essential members involved in the implementation of prone MV and play a leading role in the observation of subsequent complications (Jiang et al., 2022), including essential duties in the placement of pipes and lines, disease monitoring, preventing and addressing complications and handling emergencies (Mitchell & Seckel, 2018). Therefore, strengthening the theoretical and practical training of prone MV for ICU nurses is of great significance for improving the clinical promotion of prone MV, improving its therapeutic effect and reducing the occurrence of complications. However, a review of the literature shows that there are no professional training and education programs related to prone MV for ICU nurses and the formed operational procedures lack a reasonable training and assessment system (Malhotra, 2022; Subgroup of Critical Respiratory Diseases et al., 2020).
3 STUDY AIM
The study aims to construct a complete training system for ICU nurses on prone MV through scientific methods, training them in related knowledge and skills of prone MV.
4 METHODS/METHODOLOGY
This project takes the competency model as the guiding framework. Competency, proposed by American psychologist McClelland (1973), is a framework used to describe and evaluate the key abilities and qualities required by employees in specific positions. It defines the knowledge, skills, attitudes and behavioural characteristics needed to excel in a role. In recent years, it has been widely used to improve clinical practice, leadership, collaboration and education capabilities (De Clercq et al., 2011; Supamanee et al., 2011; Yoon et al., 2018). Our aimed to construct a complete training system for prone MV and the main training object is ICU nurses, with the basic conditions included: (1) with a college or above nursing education level (2) Obtain the nurse practising qualification certificate and register (3) ≥1 year of critical care work experience. Due to the development of intensive care diagnosis, treatment and nursing technology, ICU nurses need to understand the significance of prone position MV for patients' safety and its clinical value, foster a positive learning attitude and systematically acquire relevant knowledge and skills. Therefore, this study covers these three aspects in formulating related indicators of prone position MV training. At the same time, to improve the learning efficiency of ICU nurses, we thoroughly considered the learning needs of ICU nurses in developing the training content. We adopted a variety of training methods to fully mobilise their learning enthusiasm. In addition, we have developed assessment criteria to assess the competence of ICU nurses in prone position MV technical positions.
4.1 Design
In this study, we initially constructed the curriculum of prone MV training for ICU nurses through a literature review and semi-structured interviews. We conducted two rounds of the Delphi method to promote the construction of training courses for ICU nurses to reach a consensus.
4.2 Literature review
Using ‘prone position OR supine position OR face down position’ AND ‘nurs* OR Management’ as keywords, we conducted web searches via PubMed, Embase, CINAHL, Cochrane Library, CNKI, Wanfang and the China Biomedical Literature Database. After considering the topics, abstracts and full texts of returned articles, we obtained 20 related to the research contents, including 13 in English and 7 in Chinese. We then evaluated the remaining guidelines, expert consensuses, summaries of evidence and cross-sectional studies for quality using tools developed by the Joanna Briggs Institute Center for Evidence-Based Health Care. Finally, we conducted a content analysis to extract information on prone MV training courses.
4.3 Semi-structured interview
We collected information through a semi-structured interview based on guidelines established by Kallio et al. (2016). to improve the prone MV training course for ICU nurses. This method is advantageous because it facilitates discussions with experienced staff, thus supplementing and deepening the contents of the referenced literature (Sánchez-Guardiola Paredes et al., 2021).
4.3.1 Population and sample
From May to June 2022, we conducted a sampling procedure to select intensive care doctor clinicians, intensive care nurses, respiratory therapists and critical Care Managers from the Department of Respiratory or Critical Care at a Grade-A hospital. Inclusion and/or Exclusion Criteria: (1) ≥10 years of employment in the Department of Respiratory or Critical Care Medicine, (2) experience with MV in the prone position and (3) intermediate or above professional title. Individuals who met these criteria received an electronic notification explaining the study's purpose and methodology. Those who agreed to participate were asked to sign an informed consent form and indicate a time and place for their interview.
4.3.2 Establishing the interview outline
An interview outline should reflect the research purpose and feature closed and open-ended questions. After finishing the preliminary design, we conducted a pre-interview with two individuals who met the inclusion criteria and then revised the language and contents according to the results. The final interview outline consisted of the following: (1) Do you think it is necessary to train critical nurses on prone MV? Why? (2) What do you think should be included in prone position MV training? (3) In what ways do you think prone position MV training can be carried out? (4) Do you think the prone position MV training should be assessed by examination? If yes, what assessment method should be used? (5) What are your suggestions for prone MV training?
4.3.3 Formal interview
Two researchers participated in the interviews, which were conducted in a quiet conference room at appropriate times. The interviews lasted approximately 30–40 min, with contents recorded in both audio and written forms. Appropriate guidance and hints were permitted during the interviews, with each topic reiterated after completion so that interviewees could clarify and confirm. After each interview, the researchers promptly transcribed the results, which were analysed and refined via the thematic analysis method. Data saturation was achieved when no new interview content emerged. Ultimately, this study interviewed eight individuals in related fields.
4.4 Quality appraisal
We established a research team of eight members, including one MD graduate student, three Master of Nursing graduate students, one nursing educator, one nursing administrator, one respiratory therapist and one cardiopulmonary resuscitator, to summarise and discuss the literature search and semi-structured interview results. Based on the literature review and interview results, we summarised prone MV training courses for ICU nurses and classified them to form a draft.
4.5 Delphi process
4.5.1 Sampling and recruitment
From June to July 2022, we distributed questionnaires to Grade-A hospitals or medical schools in five regions in eastern, southern, western, northern and central China using the established criteria. We selected one doctor or one respiratory therapist, two nurses, one critical care manager or a critical care educator from each region. These individuals were sent emails explaining the research purpose and expert consultation process, along with the expert consultation questionnaire. They were also encouraged to recommend other experts potentially interested in our research. We set the following selection criteria when seeking experts for correspondence consultations: (1) clinician, nurse, nursing manager and/or nursing educator engaged in respiratory or critical care medicine; (2) bachelor's degree or higher; (3) intermediate or higher professional title; (4) ≥10 years of employment in respiratory and intensive care medicine and/or intensive care nursing education; (5) is willing and agrees to participate. According to the Delphi method, participant criteria suggested by Wu and Sun (2015), We sent out 17 questionnaires and 16 people responded after the first round of expert correspondence and 15 people responded after the second round of expert correspondence.
4.5.2 Expert letter questionnaire
The expert letter consultation questionnaire consisted of seven aspects, including (1) The informed consent for expert consultation. (2) The instructions for completing the expert letter consultation form. (3) The general framework of training courses included three first-level indicators, 12 second-level indicators and 41 third-level indicators. (4) The rating table for the importance of training indicators was completed using a 5-point Likert scale ranging from 1 (very not important) to 5 (very important); each indicator was set to modify the opinion column, with each level of indicators set to add the item column, so that the experts could modify, delete and expand the indicators. (5) The expert familiarity questionnaire was completed using a 5-point scale ranging from very unfamiliar to very familiar, marked as 0.1–0.9. (6) The expert judgement questionnaire was based on four aspects, including theoretical analysis, practical experience, reference to domestic and foreign literature and intuitive feeling; each aspect contained the three degrees of large, medium and small, with respectively assigned values of 0.3, 0.2 and 0.1 for the theoretical analysis aspect, 0.5, 0.4 and 0.3 for the practical experience aspect and 0.1 for both the reference to domestic and foreign literature and intuitive feeling aspects. (7) The general participant information questionnaire asked the experts for their age, highest education level, professional title, major and years of work related to the major.
4.5.3 Implementation of Delphi
We implemented the Delphi from July to August 2022, wherein correspondence included electronic and paper forms. There were two expert consultation rounds, each occurring over 2 weeks. Individuals who did not reply within the specified time frame were reminded by email. After the first round, we revised and improved the training course based on opinions and suggestions from the experts, then constructed the expert letter consultation form for the second round. We set the following selection criteria for each index after each round of expert letter consultation (Ye et al., 2022): (1) average score of importance >3.5, (2) coefficient of variation (CV) for each index <0.25 and (3) full score rate of each index >20%. Indicators that met all three criteria were included, while those that did not meet any criteria were excluded.
4.6 Ethical considerations
We received approval from the Medical Research Ethics Committee of the First Affiliated Hospital of University of Science and Technology of China (Ethics batch number 2022ky209). In all cases, participants were given descriptions of the research purpose and implementation methods before the semi-structured interviews and the Delphi component. All participants voluntarily engaged in this study and signed informed consent forms. They were told they had the right to withdraw at any time. All participants will be identified by number, all profiles of those who refuse to participate will be deleted and any public reporting of the results of this study will not be personally identifiable.
4.7 Data analysis
We used Excel 2016 and IBM SPSS 24.0 for data entry, sorting and analysis. The effective questionnaire recovery rate represents the expert enthusiasm (RR), expert familiarity (Cs) and expert judgement basis (Ca) scores. The effective recovery rate represents the expert authority coefficient (Cr), CV for each index and Kendall's W coefficient, reflecting the degree of concentration and coordination for the expert opinions. For the statistical descriptions of general information for the experts consulted via correspondence and the scores from each questionnaire, the measurement data were presented as means and standard deviations, with frequencies and percentages used for counting data. α = 0.05 in this study.
5 RESULTS
5.1 General information on the experts
The 15 experts who participated in the two rounds of consultation ranged from 30 to 51 years of age (average of 41.13 ± 7.14 years). As for education, nine held bachelor's degrees (60%), while six held master's degrees or higher (40%). As for professional titles, five were intermediate (33.3%), while 10 were associate seniors or higher (66.7%). Looking at employment positions, four were intensive care nurses (26.7%), two were respiratory and critical care-related clinicians (13.3%), five were nursing managers (33.4%), two were intensive care-related nursing educators (13.3%) and two were respiratory therapists (13.3%). Finally, their professional employment years ranged from 10 to 30 (average of 15.93 ± 6.02 years).
5.2 Expert positive coefficient and opinion authority degree
In the first round of expert consultations, we recovered 16 of the 17 total distributed questionnaires (effective recovery rate of 94.1%). Thus, nine experts put forward 18 written opinions. In the second round, we recovered 15 of the 16 total distributed questionnaires (effective recovery rate of 93.8%). After both rounds, Cs was 0.793 and Ca was 0.960. According to the calculation formula (Composite Reliability (Cr) = [Judgement Basis (Ca) + Familiarity (Cs)]/2), Cr was 0.876.
5.3 Degree of concentration and coordination of expert opinions
After the second round of expert correspondence consultations, the coefficients of variation for the first, second and third-level indexes were 0.07–0.18, 0.05–0.15 and 0.05–0.19, respectively. The Kendall coefficients for the first, second and third-level indexes were 0.470, 0.335 and 0.300, respectively, with significant statistical differences (p < 0.05).
5.4 Importance scores for indicators at all levels
After the second round of expert letter consultations, the average importance score for each item from the first-level indicator ranged from 4.00 to 4.87 points, with a full score rate of more than 50% for two indicators, accounting for 66.7% of all first-level indicator items. The average importance score for each item from the second-level index ranged from 4.13 to 4.93, with a full score rate of more than 50% for eight indicators, accounting for 61.5% of all second-level index items. The average importance score for each item from the third-level index ranged from 4.07 to 4.93, with a full score rate of over 50% for 31 indicators, accounting for 75.6% of all third-level index items.
5.5 Prone position MV training course
5.5.1 Training contents
Modifying indicators: After a round of correspondence consultations, one expert pointed out that ‘introduction to operating purpose’ should help nurses understand important parts of the operation; they recommended that we modify the indicator ‘prone position MV concept, function and importance’ to ‘prone position MV, purpose, function and importance’. This was adopted after a group discussion. Another expert recommended changing the expression ‘operational skills’ to ‘professional skills’. This was also adopted after a group discussion. Further, one expert believed that the description ‘prevention and management of complications’ was limited and recommended changing it to ‘risk prevention management’. This description was considered more professional and adopted after a group discussion. Next, one expert pointed out that the term ‘gastrointestinal intolerance’ in ‘prevention and treatment of gastrointestinal intolerance’ lacked professionalism. After a literature review, this was revised to ‘prevention and treatment of feeding intolerance’ (Liu et al., 2021). Another expert discussed the concepts of humanistic care and individual needs after implementing an operation in the ICU; they recommended that we change ‘prone position MV patients and their families psychological assessment and care support’ to ‘prone position MV patients psychological assessment and care support’. However, this was not adopted after a group discussion, as most patients who require prone position ventilation are seriously ill; meanwhile, their families often lack disease treatment knowledge and experience psychological worries and anxieties (Rowe, 2004). They should be offered psychological support and care.
5.5.2 Training methods
(1) Modify indicators: After a round of correspondence consultations, two experts indicated issues with the terms ‘role simulation training’ and ‘clinical practice of different roles’, recommending that we change them to ‘role simulation training’ and ‘role actual combat exercise’. These were adopted after a group discussion. (2) Enquiry to establish indicators: Two experts believed that prone position MV was a comprehensive technology and that some contents of the training mode should not be limited to a single mode; given current developments in Internet technology, parts can now be delivered via online self-study (Wang, Zhang, et al., 2016). They recommended that the training mode of secondary indexes should include ‘other teaching methods’. This was adopted after a group discussion. (3) Combined indicators: Based on expert suggestions and the above contents on additional indicators, we changed ‘face-to-face teaching’ and ‘online teaching’ to ‘theoretical teaching’ after a group discussion. Part of the contents of the ‘teaching method’ and ‘demonstration method’ was merged into the three-level index of ‘hybrid teaching method’, which is expressed as ‘self-study on a network platform’.
5.5.3 Training assessment
(1) Modification index: After a round of correspondence consultations, one expert pointed out that the ‘overall theoretical assessment’ could not be understood. This was changed to ‘final theoretical assessment’ after a group discussion. Moreover, two experts pointed out that the three indexes of ‘skill assessment’, ‘prone MV operating system assessment’ and ‘random verification of prone MV operating system’ were not clearly defined or expressed in a standard way. They recommended that we change these to ‘simulated operation assessment’ and ‘on-site operation assessment’. (2) Establish indicators: One expert pointed out that, in addition to the theoretical knowledge and skills operation evaluations, the training evaluation process should focus on a rational understanding of the training system and ensuring trainee acceptance (Dalrymple et al., 2007; Tang et al., 2016). They recommended adding the secondary indicator ‘process evaluation’, which we adopted after a group discussion and literature review. (3) Delete indicators: Three experts recommended that we delete the ‘case article’, combined with the indicator selection criteria, after a round of enquiry for training evaluation methods in the article ‘case’ importance index score <3.5, with an index variation coefficient >0.25 and index of full mark rate <20%. Therefore, we deleted the article ‘case’ and its three indicators ‘wrote prone position MV cases nursing articles’.
After two rounds of expert letter consultations, group discussions and literature reviews, we completed our assessment of the prone MV training system for critical care nurses. We finally included three first-level indicators, 13 second-level indicators and 41 third-level indicators. Table 1 lists the specific contents of each level indicator, the importance scores for each indicator and the coefficients of variation.
| Indicators | Rating of importance | Coefficient of variation |
|---|---|---|
| 1 Training contents | 4.87 ± 0.35 | 0.07 |
| 1.1 Basic knowledge | 4.53 ± 0.52 | 0.11 |
| 1.1.1 Concept, purpose, function and importance | 4.67 ± 0.49 | 0.10 |
| 1.1.2 Development and application | 4.07 ± 0.80 | 0.19 |
| 1.1.3 Pathophysiological mechanism | 4.60 ± 0.51 | 0.11 |
| 1.1.4 Indications and contraindications | 4.93 ± 0.25 | 0.05 |
| 1.1.5 Introduction to implementation methods | 4.93 ± 0.25 | 0.05 |
| 1.1.6 Implementation process and key cooperation points | 4.93 ± 0.25 | 0.05 |
| 1.1.7 Evaluation and regulation of sedation depth | 4.73 ± 0.46 | 0.10 |
| 1.1.8 Key points of disease monitoring | 4.67 ± 0.49 | 0.10 |
| 1.1.9 Implementation time, duration and evacuation indication | 4.80 ± 0.41 | 0.09 |
| 1.2 Professional skills | 4.67 ± 0.49 | 0.10 |
| 1.2.1 Three-person operation technique | 4.87 ± 0.35 | 0.07 |
| 1.2.2 Five-person operation technique | 4.93 ± 0.26 | 0.05 |
| 1.2.3 Envelope operation technique | 4.67 ± 0.49 | 0.10 |
| 1.2.4 Automatic turning bed using technology | 4.27 ± 0.40 | 0.16 |
| 1.2.5 Pipe and line treatment and placement technology | 4.80 ± 0.41 | 0.09 |
| 1.2.6 Airway management technique | 4.93 ± 0.25 | 0.05 |
| 1.2.7 Eye care technique | 4.60 ± 0.63 | 0.14 |
| 1.2.8 Position management techniques | 4.93 ± 0.25 | 0.05 |
| 1.3 Risk prevention management | 4.80 ± 0.41 | 0.09 |
| 1.3.1 Emergency plan for sudden mechanical ventilation (asphyxia, cardiac arrest) | 4.80 ± 0.41 | 0.09 |
| 1.3.2 Prevention and treatment of unplanned extubation | 4.93 ± 0.25 | 0.05 |
| 1.3.3 Prevention and treatment of stress injury | 4.73 ± 0.46 | 0.10 |
| 1.3.4 Prevention and treatment of hemodynamic disorders | 4.67 ± 0.49 | 0.10 |
| 1.3.5 Prevention and management of peripheral nerve injury | 4.33 ± 0.62 | 0.14 |
| 1.3.6 Prevention and treatment of feeding intolerance | 4.53 ± 0.52 | 0.11 |
| 1.4 Team cooperation | 4.93 ± 0.26 | 0.05 |
| 1.4.1 Personnel composition and division of duties | 4.80 ± 0.41 | 0.09 |
| 1.4.2 Importance and cultivation of teamwork | 4.87 ± 0.35 | 0.07 |
| 1.5 Humanistic care | 4.27 ± 0.46 | 0.11 |
| 1.5.1 Patient acceptance and tolerance evaluation | 4.67 ± 0.49 | 0.10 |
| 1.5.2 Psychological evaluation and nursing support for patients and their families | 4.47 ± 0.52 | 0.12 |
| 1.6 Evidence-based nursing | 4.40 ± 0.51 | 0.12 |
| 1.6.1 Literature search and quality evaluation | 4.33 ± 0.62 | 0.14 |
| 1.6.2 Evidence summary and transformation | 4.33 ± 0.62 | 0.14 |
| 2 Training methods | 4.73 ± 0.45 | 0.09 |
| 2.1 Teaching method | 4.47 ± 0.52 | 0.12 |
| 2.1.1 Theory teaching | 4.27 ± 0.70 | 0.16 |
| 2.2 Demonstration method | 4.93 ± 0.25 | 0.05 |
| 2.2.1 Simulation teaching | 4.80 ± 0.41 | 0.09 |
| 2.2.2 Bedside demonstration | 4.87 ± 0.35 | 0.07 |
| 2.3 Practice method | 4.93 ± 0.25 | 0.05 |
| 2.3.1 Role simulation training | 4.80 ± 0.41 | 0.09 |
| 2.3.2 Role practice | 4.73 ± 0.46 | 0.10 |
| 2.4 Other teaching methods | 4.47 ± 0.52 | 0.12 |
| 2.4.1 Self-study on network platform | 4.40 ± 0.63 | 0.14 |
| 3 Training assessment | 4.00 ± 0.75 | 0.18 |
| 3.1 Theory of the inspection | 4.13 ± 0.64 | 0.15 |
| 3.1.1 Final theoretical examination | 4.20 ± 0.68 | 0.16 |
| 3.1.2 In-class quiz | 4.07 ± 0.80 | 0.20 |
| 3.2 Skills assessment | 4.87 ± 0.35 | 0.07 |
| 3.2.1 Simulation operation assessment | 4.87 ± 0.35 | 0.07 |
| 3.2.2 Assessment of actual combat | 4.80 ± 0.41 | 0.09 |
| 3.3 Process evaluation | 4.87 ± 0.35 | 0.07 |
| 3.3.1 Clinical practice ability | 4.80 ± 0.41 | 0.09 |
| 3.3.2 Comments from the teacher | 4.53 ± 0.52 | 0.11 |
6 DISCUSSION
Prone MV has developed into an important technique for the treatment of severe respiratory diseases. Previous studies have suggested the need to strengthen knowledge of prone MV among ICU nurses (Li, 2021; Yang et al., 2019); however, there are currently no systematic or comprehensive training courses. This study aimed to establish a prone MV training program for ICU nurses, which can provide a reference for improving the theory and operation level of prone MV for ICU nurses.
This study constructed a prone MV training course for ICU nurses through a literature review, semi-structured interviews with eight experienced staff and two rounds of the Delphi method and obtained three first-level indexes: training content, training method and training evaluation. Basic knowledge, Professional skills, Risk prevention management, Team cooperation, Humanistic care, Evidence-based nursing, Teaching method, Demonstration method, Practice method, Other teaching methods, Theory of the inspection, skills assessment, Process evaluation, 13 second-level indicators and 41 related third-level training indicators can be used to train the MV level of prone position of ICU nurses based on this training program.
The experts selected in the semi-structured interview in this study are all experienced in implementing prone ventilation. The experience and ideas they provided in the interview can fill the gaps in literature knowledge and find the gap between theory and practice, which has also been verified in other studies (Imbert, 2010; Sánchez-Guardiola Paredes et al., 2021). The experts selected in the Delphi method cover clinicians and nurses related to respiratory or critical care, respiratory therapists, nursing managers and experts engaged in critical care education involving a wide range of related professions. The opinions and suggestions of professionals on prone MV training systems are summarised from different perspectives and the representability of the Delphi letter consultation results is protected to the greatest extent. After two rounds of expert correspondence, Cr reached 0.876, CV <0.2 and the importance scores of all indicators were more than 4 points; Xu et al. (2022) and Ye et al. (2022) studies showed that Cr reached 0.7, CV <0.25 and the importance scores of all indicators were more than 4 points, indicating that the experts had a high degree of authority, a reasonable degree of coordination of opinions and a high degree of expert recognition of indicators.
The training content index of this research includes basic knowledge, professional skills, risk prevention management, team cooperation, humanistic care and evidence-based nursing. There are 6 second-level indicators of care and 29 third-level indicators and the competency model guides the establishment of indicators at all levels of training content (Ablah et al., 2014). Wang, Jia, et al. (2016) also showed that professional knowledge, professional skills and professional attitude are the three elements of the competence of nurses, among which knowledge is the foundation, skill is the key and attitude is the guarantee; all three are indispensable. The training content of this research covers these three aspects, which can comprehensively improve the theoretical knowledge, operational level and professional attitude of nurses in prone positions in MV.
Qin et al. (2016) showed that risk prevention and management ability is essential for ICU nurses, and sound risk prevention and management awareness can help ICU nurses ensure the emergence of patients as much as possible from the perspective of predictive nursing. Humanistic care ability is one of the basic nursing abilities that all nurses, including ICU nurses, should have. Ball et al. (2001) studies suggest that the prone MV team should include at least one experienced doctor, one respiratory therapist, one nurse and two other staff members, which shows that prone MV is not cooperation that can be completed by one person and requires close cooperation and a good sense of teamwork among all participants. In addition, Haghgoshayie and Hasanpoor (2021) showed that evidence-based nursing ability can provide the best nursing plan for patients and improve the quality of nursing. Therefore, in terms of training content, this study also increased the training of risk prevention management, teamwork, humanistic care and evidence-based nursing to improve all aspects of MV management of prone positions for ICU nurses as much as possible.
Mitchell and Seckel (2018) suggested that face-to-face or online training courses could be used to train medical staff in combination with operation videos and operation guidelines and simulation exercises could be carried out promptly to improve the operation level of MV in the prone position of medical staff. Therefore, the training method of this study is not limited to a single form; it uses theoretical teaching, operational exercises, role simulation and clinical practice to help intensive care nurses master the knowledge and skills related to prone MV and strengthen clinical practice ability.
Theoretical and operational examination is a standard training and assessment method for clinical nurses. The advantage of this study is that it increases the process assessment, which can directly evaluate the clinical application ability, teamwork spirit and strain thinking of nurses in the prone position ventilation training process. Dalrymple et al. (2007) research shows that process assessment can make up for the shortcomings of traditional assessment methods, reflecting equal emphasis on objective evaluation and process evaluation, which can help educators better understand the learning situation and acceptance of the educated. In this process, real-time teacher feedback can better promote students' learning enthusiasm and help students adjust their learning ideas and master learning points (Tang et al., 2016). Therefore, when setting up the training assessment form, this study synthesised the results of previous studies and expert opinions and formed three secondary indicators and six tertiary indicators to comprehensively investigate the master of MV in the prone position of intensive care nurses.
6.1 Limitations
This study constructed a prone position MV training course for ICU nurses. Although we implemented a scientific approach, some limitations exist. First, we conducted semi-structured interviews among personnel at one hospital. Thus, experiences and practices may be relatively fixed. This limits generalisability across different hospitals, although the experts selected for the Delphi method were from five cities in China and had different working units. While this reduces problems, sample representativeness still requires further consideration. In addition, we have not yet verified the clinical training effects of the course, nor have we thoroughly investigated its degree of acceptance or satisfaction among trained personnel, which will be areas of focus in future research.
7 CONCLUSION
In this study, we constructed a prone MV training system for ICU nurses, ultimately consisting of three first-level indicators, 13 second-level indicators and 41 third-level indicators. The training course covers three aspects, including training contents, training methods and training assessment, thus guiding continued education and training among ICU nurses. It also provides a valuable reference for the clinical transformation of evidence related to prone MV and its expanded use in the clinical setting.
AUTHOR CONTRIBUTIONS
Guarantor of integrity of the entire study: Yan Jiang, Ye Lu, Jingping Cui; study design: Yan Jiang, Jingping Cui; literature research:Yan Jiang, Dongsheng Wang, Jingping Cui; semi-structured interview: Yan Jiang, Jun Ge; data acquisition: Jingping Cui; data analysis: Yan Jiang, Ye Lu, Jun Ge, Linlin Yang, Dongsheng Wang; statistical analysis: Yan Jiang, Dongsheng Wang; manuscript preparation: Yan Jiang, Jingping Cui; manuscript editing: Jingping Cui; manuscript review: Jingping Cui.
ACKNOWLEDGEMENTS
We would like to thank all the staff and experts who interviewed us for their support.
FUNDING INFORMATION
This research was supported by the fund of Anhui Province Key Medical and Health Specialty Construction Project (grant number: WWH [2021] No. 273).
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
This research was approval from the Medical Research Ethics Committee of First Affiliated Hospital of University of Science and Technology of China (Ethics batch number 2022ky209). In all cases, Participants were given descriptions of research purpose and implementation methods before the semi-structured interviews and the Delphi component. All participants voluntarily engaged in this study and signed informed consent forms. They were told they had the right to withdraw at any time. All participants will be identified by number, all profiles of those who refuse to participate will be deleted, and any public reporting of the results of this study will not be personally identifiable.
STUDY STATEMENT
We have completed this study on the construction of a prone mechanical ventilation training system for ICU nurses.
Open Research
DATA AVAILABILITY STATEMENT
Author elects to not share data.
