Nurses' Knowledge, Attitude, and Practice Regarding Ventilator-Associated Pneumonia Among Patients in Intensive Care Units at West Bank Hospitals in Palestine

Nurses' Knowledge, Attitude, and Practice Regarding Ventilator-Associated Pneumonia Among Patients in Intensive Care Units at West Bank Hospitals in Palestine | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nurses' Knowledge, Attitude, and Practice Regarding Ventilator-Associated Pneumonia Among Patients in Intensive Care Units at West Bank Hospitals in Palestine Aktham Thweib, Hamza abufara This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8715626/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Ventilator-associated pneumonia (VAP) is a common, largely preventable healthcare-associated infection among mechanically ventilated patients and remains an important cause of morbidity, mortality and increased health costs. Aim To assess ICU nurses’ knowledge, attitudes, and practices (KAP) regarding evidence-based VAP prevention in West Bank hospitals and to identify predictors of KAP. Methods Cross-sectional electronic survey of 264 registered ICU nurses conducted in May 2024. A structured questionnaire included: identification form (IFN), knowledge questionnaire about evidence-based VAP prevention (QVAP), practice questionnaire (QNP) and attitude items (ABQ). Data were analyzed with SPSS v27 using descriptive statistics, chi-square, t-tests, ANOVA and multivariable regression to identify predictors. Results Mean participant age was 28 years; 59.3% were male. Knowledge levels: poor 16.3%, moderate 48.8%, high 35.0%. Practice levels: high 58.1%, moderate 39.8%, poor 2.0%. Attitude: high 76.0%, moderate 23.2%, poor 0.8%. Years of ICU experience and workplace area were significant positive predictors of knowledge and practice; age, experience, and infection-control training predicted attitude. Conclusion ICU nurses in this sample generally showed positive attitudes and acceptable practice levels but gaps in knowledge persist for a subset. Targeted continuous education, practical training and institutional support are recommended to close the knowledge-practice gap and strengthen VAP prevention. Ventilator-associated pneumonia VAP prevention ICU nurses knowledge attitude practice Palestine Background Ventilator-associated pneumonia (VAP) is a type of hospital-acquired pneumonia that develops 48–72 hours or more after endotracheal intubation and initiation of mechanical ventilation. It remains one of the most common and serious healthcare-associated infections in intensive care units (ICUs) worldwide and represents a substantial burden on critically ill patients and healthcare systems [ 1 , 2 ]. Globally, VAP accounts for a large proportion of ICU-acquired infections, with reported incidence rates varying widely depending on patient population, diagnostic criteria, and infection-control practices. Patients who develop VAP experience prolonged mechanical ventilation, extended ICU and hospital length of stay, increased antimicrobial exposure, higher healthcare costs, and significantly increased morbidity and mortality compared with non-infected ventilated patients [ 3 – 5 ]. Attributable mortality has been estimated to range from 10% to 40%, particularly among high-risk and immunocompromised populations [ 4 ]. Although the pathogenesis of VAP is multifactorial, microaspiration of contaminated oropharyngeal secretions, impaired host defenses, biofilm formation on endotracheal tubes, and frequent airway manipulation contribute to infection development [ 6 ]. Importantly, many of these risk factors are preventable through evidence-based interventions. International guidelines recommend the implementation of VAP prevention bundles, including strict hand hygiene, elevation of the head of the bed, daily sedation interruption and assessment of readiness to extubate, oral hygiene with antiseptics, subglottic secretion drainage, appropriate cuff pressure maintenance, and minimizing ventilator circuit changes [ 7 , 8 ]. Consistent adherence to these measures has been associated with significant reductions in VAP incidence. Nurses play a central role in VAP prevention because they provide continuous bedside care and are directly responsible for implementing most bundle components. Therefore, their knowledge, attitudes, and practices (KAP) strongly influence the effectiveness of infection-control strategies [ 9 ]. Previous studies have shown that insufficient knowledge, inconsistent training, workload, and lack of institutional support may negatively affect adherence to preventive measures [ 10 ]. Assessing nurses’ KAP is thus essential to identify gaps and design targeted educational and organizational interventions. In Palestine and similar resource-limited settings, limited data exist regarding ICU nurses’ preparedness and compliance with VAP prevention guidelines. Understanding current knowledge levels and practice patterns is critical for improving patient safety and reducing preventable ICU infections. Therefore, this study aims to assess ICU nurses’ knowledge, attitudes, and practices regarding VAP prevention in West Bank hospitals and to identify factors associated with optimal preventive behaviors. Aim of the Study The aim of this study was to assess intensive care unit (ICU) nurses’ knowledge, attitudes, and practices (KAP) regarding evidence-based ventilator-associated pneumonia (VAP) prevention measures in West Bank hospitals, Palestine. Specifically, the study sought to (1) determine the level of nurses’ knowledge of VAP prevention guidelines, (2) evaluate their self-reported adherence to recommended preventive practices, (3) examine their attitudes toward VAP prevention and infection-control responsibilities, and (4) identify demographic and professional factors associated with optimal knowledge, attitudes, and practices. Significance of the Study Ventilator-associated pneumonia remains a major preventable cause of morbidity, mortality, prolonged hospitalization, and increased healthcare costs among critically ill patients receiving mechanical ventilation. Nurses play a pivotal role in implementing most VAP prevention bundle components, making their competence and adherence essential for patient safety. Despite this critical role, limited evidence is available regarding ICU nurses’ preparedness and compliance with VAP prevention strategies in Palestine and similar resource-limited settings. This study provides baseline evidence on current knowledge gaps, behavioral practices, and attitudinal barriers that may influence adherence to infection-control measures. The findings can inform the development of targeted educational programs, institutional policies, and quality-improvement initiatives aimed at strengthening evidence-based nursing practice and reducing VAP incidence. Additionally, the results may support hospital administrators and policymakers in optimizing workforce training and patient safety strategies at both local and national levels. Methods Design This study employed a cross-sectional, descriptive design to assess intensive care unit (ICU) nurses’ knowledge, attitudes and self-reported practices (KAP) regarding evidence-based ventilator-associated pneumonia (VAP) prevention. Data were collected at a single time point using a structured, self-administered electronic questionnaire. Study settings The study was conducted across multiple governmental and private hospitals in the West Bank, Palestine, covering a range of intensive care settings (adult ICUs, pediatric ICUs and other specialized critical care units). Hospitals from different governorates were included to maximise geographic representation and variability in ICU practice environments. Data collection took place in May 2024. Sample and sampling procedure Eligible participants were registered nurses who: (1) were currently employed in an ICU, (2) had direct responsibility for mechanically ventilated patients, and (3) had at least six months of ICU experience. Nurses in purely administrative positions or those without sufficient ICU exposure were excluded. A convenience sampling approach was used: the questionnaire link was distributed via official hospital communication channels and professional nursing groups. Based on the estimated total ICU nursing workforce and a 95% confidence level with a 5% margin of error, the minimum sample size was calculated a priori; the final analytic sample comprised 264 completed questionnaires. Incomplete responses were excluded from analysis. Instrument development, validity, and reliability The questionnaire was developed from current evidence-based VAP prevention guidelines and the published literature, and it comprised four sections: (1) sociodemographic and professional information, (2) knowledge items (scored correct/incorrect), (3) self-reported practices (5-point Likert scale), and (4) attitudes (5-point Likert scale). Content validity was established through review by a panel of critical-care and infection-control experts; a pilot test was conducted to assess clarity and feasibility. Internal consistency reliability in pilot/field testing produced acceptable Cronbach’s alpha coefficients for the domains (Knowledge α ≈ 0.83; Attitude α ≈ 0.87; Practice α ≈ 0.81). Scoring thresholds for categorising poor/moderate/high levels were predefined based on item counts and percentage cutoffs. Data collection procedure The final questionnaire was distributed electronically. Participation was voluntary and anonymous; an explanatory cover page described the study purpose, confidentiality assurances and that submission implied informed consent. Reminders were sent through the same professional channels to improve response rate. Ethical approval and institutional permissions were obtained from the relevant institutional review board and participating facilities prior to data collection. Statistical analysis Data were exported and analysed using IBM SPSS Statistics for Windows, version 27.0. Descriptive statistics summarized participant characteristics and KAP domain scores (means ± SD for continuous variables; frequencies and percentages for categorical variables). Knowledge items were reported as percent correct per item and by overall category (poor/moderate/high). Group comparisons were performed using independent-samples t-tests (two groups) or one-way ANOVA (three or more groups) for continuous outcomes; when ANOVA was significant, post-hoc pairwise comparisons were conducted (e.g., Tukey). Associations between categorical variables were assessed with chi-square tests. To identify independent predictors of KAP domain scores, multiple linear regression models were constructed, entering candidate covariates (e.g., age, gender, education level, years of ICU experience, type of ICU, prior infection-control training). Model diagnostics included evaluation of residual normality, homoscedasticity, and multicollinearity (variance inflation factor). Regression coefficients (β), 95% confidence intervals and p-values are reported; statistical significance was set at p < 0.05. If applicable, non-parametric alternatives (e.g., Mann–Whitney U, Kruskal–Wallis tests) were used for variables that violated normality assumptions. Missing data were handled by listwise deletion for analyses that required complete data. Ethical Consideration All required ethical approvals were met. IRB approval was taken for this study from the ethical committee at the Palestine Ahliya University. Further permissions to access included settings were taken from each corresponding hospital in the study. Consent of participants to participate was approved by them prior to start. All data collection reserved anonymity. Samples can terminate their involvement in the study at any time. Results General Characteristics of Participants A total of 264 ICU nurses completed the survey. The mean age of participants was approximately 28 years (range 20–43 years). Most respondents were male (59.3%), and the majority held a bachelor’s degree in nursing (96.7%). Regarding professional experience, most nurses had between one and five years of ICU experience. Participants were recruited from multiple governmental and private hospitals across the West Bank, representing different ICU settings including adult, pediatric, and specialized critical care units. Knowledge regarding VAP prevention Overall, nurses demonstrated moderate to high knowledge of evidence-based VAP prevention measures. Based on the predefined scoring criteria, 35.0% of participants had high knowledge levels, 48.8% had moderate knowledge, and 16.3% had poor knowledge. Higher correct response rates were observed for items related to hand hygiene and head-of-bed elevation, whereas lower scores were found for questions concerning ventilator circuit replacement frequency and specific technical preventive measures. Preventive practices Self-reported adherence to VAP preventive practices was generally satisfactory. More than half of the nurses (58.1%) demonstrated high practice levels, while 39.8% reported moderate adherence and only 2.0% reported poor practices. Frequently reported practices included regular hand hygiene, maintaining head-of-bed elevation at 30–45°, using sterile suction techniques, and performing routine oral care. Variability was noted in advanced preventive measures such as subglottic secretion drainage and standardized ventilator circuit management. Attitudes toward VAP prevention Participants showed predominantly positive attitudes toward VAP prevention and infection-control responsibilities. Most nurses agreed that VAP is preventable and that adherence to guidelines improves patient outcomes. Overall, 76.0% demonstrated high attitude scores, 23.2% moderate scores, and 0.8% poor scores. The majority supported ongoing education and institutional monitoring to enhance compliance. Factors associated with knowledge, practice, and attitudes Inferential analyses revealed statistically significant associations between professional experience and higher knowledge and practice scores (p < 0.05). Nurses working in specialized critical care areas also demonstrated better performance compared with those in general ICUs. Regression analysis indicated that years of ICU experience and workplace area were significant predictors of knowledge and practice, while age, ICU experience, and previous infection-control training predicted more positive attitudes. Table 1 Sociodemographic and professional characteristics of participants (n = 264) Variable Category n (%) Gender Male 156 (59.3) Female 108 (40.7) Education level Bachelor’s degree 255 (96.7) Postgraduate 9 (3.3) ICU experience 1–5 years Majority > 5 years Remaining Work setting Governmental/Private ICUs Multiple hospitals Table 2 Levels of knowledge, practice, and attitude regarding VAP prevention Domain Poor n (%) Moderate n (%) High n (%) Knowledge 43 (16.3) 129 (48.8) 92 (35.0) Practice 5 (2.0) 105 (39.8) 154 (58.1) Attitude 2 (0.8) 61 (23.2) 201 (76.0) Table 3 Predictors of knowledge, practice, and attitude scores (multiple regression) Outcome Predictor β p-value Knowledge ICU experience + < 0.05* Knowledge Workplace area + < 0.05* Practice ICU experience + < 0.05* Practice Workplace area + < 0.05* Attitude Age + < 0.05* Attitude Infection-control training + < 0.05* * Statistically significant Discussion In this cross-sectional survey of 264 ICU nurses across West Bank hospitals, most participants demonstrated positive attitudes toward VAP prevention (76.0% high attitude) and satisfactory self-reported adherence to core preventive practices (58.1% high practice). However, knowledge levels were more heterogeneous: 35.0% of nurses achieved high knowledge scores while 16.3% fell into the poor knowledge category. Multivariable analysis identified years of ICU experience and workplace area as significant predictors of both knowledge and practice, whereas age, ICU experience and prior infection-control training predicted more favourable attitudes. Interpretation and comparison with existing evidence The combination of generally favourable attitudes and relatively high self-reported practice is encouraging and suggests that nurses recognise the importance of VAP prevention and often attempt to apply recommended measures at the bedside. Nevertheless, the observed gap between attitudes/practices and knowledge for a substantial minority indicates that positive intent does not always translate into full evidence-based understanding. This pattern — good reported compliance alongside identifiable knowledge gaps — has been described in other settings where routine practices are supported by local custom or supervision but technical or guideline-specific items (e.g., details of circuit management or subglottic suctioning) are less consistently understood or implemented. The finding that greater ICU experience and working in certain specialised units predict better KAP scores supports the notion that repeated exposure, unit protocols, and peer learning enhance both competence and adherence. Prior infection-control training likewise strengthened attitudes, underscoring the value of structured education. These associations highlight modifiable targets (training, unit-level protocols, mentorship) that can improve uptake of best practices. Practical implications for practice and policy First, targeted, competency-based education should be prioritised to address the specific knowledge deficits identified (for example, technical items related to ventilator circuit management and advanced preventive measures). Educational strategies that combine didactic teaching with hands-on simulation and bedside coaching are more likely to change behaviour than lecture alone. Second, standardising unit-level VAP bundles and embedding clear checklists or cognitive aids into clinical workflows can reduce variability and make correct practice the default. Third, routine monitoring (audits) with timely feedback and supportive supervision will help sustain adherence and identify persistent gaps. Finally, infection-control training should be mandatory and regularly updated, with particular attention to newer or less experienced staff. Strengths and limitations Strengths of the study include its relatively large sample size and coverage of multiple hospitals and ICU types across the West Bank, which increase the external relevance of the findings within the local health system. The instrument was content-validated and demonstrated acceptable internal consistency. However, several limitations warrant caution. The cross-sectional design prevents causal inference between predictors and outcomes. The use of convenience sampling and electronic self-report measures may introduce selection bias and social desirability bias, potentially inflating reported adherence. Some practice items (e.g., frequency of circuit changes) are difficult to verify without observational audit, limiting the ability to confirm self-reported behaviour. Finally, although the questionnaire was piloted, residual measurement error (e.g., misinterpretation of technical questions) cannot be excluded. These limitations should be considered when interpreting the prevalence estimates and associations. Recommendations for future research Future studies should complement self-reported data with direct observational audits and objective outcome measures (e.g., unit VAP rates) to assess the impact of KAP on patient-level outcomes. Interventional studies — such as cluster-randomised trials of multifaceted educational programmes, simulation-based training, or bundle implementation with audit-and-feedback — would provide stronger evidence on effective strategies to close the knowledge–practice gap. Qualitative work exploring barriers and facilitators at the unit and organisational level would further inform tailored implementation strategies. Conclusion ICU nurses in the West Bank demonstrate predominantly positive attitudes and acceptable self-reported adherence to core VAP prevention practices, yet knowledge gaps persist for a meaningful minority. Strengthening targeted, practical education, standardising bundle implementation, and instituting routine monitoring and feedback are practical steps likely to improve evidence-based practice and reduce VAP risk. Concerted efforts that combine education, systems redesign, and evaluation are recommended to translate positive attitudes into uniformly high-quality care. Declarations Author Contribution AT conceived and designed the study, developed the methodology, coordinated data collection, performed the statistical analysis, interpreted the results, and drafted the original manuscript. HM contributed to study design, assisted with data collection and data interpretation, supervised the research process, and critically revised the manuscript for important intellectual content. Both authors read and approved the final version of the manuscript. References Abad CL, Formalejo CP, Mantaring DML. 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PLoS ONE. 2021;16(3):e0247832. 10.1371/journal.pone.0247832 . Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(6):687–713. 10.1017/ice.2022.88 . Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(8):915–36. 10.1086/677144 . Koeman M, van der Ven AJAM, Hak E, Joore HCA, Kaasjager K, de Smet AGA, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;173(12):1348–55. 10.1164/rccm.200505-820OC . Kohbodi GA, Rajasurya V, Noor A, Ventilator-Associated P. 2024. (Entry in thesis — full citation details as listed in original file). Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol. 2012;33(3):250–6. 10.1086/664049 . Koulenti D, Tsigou E, Rello J. Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study. Eur J Clin Microbiol Infect Dis. 2017;36(11):1999–2006. 10.1007/s10096-016-2703-z . Labeau S, Vandijck DM, Claes B, Van Aken P, Blot SI, Executive Board of the Flemish Society for Critical Care Nurses. Critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: an evaluation questionnaire. Am J Crit Care. 2007;16(4):371–7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8715626","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581482161,"identity":"c74a8e89-0183-4912-bb76-465af7545d02","order_by":0,"name":"Aktham Thweib","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Aktham","middleName":"","lastName":"Thweib","suffix":""},{"id":581482167,"identity":"96029ec1-f7a8-4885-933c-a9993ed5c2d5","order_by":1,"name":"Hamza abufara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYBACAyjJDyQZH4M5zMwNRGgpYJAEKmM2BvOZGYnR8gGshU0awiegxZz9dPKHHwYMEubtzceqCyr+RPO3A7X8qNiGU4tlT+4Gwx6gFpkzx9JuzzhjkDvjMGMDY8+Z27gddiB3QwKPAUOdhESO2W3eNoPcBqAWZsY2PFrOv91w8A/QFgn599+KQVrmE9RyI3djMw9IiwQPGzNIywbCWt5uZpYBaeFJM5bmOWOcuxGo5SBev5zP3fzxzR+gFvbDDz/zVMjlzjt/+OCDHxW4tUDBf1TuAULqR8EoGAWjYBTgBwDcE1Whtd4U7QAAAABJRU5ErkJggg==","orcid":"","institution":"Modern University College","correspondingAuthor":true,"prefix":"","firstName":"Hamza","middleName":"","lastName":"abufara","suffix":""}],"badges":[],"createdAt":"2026-01-28 03:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8715626/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8715626/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101398342,"identity":"02b94275-dca2-404d-9560-48bb89d835fe","added_by":"auto","created_at":"2026-01-29 09:41:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":793707,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8715626/v1/0894059e-79d3-46aa-a41b-159ccc96383f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nurses' Knowledge, Attitude, and Practice Regarding Ventilator-Associated Pneumonia Among Patients in Intensive Care Units at West Bank Hospitals in Palestine","fulltext":[{"header":"Background","content":"\u003cp\u003eVentilator-associated pneumonia (VAP) is a type of hospital-acquired pneumonia that develops 48\u0026ndash;72 hours or more after endotracheal intubation and initiation of mechanical ventilation. It remains one of the most common and serious healthcare-associated infections in intensive care units (ICUs) worldwide and represents a substantial burden on critically ill patients and healthcare systems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, VAP accounts for a large proportion of ICU-acquired infections, with reported incidence rates varying widely depending on patient population, diagnostic criteria, and infection-control practices. Patients who develop VAP experience prolonged mechanical ventilation, extended ICU and hospital length of stay, increased antimicrobial exposure, higher healthcare costs, and significantly increased morbidity and mortality compared with non-infected ventilated patients [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Attributable mortality has been estimated to range from 10% to 40%, particularly among high-risk and immunocompromised populations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the pathogenesis of VAP is multifactorial, microaspiration of contaminated oropharyngeal secretions, impaired host defenses, biofilm formation on endotracheal tubes, and frequent airway manipulation contribute to infection development [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Importantly, many of these risk factors are preventable through evidence-based interventions. International guidelines recommend the implementation of VAP prevention bundles, including strict hand hygiene, elevation of the head of the bed, daily sedation interruption and assessment of readiness to extubate, oral hygiene with antiseptics, subglottic secretion drainage, appropriate cuff pressure maintenance, and minimizing ventilator circuit changes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Consistent adherence to these measures has been associated with significant reductions in VAP incidence.\u003c/p\u003e \u003cp\u003eNurses play a central role in VAP prevention because they provide continuous bedside care and are directly responsible for implementing most bundle components. Therefore, their knowledge, attitudes, and practices (KAP) strongly influence the effectiveness of infection-control strategies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Previous studies have shown that insufficient knowledge, inconsistent training, workload, and lack of institutional support may negatively affect adherence to preventive measures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Assessing nurses\u0026rsquo; KAP is thus essential to identify gaps and design targeted educational and organizational interventions.\u003c/p\u003e \u003cp\u003e In Palestine and similar resource-limited settings, limited data exist regarding ICU nurses\u0026rsquo; preparedness and compliance with VAP prevention guidelines. Understanding current knowledge levels and practice patterns is critical for improving patient safety and reducing preventable ICU infections. Therefore, this study aims to assess ICU nurses\u0026rsquo; knowledge, attitudes, and practices regarding VAP prevention in West Bank hospitals and to identify factors associated with optimal preventive behaviors.\u003c/p\u003e\n\u003ch3\u003eAim of the Study\u003c/h3\u003e\n\u003cp\u003eThe aim of this study was to assess intensive care unit (ICU) nurses\u0026rsquo; knowledge, attitudes, and practices (KAP) regarding evidence-based ventilator-associated pneumonia (VAP) prevention measures in West Bank hospitals, Palestine. Specifically, the study sought to (1) determine the level of nurses\u0026rsquo; knowledge of VAP prevention guidelines, (2) evaluate their self-reported adherence to recommended preventive practices, (3) examine their attitudes toward VAP prevention and infection-control responsibilities, and (4) identify demographic and professional factors associated with optimal knowledge, attitudes, and practices.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSignificance of the Study\u003c/h2\u003e \u003cp\u003eVentilator-associated pneumonia remains a major preventable cause of morbidity, mortality, prolonged hospitalization, and increased healthcare costs among critically ill patients receiving mechanical ventilation. Nurses play a pivotal role in implementing most VAP prevention bundle components, making their competence and adherence essential for patient safety. Despite this critical role, limited evidence is available regarding ICU nurses\u0026rsquo; preparedness and compliance with VAP prevention strategies in Palestine and similar resource-limited settings.\u003c/p\u003e \u003cp\u003eThis study provides baseline evidence on current knowledge gaps, behavioral practices, and attitudinal barriers that may influence adherence to infection-control measures. The findings can inform the development of targeted educational programs, institutional policies, and quality-improvement initiatives aimed at strengthening evidence-based nursing practice and reducing VAP incidence. Additionally, the results may support hospital administrators and policymakers in optimizing workforce training and patient safety strategies at both local and national levels.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis study employed a cross-sectional, descriptive design to assess intensive care unit (ICU) nurses\u0026rsquo; knowledge, attitudes and self-reported practices (KAP) regarding evidence-based ventilator-associated pneumonia (VAP) prevention. Data were collected at a single time point using a structured, self-administered electronic questionnaire.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy settings\u003c/h3\u003e\n\u003cp\u003eThe study was conducted across multiple governmental and private hospitals in the West Bank, Palestine, covering a range of intensive care settings (adult ICUs, pediatric ICUs and other specialized critical care units). Hospitals from different governorates were included to maximise geographic representation and variability in ICU practice environments. Data collection took place in May 2024.\u003c/p\u003e\n\u003ch3\u003eSample and sampling procedure\u003c/h3\u003e\n\u003cp\u003eEligible participants were registered nurses who: (1) were currently employed in an ICU, (2) had direct responsibility for mechanically ventilated patients, and (3) had at least six months of ICU experience. Nurses in purely administrative positions or those without sufficient ICU exposure were excluded. A convenience sampling approach was used: the questionnaire link was distributed via official hospital communication channels and professional nursing groups. Based on the estimated total ICU nursing workforce and a 95% confidence level with a 5% margin of error, the minimum sample size was calculated a priori; the final analytic sample comprised 264 completed questionnaires. Incomplete responses were excluded from analysis.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInstrument development, validity, and reliability\u003c/h2\u003e \u003cp\u003e The questionnaire was developed from current evidence-based VAP prevention guidelines and the published literature, and it comprised four sections: (1) sociodemographic and professional information, (2) knowledge items (scored correct/incorrect), (3) self-reported practices (5-point Likert scale), and (4) attitudes (5-point Likert scale). Content validity was established through review by a panel of critical-care and infection-control experts; a pilot test was conducted to assess clarity and feasibility. Internal consistency reliability in pilot/field testing produced acceptable Cronbach\u0026rsquo;s alpha coefficients for the domains (Knowledge α\u0026thinsp;\u0026asymp;\u0026thinsp;0.83; Attitude α\u0026thinsp;\u0026asymp;\u0026thinsp;0.87; Practice α\u0026thinsp;\u0026asymp;\u0026thinsp;0.81). Scoring thresholds for categorising poor/moderate/high levels were predefined based on item counts and percentage cutoffs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection procedure\u003c/h3\u003e\n\u003cp\u003eThe final questionnaire was distributed electronically. Participation was voluntary and anonymous; an explanatory cover page described the study purpose, confidentiality assurances and that submission implied informed consent. Reminders were sent through the same professional channels to improve response rate. Ethical approval and institutional permissions were obtained from the relevant institutional review board and participating facilities prior to data collection.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were exported and analysed using IBM SPSS Statistics for Windows, version 27.0. Descriptive statistics summarized participant characteristics and KAP domain scores (means\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for continuous variables; frequencies and percentages for categorical variables). Knowledge items were reported as percent correct per item and by overall category (poor/moderate/high). Group comparisons were performed using independent-samples t-tests (two groups) or one-way ANOVA (three or more groups) for continuous outcomes; when ANOVA was significant, post-hoc pairwise comparisons were conducted (e.g., Tukey). Associations between categorical variables were assessed with chi-square tests.\u003c/p\u003e \u003cp\u003eTo identify independent predictors of KAP domain scores, multiple linear regression models were constructed, entering candidate covariates (e.g., age, gender, education level, years of ICU experience, type of ICU, prior infection-control training). Model diagnostics included evaluation of residual normality, homoscedasticity, and multicollinearity (variance inflation factor). Regression coefficients (β), 95% confidence intervals and p-values are reported; statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. If applicable, non-parametric alternatives (e.g., Mann\u0026ndash;Whitney U, Kruskal\u0026ndash;Wallis tests) were used for variables that violated normality assumptions. Missing data were handled by listwise deletion for analyses that required complete data.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Consideration\u003c/strong\u003e \u003cp\u003e All required ethical approvals were met. IRB approval was taken for this study from the ethical committee at the Palestine Ahliya University. Further permissions to access included settings were taken from each corresponding hospital in the study. Consent of participants to participate was approved by them prior to start. All data collection reserved anonymity. Samples can terminate their involvement in the study at any time.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Characteristics of Participants\u003c/h2\u003e \u003cp\u003eA total of 264 ICU nurses completed the survey. The mean age of participants was approximately 28 years (range 20\u0026ndash;43 years). Most respondents were male (59.3%), and the majority held a bachelor\u0026rsquo;s degree in nursing (96.7%). Regarding professional experience, most nurses had between one and five years of ICU experience. Participants were recruited from multiple governmental and private hospitals across the West Bank, representing different ICU settings including adult, pediatric, and specialized critical care units.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge regarding VAP prevention\u003c/h2\u003e \u003cp\u003eOverall, nurses demonstrated moderate to high knowledge of evidence-based VAP prevention measures. Based on the predefined scoring criteria, 35.0% of participants had high knowledge levels, 48.8% had moderate knowledge, and 16.3% had poor knowledge. Higher correct response rates were observed for items related to hand hygiene and head-of-bed elevation, whereas lower scores were found for questions concerning ventilator circuit replacement frequency and specific technical preventive measures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePreventive practices\u003c/h2\u003e \u003cp\u003eSelf-reported adherence to VAP preventive practices was generally satisfactory. More than half of the nurses (58.1%) demonstrated high practice levels, while 39.8% reported moderate adherence and only 2.0% reported poor practices. Frequently reported practices included regular hand hygiene, maintaining head-of-bed elevation at 30\u0026ndash;45\u0026deg;, using sterile suction techniques, and performing routine oral care. Variability was noted in advanced preventive measures such as subglottic secretion drainage and standardized ventilator circuit management.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAttitudes toward VAP prevention\u003c/h2\u003e \u003cp\u003eParticipants showed predominantly positive attitudes toward VAP prevention and infection-control responsibilities. Most nurses agreed that VAP is preventable and that adherence to guidelines improves patient outcomes. Overall, 76.0% demonstrated high attitude scores, 23.2% moderate scores, and 0.8% poor scores. The majority supported ongoing education and institutional monitoring to enhance compliance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with knowledge, practice, and attitudes\u003c/h2\u003e \u003cp\u003eInferential analyses revealed statistically significant associations between professional experience and higher knowledge and practice scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Nurses working in specialized critical care areas also demonstrated better performance compared with those in general ICUs. Regression analysis indicated that years of ICU experience and workplace area were significant predictors of knowledge and practice, while age, ICU experience, and previous infection-control training predicted more positive attitudes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and professional characteristics of participants (n\u0026thinsp;=\u0026thinsp;264)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156 (59.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 (40.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e255 (96.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMajority\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRemaining\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernmental/Private ICUs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultiple hospitals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLevels of knowledge, practice, and attitude regarding VAP prevention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (16.3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129 (48.8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92 (35.0)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (39.8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e154 (58.1)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAttitude\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2 (0.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e61 (23.2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e201 (76.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictors of knowledge, practice, and attitude scores (multiple regression)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkplace area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePractice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eICU experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e+\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePractice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWorkplace area\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e+\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAttitude\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e+\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAttitude\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInfection-control training\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e+\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Statistically significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this cross-sectional survey of 264 ICU nurses across West Bank hospitals, most participants demonstrated positive attitudes toward VAP prevention (76.0% high attitude) and satisfactory self-reported adherence to core preventive practices (58.1% high practice). However, knowledge levels were more heterogeneous: 35.0% of nurses achieved high knowledge scores while 16.3% fell into the poor knowledge category. Multivariable analysis identified years of ICU experience and workplace area as significant predictors of both knowledge and practice, whereas age, ICU experience and prior infection-control training predicted more favourable attitudes.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation and comparison with existing evidence\u003c/h2\u003e \u003cp\u003eThe combination of generally favourable attitudes and relatively high self-reported practice is encouraging and suggests that nurses recognise the importance of VAP prevention and often attempt to apply recommended measures at the bedside. Nevertheless, the observed gap between attitudes/practices and knowledge for a substantial minority indicates that positive intent does not always translate into full evidence-based understanding. This pattern \u0026mdash; good reported compliance alongside identifiable knowledge gaps \u0026mdash; has been described in other settings where routine practices are supported by local custom or supervision but technical or guideline-specific items (e.g., details of circuit management or subglottic suctioning) are less consistently understood or implemented.\u003c/p\u003e \u003cp\u003eThe finding that greater ICU experience and working in certain specialised units predict better KAP scores supports the notion that repeated exposure, unit protocols, and peer learning enhance both competence and adherence. Prior infection-control training likewise strengthened attitudes, underscoring the value of structured education. These associations highlight modifiable targets (training, unit-level protocols, mentorship) that can improve uptake of best practices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePractical implications for practice and policy\u003c/h2\u003e \u003cp\u003eFirst, targeted, competency-based education should be prioritised to address the specific knowledge deficits identified (for example, technical items related to ventilator circuit management and advanced preventive measures). Educational strategies that combine didactic teaching with hands-on simulation and bedside coaching are more likely to change behaviour than lecture alone. Second, standardising unit-level VAP bundles and embedding clear checklists or cognitive aids into clinical workflows can reduce variability and make correct practice the default. Third, routine monitoring (audits) with timely feedback and supportive supervision will help sustain adherence and identify persistent gaps. Finally, infection-control training should be mandatory and regularly updated, with particular attention to newer or less experienced staff.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003e Strengths of the study include its relatively large sample size and coverage of multiple hospitals and ICU types across the West Bank, which increase the external relevance of the findings within the local health system. The instrument was content-validated and demonstrated acceptable internal consistency.\u003c/p\u003e \u003cp\u003eHowever, several limitations warrant caution. The cross-sectional design prevents causal inference between predictors and outcomes. The use of convenience sampling and electronic self-report measures may introduce selection bias and social desirability bias, potentially inflating reported adherence. Some practice items (e.g., frequency of circuit changes) are difficult to verify without observational audit, limiting the ability to confirm self-reported behaviour. Finally, although the questionnaire was piloted, residual measurement error (e.g., misinterpretation of technical questions) cannot be excluded. These limitations should be considered when interpreting the prevalence estimates and associations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for future research\u003c/h2\u003e \u003cp\u003eFuture studies should complement self-reported data with direct observational audits and objective outcome measures (e.g., unit VAP rates) to assess the impact of KAP on patient-level outcomes. Interventional studies \u0026mdash; such as cluster-randomised trials of multifaceted educational programmes, simulation-based training, or bundle implementation with audit-and-feedback \u0026mdash; would provide stronger evidence on effective strategies to close the knowledge\u0026ndash;practice gap. Qualitative work exploring barriers and facilitators at the unit and organisational level would further inform tailored implementation strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eICU nurses in the West Bank demonstrate predominantly positive attitudes and acceptable self-reported adherence to core VAP prevention practices, yet knowledge gaps persist for a meaningful minority. Strengthening targeted, practical education, standardising bundle implementation, and instituting routine monitoring and feedback are practical steps likely to improve evidence-based practice and reduce VAP risk. Concerted efforts that combine education, systems redesign, and evaluation are recommended to translate positive attitudes into uniformly high-quality care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAT conceived and designed the study, developed the methodology, coordinated data collection, performed the statistical analysis, interpreted the results, and drafted the original manuscript. HM contributed to study design, assisted with data collection and data interpretation, supervised the research process, and critically revised the manuscript for important intellectual content. Both authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbad CL, Formalejo CP, Mantaring DML. 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Am J Crit Care. 2007;16(4):371\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ventilator-associated pneumonia, VAP prevention, ICU nurses, knowledge, attitude, practice, Palestine","lastPublishedDoi":"10.21203/rs.3.rs-8715626/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8715626/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVentilator-associated pneumonia (VAP) is a common, largely preventable healthcare-associated infection among mechanically ventilated patients and remains an important cause of morbidity, mortality and increased health costs.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo assess ICU nurses\u0026rsquo; knowledge, attitudes, and practices (KAP) regarding evidence-based VAP prevention in West Bank hospitals and to identify predictors of KAP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCross-sectional electronic survey of 264 registered ICU nurses conducted in May 2024. A structured questionnaire included: identification form (IFN), knowledge questionnaire about evidence-based VAP prevention (QVAP), practice questionnaire (QNP) and attitude items (ABQ). Data were analyzed with SPSS v27 using descriptive statistics, chi-square, t-tests, ANOVA and multivariable regression to identify predictors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMean participant age was 28 years; 59.3% were male. Knowledge levels: poor 16.3%, moderate 48.8%, high 35.0%. Practice levels: high 58.1%, moderate 39.8%, poor 2.0%. Attitude: high 76.0%, moderate 23.2%, poor 0.8%. Years of ICU experience and workplace area were significant positive predictors of knowledge and practice; age, experience, and infection-control training predicted attitude.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eICU nurses in this sample generally showed positive attitudes and acceptable practice levels but gaps in knowledge persist for a subset. Targeted continuous education, practical training and institutional support are recommended to close the knowledge-practice gap and strengthen VAP prevention.\u003c/p\u003e","manuscriptTitle":"Nurses' Knowledge, Attitude, and Practice Regarding Ventilator-Associated Pneumonia Among Patients in Intensive Care Units at West Bank Hospitals in Palestine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 09:00:45","doi":"10.21203/rs.3.rs-8715626/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-09T20:37:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-07T03:10:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-07T03:09:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-01-28T02:51:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"88a8ef09-9d3c-4a54-b89e-72b46254b7fb","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:38:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 09:00:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8715626","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8715626","identity":"rs-8715626","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}