1226


Aline Wolfensberger et al Table 5. Barriers and Facilitators Identified From the Focus Group Interviews Mapped According to the Behavior Change Wheel Framework


Sources of Behavior


Components Subdivision Capability


Physical Description


Individual’s physical capability to engage in the behavior


Psycho-logical Individual’s


psychological capability (eg, comprehension, reasoning) to engage in the behavior


Motivation Reflective


Evaluations or plans that energize and direct behavior


Barriers: Typical Quotes From the Interviews


Female nurse: “30° is very steep indeed. We often underestimated how steep 30° is.” (inability to estimate angle)


Male physician: “We do oral care with chlorhexidine...” - checks back with the group: “Yes, we do. Is this [an] official [prevention measure]?” (lack of knowledge)


Male nurse: “Sometimes people forget one or the other thing.” (forgetfulness)


Male physician: “This head of bed elevation... the beneficial effect is not really proven, right?” (lack of evidence)


Female nurse: “The patients with noninvasive ventilation, they are often struggling ... they swallow air, then burp and then aspirate.” (perceived inefficacy of prevention measure)


Automatic


Emotions and impulses that that energize and direct behavior


Opportunity Social


Cultural milieu outside the individual that make the behavior possible or prompt it


Female nurse: “... this continuous subglottic drainage ... to hear this noise 24h a day ... that is a nuisance for the patients.” (perceived conflict with patient’s well-being)


Female nurse: “We do turn our patients to the side. Then, head of bed elevation to 30° is really uncomfortable.” (perceived conflict with patient’s well-being)


Female nurse: “Head of bed elevation and mobilization of the patient is really important, and I find it too bad that we don’t get support from our head nurse to do it properly – and get enough time for that.” (hierarchical structures, social influence)


Male nurse: “To decide about contraindications is in the decision power of the physician team [vs the nurse team].” (professional role and responsibilities)


Physical


Environment outside the individual that make the behavior possible or prompt it


Female nurse: “I left patients intubated on the ventilator overnight [even though they were ready to extubate] because I was responsible for 2 patients.” (lack of staffing/time)


Female nurse: “… head of bed elevation of 30° or higher is important. [But] this is often not possible, if the patient has a high amount of catecholamines running.” (side effects of prevention measures)


Male nurse: “I do not understand why we do not have a tracheostomy tube with a subglottic suction system.” (barrier: lack of devices)


Male nurse: “This oral care... when the patients are not deeply sedated, they just swallow the chlorhexidine, and off it goes...!” (feasibility)


Note. ICU, intensive care unit; VAP, ventilator-associated pneumonia.


Male nurse: “You know, they do not save money for technical things ... all our patients now do have this machine for subglottic suctioning.” (infrastructure/ equipment)


Male nurse: “This one surgeon, Dr. S., he is really strict. He wants all his patients to have head of bed elevation of more than 30°, always.” (champions)


Facilitators: Typical Quotes From the Interviews


N.A.


Male nurse: “I think we have to … bring the subject over and over back into our minds to not forget to apply the prevention measures.” (self-discipline, awareness)


Male physician: “VAP is one of the most common nosocomial infections in the ICU.” (perceived importance of VAP)


Female nurse: “I do believe we can prevent VAP—at least 50% of VAP are preventable, or even more!” (perceived preventability of VAP)


Female nurse: “Oral care with chlorhexidine … I do that all the time, automatically.” (habit)


tubes with ports for subglottic suctioning were most often men- tioned. Second, alarm systems as reminders were mentioned several times, predominantly in the context of head of bed ele- vation, which we mapped to the components ‘environmental restructuring’ and ‘HCP enabling.’ Third, introduction of proto- cols and checklist for the bundle in general and for sedation interruption specifically were brought up, which belong to the components ‘restriction’ and ‘HCP enabling,’ respectively. Table 6 outlines observed adherence measures, self-reported adherence rates, and barriers, facilitators, and intervention ideas according the BCW for every VAP bundle component.


Discussion


This mixed-method study measured adherence to 4 VAP pre- vention measures and found poor adherence to head of bed ele- vation and oral care and good adherence to sedation vacation and subglottic suctioning. Corresponding to the BCW ‘sources of behavior,’ facilitators for adherence belonged primarily to the component ‘reflective motivation’: perceived seriousness of VAP and self-efficacy to prevent VAP. Barriers mainly belonged to the BCW component ‘physical capability’: lack of equipment and staffing and side-effects of prevention measures. To improve


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