Effectiveness of In-Service Training Module on Intensive Care Nurses’ Performance Regarding Mechanical Ventilator Patients' Skillful Handling

Background: Mechanical ventilation is life-saving handling to the maintenance of patients throughout oxygenation and ventilation. Critical care nurses have the most crucial role among health care workers in the skillful handling of mechanically ventilated patients. So, nurses must have the awareness, skills, and capabilities to handle a patient receiving mechanical ventilation adequately. Aim : to assess the effectiveness of the in-service training module on intensive care nurses’ performance regarding mechanical ventilator patients' skillful handling. Design : A quasi-experimental design was used. Setting : The study was conducted at intensive care units affiliated with 3 Public Hospitals related to the Ministry of Health. Subjects: A purposive sample of 60 nurses who worked in the previously mentioned setting. Data collection tools: Nurses' structured self-administered questionnaire and nurses' practical skill competency checklist. Results: The study shows that (85% & 80%) of the studied nurses gained a higher retained level of knowledge and practice in the follow-up phase compared with (31.7% & 35%) in the pre-test phase. Conclusion: The majority of studied nurses get promoting the achievement of nurses' knowledge level and enhancement of nurses' practice level with a highly statistically significant positive correlation between cumulative total knowledge and practice regarding care of mechanically ventilated patients during pre, post & three months follow-up phases at (r= 0.987 and P= 0.000). Recommendations: Develop ongoing in-service training courses on mechanically ventilated patient care which should be mandatory for newly employed nurses. Emerging a regular rating determines nurses’ training requirements for updating nurses’ knowledge and practice.

Furthermore, nurses' education can lead to the advancement of nursing care if it is performed and intended based on nurses' requirements and appropriate fundamental principles (Hassen et al., 2023).
There are numerous circumstances where MV is essential. These may involve oxygenating the blood and relaxing the respiratory muscles when the patient is undergoing surgery or receiving therapy for a severe traumatic brain injury. Along with the effects of numerous illnesses or injury processes, such as drug overdose, COPD, asthma, pneumonia, neuromuscular diseases, shock or trauma, and multiple organ failure (Al-Gunaid, 2020; Attia, 2022).
Commonly, nurses are the first to handle critically ill patients and are familiar with the recognition and understanding of how to address issues and apply MV settings that frequently change and affect patient physiological status and management in response to disease circumstances (Hickey & Giwa, 2022 (Brackett et al., 2022).
In reality, best practices for performing various tasks and duties are developed through inservice training as well as to bring up-to-date the nurses' staff job-related knowledge and proficient abilities. Applicability is one of the key characteristics of in-service training modules.
Another crucial aspect of the nursing staff's inservice training is nurses' active engagement, which promotes efficient learning and professional

growth (Ahamed & Mesbah, 2019).
Additionally, the development of nurses' performance and skilled handling of mechanical ventilator patient care came naturally as a result of computer-aided presentation with virtual reality.
The importance of inpatient standard-ofcare education is demonstrated in a nursing inservice training program. A crucial requirement is the need to increase the effectiveness of nurses' inservice training. A novel, ideal module for nursing staff's in-service training was planned in this study (Chaghari et al., 2017;Elfaki, 2022

Technical Design:
The technical design includes the research setting, subjects, and tools for data collection.

Setting:
The study was performed at 3 Public  ≥ 80% was considered competent level of practice.  ˂ 80% was considered an incompetent level of practice.

Operational Design:
It includes the preparatory phase, pilot study, and fieldwork.

Preparatory Phase:
In order to design the data collection tools, the researchers conducted a comprehensive study of previously available material and utilized information from various sources, including books, journals, the internet, periodicals, and magazines to theorize about various aspects of the study.

Content validity:
Five specialists from the medical-surgical nursing staff at the faculty of nursing at Helwan University judged the study instrument for relevance, importance, adjustment, and permission as part of the content validity process. Professors and assistant professors made up the jury, which represented several academic categories.

Testing reliability:
The reliability scores of study tools, including the Arabic versions of tools I and II for nurses' practical observational checklists and selfadministered knowledge questionnaires, were examined in accordance with the Cronbach alpha (0.879 & 0.912), respectively.

Ethical Considerations:
After the purpose of the study has been clearly defined prior to data collection, informed consent was obtained from the hospital director, the director of the intensive care unit, and the staff nurses who engage in the study procedure. They received guarantees that they would remain anonymous, that the study's confidentiality would be upheld, and that they would have the freedom to leave at any moment without providing a reason.
Beliefs, values, and culture would all be upheld.

Pilot Study:
A pilot research was conducted on a group of 6 nurses (or 10% of the sample) in order to assess the usefulness of the data-collecting tools, clarify the desired questionnaire, and determine the time needed to complete the tools. Because the instruments weren't changed, nurses included in the pilot study were also mixed in with the primary study subject.

Field Work:
 This study was performed through three phases: Assessment phase, in-service training module implementation phase including both theoretical and practical stages, and evaluation phase:

I-Assessment phase:
-The study was carried out as part of an agreement between the Ministry of Health, Amira Fatma Academy, and the Faculty of Nursing at Helwan University to offer intensive care nurses an inservice training module with the main objective of raising the nurses' competency level in terms of knowledge and practice.
-Before the in-service training module implementation, nurses who were available at the time of the study were chosen, and formal consent to participate in the collection of study pre-data was obtained. This step also involved describing the purpose and advantages of the study to the nurses.
-In this phase, the researchers were gathering information from nurses, starting with the demographic details, using practical observational checklists to observe and interview nurses in order to assess nursing staff members' skill proficiency.

II-Implementation phase
The in-service training module was repeated in the same manner at each hospital in the previously mentioned places respectively over 6 weeks.
-Nurses were divided into two groups, each group consisting of ten nurses, and the theoretical portion of the in-service training module was primarily -The in-service training module was administered on the same day with the following instructions; applying the pre-test before it and then completing the post-test, nurses had given a soft audio-visual method and a Powerpoint presentation were sending to nurses on their phones to read and the source was given to the hospital education team.

II-Evaluation phase:
The effect of the in-service training module on the intensive care nurses' performance regarding mechanical ventilator patients' skillful handling was evaluated by comparing the results of pre, post, and post 3 months of the follow-up tests applied using the same data collection tools.
-Data collection and teaching sessions for the study group took about 5 months and were carried out in morning shifts starting from the beginning of November 2022 until the end of March 2023.

Administrative Design:
The existing study was approved after taking official permission from the ethics committee of were females with a male-to-female ratio was 1:9.
As well as, 73.3% of the studied nurses were between 20 < and 30 years with a mean age (25.95 ± 6.02) years. As well, 50% of the studied nurses had secondary school nursing education with 45% of the studied nurses had experience (6 ≥ 10) years, 35% of them had less than 5 years, and twentieth of them had more than 10 years with the mean experience years were (9.63 ± 5.34) years.
Finally, 95% of the studied nurses didn't attend training courses related to the skillful handling of mechanically ventilated patients.             nurses caring for patients on ventilators must be able to provide efficient nursing care for this patient population. Additionally, an effective training program for nursing staff will raise the standard of nursing care (Stawicki et al., 2020).  -Gunaid (2020), which revealed that more than two third of ICU nurses had a diploma in nursing and nearly three-quarters were working in ICU for 1-5 years.
Considering years of experience, more than two-fifths of the studied nurses had a year of experience ranging from sex to equal or less than ten years with a mean of 9.63 ± 5.34. From the investigator's point of view, the studied nurses' years of experience were matched with their educational qualifications, age, and hiring date.
Moreover, the study result illustrated that most of the studied nurses did not attend training courses regarding mechanical ventilation.
As well, the study statistics were supported by Regarding the total mean score of knowledge regarding care of mechanically ventilated patients, the study result discusses that, during the post-test phase, the studied nurses gained a higher mean score of knowledge regarding care of mechanically ventilated patients followed by the follow-up phase as compared with the pre-test phase. Moreover, a highly statistically significant difference existed between the total mean score of knowledge regarding care of mechanically ventilated patients during the pre, post, and 3 months follow-up phase among the studied nurses at P = 0.000.
Additionally, throughout the implementation phases; Shubra Hospital gained a higher mean score of knowledge, followed by Embaba Hospital as compared Om-Elmasreen Hospital, respectively.
As the researcher's Explanation, the decline of the mean score of knowledge in the pre-test phase may be due to a lack of concern from the authority

Recommendations
From the previous conclusion, the following recommendation is suggested:  A further study is to be carried out in different settings on a larger sample for a wider utilization of the in-service training module, in order to attain higher gained performance in public hospitals.
 Implement a periodic evaluation to determine the nurses' proficiency for evaluating nurses' knowledge and improving nurses' practice.
 Reassure in-service training courses about mechanically ventilated patient care that should be obligatory for recently hired nurses.
 To achieve greater gained performance in public hospitals, a future study is to be conducted in various contexts on a larger sample for wider use of the in-service training program.