Most of the participants were female (10 cases). The means of their age and professional experience were 25.3 and 4.6 years, respectively. Their experiences of the barriers to VAP management came into two main themes of low quality of working life and poor organizational culture which are shown in Table 1 and explained in what follows.

Table 1: Main themes, categories and subcategories of critical care nurses’ experiences of the barriers to VAP management

A. Low quality of working life
Quality of working life (QWL) is the result of workers’ satisfaction with their needs and is achieved through attending workplaces. In healthcare organizations, QWL is among the principal factors behind the quality of workers’ performance and care. According to our participants, low QWL was among the main barriers to effective VAP management. The five main categories of this main theme were difficult nature of critical care delivery, lack of opportunities for learning and skill development, unfair salaries, complex nature of work, and unprofessional practice.

A1. Difficult nature of critical care delivery
Critical care delivery is complex and difficult because patients who are hospitalized in ICUs usually are critically ill and suffer from life-threatening conditions. The participating nurses referred to low nurse-patient ratio as a major barrier to effective VAP management.

The number of nurses is low and we have to do extra working shifts. Therefore, we are too fatigued to provide quality care. Or, we are very busy at work. There are only two nurses in each shift and hence, we have not adequate time for implementing care measures properly. For instance, instead of letting gavage soup pass through the nasogastric tube, we push it forcibly by using a gavage syringe. Another instance is that we do not perform suctioning properly in order to be able to carry out our other care-related responsibilities (P. 2).

Nursing staff shortage negatively affected the participants’ care quality through increasing their workload and the number of their mandatory extra shifts. Mandatory extra shift was referred to by the participants as another barrier to effective VAP management. Such working schedule tired them, disturbed their personal life, broke their concentration, and reduced the quality of care.

As I have a little baby, I don’t want to do extra shifts. However, the hospital nursing office doesn’t agree and thus, I have to do extra shifts. When doing extra shifts, I’m greatly preoccupied with my baby and hence, I cannot perform my tasks properly. For instance, I may avoid performing suctioning accurately (P. 1).

Another workforce-related barrier to effective VAP management was lack of professional physiotherapists in hospitals. Therefore, the participants were required to do the extra task of performing physiotherapy for patients. However, they considered physiotherapy neither as their own responsibilities nor as a routine practice and hence, it was usually overlooked.

It is for about two years that there is no physiotherapist in our hospital and thus, physiotherapy is usually performed by us even though it is not among our responsibilities. We perform physiotherapy only for the sake of patients. Of course, our physiotherapies are not standard enough (P. 3).

Critical conditions of patients who are hospitalized in ICUs and their greater need for specialized care services along with serious staff shortage had dramatically expanded our participants’ workload. Such a working condition had forced them to pay little attention to the quality of care. On the other hand, during shift handover, the quantity of care was valued much greater than its quality. In other words, if nurses performed smaller number of their tasks with greater quality, they were accused of shirking. Such a practice had resulted in the delivery of low-quality care.

When I’m too busy, I cannot perform suctioning or other care measures accurately because I need to perform each measure quickly in order to have adequate time for my other tasks. Thus, I usually pay little attention to the quality of work because during shift handover, no one values the quality of my care; rather, they only value the amount of undone tasks. Therefore, I need to do all my tasks at any level of quality in order not to be accused of shirking (P. 4).

Despite the necessity to use high-tech equipment in ICUs, our participants noted that they had little access to such equipment. They referred to defective or inadequate equipment as another barrier to effective VAP management. In other words, they had many difficulties in providing quality patient care due to having limited access to basic critical care equipment. Defective equipment resulted in providing nonstandard care while lack of equipment resulted in failure to perform some care measures such as measuring the pressure of endotracheal tube cuff.

The remote controllers of the beds in our unit are defective. When we are too busy with other care measures, we are unable to change the controllers and thus, patients may be in an inaccurate position during gavage (P. 5). We never measure the pressure of endotracheal tube cuff because we have no access to the necessary equipment (P. 7).

Another barrier to effective VAP management was poor and nonstandard structural conditions of ICUs both for patients and nurses. For instance, the participants’ working unit had neither an air conditioning system nor an isolated room for patients with infectious diseases. Besides, the windows to open space were kept open for long hours and inter-bed distances were too small. Therefore, the likelihood of infection transmission was high. In addition, the staff resting room was in poor condition.

The physical space of the unit is too awful. There is a small space between the beds and there is no air conditioning system in the unit. In case of poor air conditioning, both nurses and patients are at risk of bacterial infections (P. 6).

A2. Lack of opportunities for learning and skill development
One of the key characteristics of critical care nurses is to have great knowledge of care. In other words, nurses who are not knowledgeable enough cannot work in these units. Nonetheless, our participants’ experiences showed that critical care services were provided based on usual routines. In other words, novice nurses learned the way of care delivery from their experienced colleagues and took professional knowledge-based practice for granted. Such a practice had resulted in nonstandard care delivery.

The most important thing for us is that the endotracheal tube cuff be kept full. Therefore, other things (such as the pressure of the cuff) are not very important. We just inject 5 cc of air into the cuff.

According to the participants, some critical care nurses did not have enough professional competence for working in ICUs due to poor in-service education. For instance, some nurses were not skillful enough for measuring the pressure of endotracheal tube cuff or doing physiotherapy. Moreover, as attending physicians or anesthesiologist refrained from setting ventilators, nurses were obliged to do this task despite having received no in-depth training in this area. Consequently, they set ventilators based on their own personal experience.

I have no adequate knowledge about ventilators. Thus, there may be an opportunity for weaning a patient from the ventilator while I cannot take advantage of such opportunity due to having poor weaning skills. Therefore, the patient may unnecessarily receive mechanical ventilation for many days (P. 8).

A3. Unfair salaries
Because of their heavier workload and stressful work condition, the participating nurses expected to receive higher salaries compared with nurses in other hospital wards. However, hospital administrators’ inattention to fair budget and resource allocation had reduced their motivation for work. Financial issues were so important to the nurses that they referred to them as a significant factor behind care quality.

The salaries of critical care nurses should be different from those of nurses in other hospital wards. However, there is no difference between the salaries of these two groups in our hospital. Sometimes, critical care nurses’ salaries are even less than other nurses. Such practice significantly contributes to our poor motivation for work (P. 1).

A4. Complex nature of work
When providing care to critically-ill patients in critical situations, the nurses focused mainly on saving patients’ life and paid little attention, if any, to the requirements of each care-related activity. Accordingly, they might insert an intra-tracheal tube or perform suctioning under unsterile conditions, resulting in greater risk for VAP. The likelihood of such an unsterile practice was greater in stressful situations such as in emergencies or once working with an inexperienced colleague.

When a patient is critically-ill and needs intubation, I just focus on intubating him/her irrespective of the quality or the sterility of the procedure. The most important thing in such situations is to prevent patient’s death (P. 9; group discussion).

Shortage of personal protective equipment had also caused most of the participants to develop hospital-acquired respiratory infections. They referred to this fact as a negative experience and mentioned that they avoid providing standard care to patients with serious infections in order to protect themselves against infections.

Here, I developed pneumonia several times. In order to prevent another episode of pneumonia, I perform suctioning for patients with pneumonia in a very short period of time. Such practice reduces the quality of my care (P. 6).

A5. Unprofessional practice
Due to the critical conditions of patients who are hospitalized in ICUs, critical care nurses need to have high levels of critical care specialty, knowledge, and experience. They not only need to be highly knowledgeable, but also should properly use their knowledge in their practice. Nonetheless, nursing staff shortage in the study setting had resulted in the recruitment of inexperienced nurses for ICU. Inexperienced nurses avoided providing care services independently in order not to be involved in malpractice lawsuits.

I avoid weaning a patient from ventilator independently and attempt to do it after obtaining my senior or manager’s permission. I usually perform what they recommend (P. 8).

Some of the participating nurses had no healthy attitude toward quality care delivery and hence, they used to provide care based on their own beliefs and experience. For instance, some of them did not maintain sterility while doing nursing procedures and believed that such practice is sound.

When I go from one patient to another, I simply change my gloves and believe that it is enough for preventing infections. I have no firm belief in washing hands before doing procedures (P. 9, group discussion).

B. Poor organizational culture
Another major barrier to effective VAP management was poor organizational culture. Organizational culture has a significant effect on organizational and employee performance. Factors such as supervision and control, organizational relations, and managerial support can contribute to the formation of cultural norms.

B1. Strict supervision of nurses
Our nurses were continuously monitored by their administrators. However, they believed that evaluation of employee performance is not performed effectively because administrators who did evaluations usually focused more on nursing documentations than the process of care delivery and attempted to pinpoint employees’ weaknesses in order to punish them instead of minimizing shortages and weaknesses. Some of the participants also argued that administrators usually evaluate each nurse based on their own previous attitudes towards her/him. Such a poor evaluation had reduced the participants’ motivation for quality care delivery.

Previously, they recruited many novice staff to the unit and thus, several errors happened in the unit and all of us were punished consequently. Thereafter, they never pay attention to the ICU and our matron believes that ICU staff never perform their tasks appropriately (P. 10).

B2. Poor professional interactions
The ability to establish effective communications with colleagues is a basic clinical skill and a key component of efficient care delivery in ICUs. Nonetheless, most participants referred to poor inter- and intra-professional interactions as another barrier to effective VAP management. Inter-professional distrust and poor interdisciplinary collaboration were among the participants’ main concerns. In the study setting, physicians had no trust in nurses and accused them of shirking, resulting in the reduction of nurses’ motivation for quality care delivery.

Every morning, we wash and rinse patients’ mouth with chlorhexidine. However, when attending the unit, physicians get angry and complain that why we do not perform mouth washing for patients. They do not trust us when we say that we have done mouth washing. Such behaviors of physicians make us unmotivated (P. 5).

On the other hand, there were weak intra-professional interactions among nurses due to their heavy workload. In other words, they were unable to help each other in doing care-related activities. Sometimes, the nurses were even unable to perform their activities due to the lack of help and support.

I cannot ask my colleagues to help me because they are heavily involved with their own duties. If they help me, their duties would remain undone. Therefore, I cannot efficiently perform suctioning when I’m alone (P. 11).

B3. Reluctance to perform care measures
Our participants’ detailed another problem in managing VAP as their reluctance and lack of motivation for performing care measures. Factors contributing to such reluctance were, but not limited to, inaccurate judgments, administrators’ inattention to nurses, poor accommodation for nurses, and similar salaries for critical care nurses and the nurses of other hospital wards. Such situations disappointed the participants and hence, they had no motivation for better care delivery.

Our resting room is of poor condition. No one values our welfare. When we go to the resting room to take some rest, such problems add psychological fatigue to our physical fatigue because we feel that no one values us (P. 10).

B4. Routine-based practice
The other barrier to effective VAP management was nurses’ routine-based practice due to lack of efficient incentive systems and poor workforce development policies. According to the participants, their administrators paid little attention, if any, to their career advancement and professional development, did not encourage them, and used punishment instead of encouragement. Therefore, the nurses were reluctant to learn and provide quality care.

If you do your tasks correctly, our administrators never encourage you. However, if you commit an error, they will punish you. The predominant system in our setting is punishment not incentive (P. 1).