JOURNAL OF AEROSOL MEDICINE AND PULMONARY DRUG DELIVERY Volume 29, Number 1, 2016 ª Mary Ann Liebert, Inc. Pp. 86–93 DOI: 10.1089/jamp.2014.1198
Knowledge and Attitudes of Nurses in Spain about Inhaled Therapy: Results of a National Survey Jordi Giner, MSc, RN,1 Pere Roura, MB, MPH,2 Carme Herna´ndez, MSc, RN,3 Montserrat Torrejo´n, MSc, RN,1 Meritxell Peiro´, MSc, RN,1 M a Jesu´s Ferna´ndez, RN,4 Elena Lo´pez de Santa Marı´a, RN,5 M a Angeles Gimeno, MSc, RN,6 Vicente Macian, RN,7 Eduard Tarragona, MD,8 and Vicente Plaza, MD, PhD1
Abstract
Background: The main problem with inhalation therapy is incorrect use of inhalers. Nurses’ limited knowledge may contribute to this situation. This study aimed to assess the level of knowledge and attitudes of respiratory nurses about inhaled therapy. Methods: A 12-item multiple-choice questionnaire was sent to members in the Nursing Area of the Spanish Society of Pneumology and Thorax Surgery and to nurses working with respiratory patients using inhalers devices. The survey was voluntary, self-administered, and anonymous. It collected demographic characteristics, preferences, and knowledge and education about devices and inhalation technique. Results: A total of 1496 nurses completed the questionnaire correctly. Results showed 65.4% preferred dry powder inhalers (DPI), 8.7% were familiar with all 12 devices listed, 59.6% identified ‘‘firing the device after beginning inspiration’’ as the most important step when using the pressurized metered dose inhaler (pMDI), 53.5% identified ‘‘inhale deeply and forcefully’’ as the most significant step using DPI, and 20.4% ‘‘always checked a patient’s inhalation technique when a new inhaler was prescribed.’’ A composite, variable, general inhaled therapy knowledge pooled the correct answers related to knowledge and showed only 14% of nurses had adequate knowledge of inhaled therapy. Conclusions: In spite of recent training activities, knowledge concerning use of inhaler devices among Spanish nurses managing patients with respiratory diseases continues to be poor. Improvements are also needed in patient education and follow-up of inhalation techniques. Undergraduate and postgraduate educational programs need to be further developed. Key words: DPI, inhalation devices, inhalation technique, inhaled therapy, misuse of pMDI, nurse, pMDI though simpler and more effective devices have appeared since the first pressurized metered dose inhaler (pMDI), the Medihaler, was introduced in the 1950s,(1) the issue of their proper use persists. The main disadvantage of the inhaled route is that it demands a technique with which many patients are not familiar, compromising the effectiveness of this
Introduction
I
nhalation is the delivery route of choice for bronchodilator and anti-inflammatory drugs. Its main advantages are rapid onset of action, greater therapeutic effect with a smaller dose, and fewer side effects. However, al-
1 Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d’Investigacio´ Biome´dica Sant Pau (IIB Sant Pau), Universitat Auto`noma de Barcelona, Department of Medicine, Barcelona, Spain. 2 Service of Clinical Epidemiology, Hospital General de Vic, Barcelona, Spain. 3 Integrated Care Unit, Medical and Nursing Direction, Hospital Clı´nic, IDIBAPS, CIBER de Enfermedades Respiratorias (CIBERES), Universitat de Barcelona, Spain. 4 Lung Management Area, Central University Hospital of Asturias, Oviedo, Spain. 5 Pneumology Department, Hospital Universitario Cruces, Barakaldo, Basque Country, Spain. 6 Service of Pneumology, Hospital de Palamo´s, Palamo´s, Girona, Spain. 7 Service of Pneumology, Hospital Arnau de Vilanova, Valencia, Spain. 8 Medical Advisor of Medical Department Chiesi, L’Hospitalet del Llobregat, Barcelona, Spain.
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NURSE KNOWLEDGE ABOUT INHALED THERAPY
Table 1. Device Knowledge and Preferences Device Dry Powder Inhaler (DPI) Turbuhaler Accuhaler (Diskus) Handihaler Aerolizer Novolizer Breezhaler Easyhaler Respimat Twisthaler Metered Dose Inhaler (pMDI) pMDI pMDI + Chamber pMDI Modulite
(4a) Device (4b) Preferred knowledge (%) (%) 93.6 89.1
65.4 35.6 18.4
38 34.2 30.6 28.6 26.6 23.9 17.5
3.4 0.6 1.9 1.6 0.2 2.1 1.6 34,7
84.8 84.6 38.5
6.8 23.2 4.7
Device knowledge (4a): multiple choice; preferred (4b): only one device accepted.
approach. Studies show that the percentage of patients correctly using pMDIs ranges from 0% to 77%,(2) and in the case of dry powder inhalers (DPIs), it is from 0% to 66%.(2) Such indications of wide misuse may lead to poor control of both asthma and COPD.(3,4) For this reason, the main guidelines on asthma and COPD, such as GINA (Global Initiative for Asthma)(5) GEMA (Spanish guide to manage asthma, in its Spanish acronym),(6) and GOLD (Global Initiative for Chronic Obstructive Lung Disease),(7) recommend education and training in all stages of the disease. Training and follow-up in the use of inhaler devices are regarded as the most important steps in the education programs. Similarly, national societies, such as the Spanish Society of Pneumology and Thoracic Surgery (SEPAR)(8) and international societies such as the European Respiratory Society (ERS) and the International Society of Aerosol in Medicine (ISAM)(9) have developed guidelines and consensus for the use of inhaled therapy. But are healthcare personnel responsible for instructing patients in the use of inhalation devices competent and knowledgeable in the proper technique? Several studies have found that their level of knowledge is low, being 54%(10) for
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pMDIs and between 12% and 35%(11) for DPIs. Plaza et al.(12) recently published the results of the OPTIM survey on knowledge about inhaled therapy among 1514 respiratory disease physicians in Spain. The conclusions indicated that physicians’ knowledge about inhaler devices and inhalation remains inadequate. Since nurses in many settings provide a continuum of care and are responsible for teaching patients how to use inhalers, we would expect to find more favorable results. Using a survey and method similar to a previous study in physicians, our aim was to assess knowledge and attitudes about inhaler devices among nurses working directly with patients with asthma or COPD.(12) Material and Methods
We performed a multicenter study to assess knowledge, attitudes, and preferences regarding inhaled therapy among nurses providing training and follow-up of patients with asthma or COPD. Participants worked in pneumology, primary care centers, allergy, and internal medicine areas in Spain. They completed a self-administered questionnaire with 12 categorized multiple choice or numerical closed questions, similar to that used in the OPTIM study for physicians,(12) with the addition of question 4b (see Appendix 1). The questionnaire took less than 5 minutes to answer. Participation in the study was voluntary and anonymous. Between September and October 2012, a first set of webbased surveys was sent by email (Google-Drive) to the 257 members of the Nursing Area of SEPAR (The Spanish Society of Pneumology and Thoracic Surgery). They were asked to forward the survey to other nurses they knew working directly with patients receiving inhaled therapy. Between October 2012 and March 2013, a paper version of the questionnaire was distributed to other nurses in Spain who worked in relation to respiratory patients but had not been sent the survey by e-mail. All possible participants were specifically asked to return only one completed survey if they received it from more than one source. The questionnaire was identical in its e-mail and paper forms, and it had three parts. The first part, questions 1 to 5, was about sociodemographic data and the department where the participant worked. The second part, containing questions 6 to 9, asked participants about their knowledge of inhaled therapy, types of devices, their preferred device, and their technical knowledge about pMDIs, inhalation chambers, and
FIG. 1.
Percentage of known devices.
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Pneumology (n = 404)
Allergy (n = 135)
Primary care (n = 528)
Internal medicine (n = 57)
Values are shown as the mean with percentages in brackets. DPI = dry-powder inhaler; ns = not significant; pMDI = metered-dose inhaler; SD = standard deviation. *Correct answers for items 8, 9, 10, and 11 used to generate the composite variable general inhaled therapy knowledge.
Demographic Characteristics Age, mean (SD) 46.1 (9.4) 47.0 (9.5) 46.3 (10.4) 46.1 (9.1) 46.1 (8.5) Men/Women, % 18/82 12/88 10/90 22/78 16/84 Preferences ITEM 6. Your knowledge of inhaler use comes mainly from (valid surveys, n = 1,429) - Meetings by scientific societies 377 (26.4) 107 (27.1) 27 (20.1) 140 (26.6) 10 (18.2) - Meetings by industries 250 (17.5) 49 (12.4) 16 (11.9) 105 (19.9) 10 (18.2) - Reading scientific articles 160 (11.2) 56 (14.2) 13 ( 9.7) 58 (11.0) 7 (12.7) - Reading the leaflet device 139 ( 9.7) 21 (5.3) 13 ( 9.7) 68 (12.9) 7 (12.7) - Personal experience 328 (23.0) 99 (25.1) 46 (34.3) 106 (20.1) 15 (27.3) - Two or more sources of knowledge 175 (12.2) 63 (15.9) 19 (14.2) 50 ( 9.5) 6 (10.9) Issues Related to the Knowledge of Inhalation Techniques and Prescription ITEM 8:The most important step for correct pMDI inhalation is: (valid surveys, n = 1,415) - Shake the device before inhalation 147 (10.4) 33 (8.3) 14 (10.7) 58 (11.2) 3 (5.4) - Exhale deeply before inhalation 130 ( 9.2) 29 (7.3) 6 (4.6) 58 (11.2) 5 (8.9) - Firing the device after beginning inspiration* 844 (59.6) 281 (70.8) 80 (61.1) 280 (53.9) 36 (64.3) - Inhale deeply and forcefully 123 ( 8.7) 26 (6.6) 13 (9.9) 47 (9.1) 8 (14.3) - Continue deep, slow inspiration 171 (12.1) 28 (7.1) 18 (13.7) 76 (14.6) 4 (7.1) ITEM 9: The most important step for correct DPI inhalation is: (valid surveys, n = 1,426) - Shake the device before inhalation 48 (3.4) 8 (2.0) 5 (3.7) 17 (3.3) 6 (10.7) - Exhale deeply before inhalation 228 (16.0) 63 (15.9) 20 (14.8) 85 (16.3) 10 (17.9) - Firing the device after beginning inspiration 143 (10.0) 21 (5.3) 18 (13.3) 63 (12.1) 7 (12.5) - Inhale deeply and forcefully* 763 (53.5) 242 (61.0) 70 (51.9) 255 (48.9) 27 (48.2) - Continue deep, slow inspiration 244 (17.1) 63 (15.9) 22 (16.3) 101 (19.4) 6 (10.7) ITEM 10: When you prescribe an inhaler device, which of the following variables do you consider most important?: (valid surveys, n = 1,389) - Disease to treat 318 (22.9) 94 (24.5) 32 (25.2) 109 (21.2) 10 (18.9) - Patient’s preferences* 169 (12.2) 50 (13.0) 16 (12.6) 54 (10.5) 13 (24.5) - Patient’s age 364 (26.2) 72 (18.8) 28 (22.0) 160 (31.1) 9 (17.0) - Patient’s experience with device 448 (32.3) 155 (40.4) 38 (29.9) 153 (29.7) 17 (32.1) - Patient’s cultural level 90 ( 6.5) 13 (3.4) 13 (10.2) 39 (7.6) 4 (7.5) Issues Related to Education in Device Inhalation Techniques ITEM 11: In your centre when is prescribed a new inhaler, do you or another healthcare worker assess the patient’s skill in its use? (valid surveys, n = 1,434) - Always* 293 (20.4) 138 (34.5) 35 (26.3) 48 (9.1) 8 (14.0) - Usually 498 (34.7) 154 (38.5) 50 (37.6) 152 (28.9) 23 (40.4) - Sometimes 452 (31.5) 80 (20.0) 42 (31.6) 234 (44.5) 18 (31.6) - Hardly ever 134 ( 9.3) 26 (6.5) 5 (3.8) 60 (11.4) 8 (14.0) - Never 57 ( 4.0) 2 (0.5) 1 (0.8) 32 (6.1) 0 (0.0) ITEM 12: Who trains the patients on the inhaler device technique at your centre? (valid surveys, n = 1,435) - Physicians 130 (9.1) 14 (3.5) 16 (11.9) 55 (10.2) 3 ( 5.5) - Nurses 602 (42.0) 223 (55.3) 56 (41.8) 168 (32.0) 33 (60.0) - Either, nurses or physicians 646 (45.0) 162 (40.2) 61 (45.5) 262 (49.9) 19 (34.5) - Nobody, but written information is provided 21 ( 1.5) 2 (0.5) 1 (0.7) 10 (1.9) 0 (0.0) - Nobody, and written information is not provided 36 (2.5) 2 (0.5) 0 (0.0) 30 (5.7) 0 (0.0) GENERAL KNOWLEDGE (valid surveys, n = 1,443) - Poor (£2 points) 1,241 (86,0%) 308 (76,2%) 119 (88,1%) 488 (92,4%) 51 (89,5%) - Adequate (‡3 points) 202 (14,0%) 26 (23,8) 16 (11,9%) 40 (7,6%) 6 (10,5)
Total sample (n = 1,443)
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001 < 0.001
P (between groups)
Table 2. Results from Questionnaire for Whole Sample and Each Department Where Nurses Work (Excluding Other Departments)
NURSE KNOWLEDGE ABOUT INHALED THERAPY
DPIs. The third part, questions 10 to 12, addressed attitudes and activities in patient education regarding inhalation techniques (see Appendix 1). The level of knowledge about inhaled therapy was assessed by the sum of the correct responses to questions 8, 9, 10, and 11. Correct responses were 8.3, 9.4, 10.2, and 11.1, respectively (see Table 2), based on the recommendations for inhaled therapy.(8,9) Each correct response was scored 1 point. The resulting number generated a new variable, general knowledge about inhaled therapy. This variable was then arbitrarily stratified into two knowledge groups, poor (0, 1, or 2 points) and adequate (3 or 4 points). Quality control of questionnaires
The web-based questionnaire did not allow errors such as blank responses, multiple responses, or incoherent responses. Double data entry was performed for paper-based questionnaires (to detect a minimum of 5% of surveys with blank or unforeseen multiple responses) verifying and guaranteeing the quality of all questionnaires received. The data and values included in the databases therefore accurately reflect what was stated by those surveyed. Statistical analysis
Descriptive statistics were performed for the overall sample. The results for each question were expressed as percentages and compared between department groups. The Chi-square test was used between qualitative variables; analysis of variance (and Bonferroni adjustment) was used when comparisons were between quantitative variables following a normal distribution and qualitative variables. If quantitative variables did not follow a normal distribution, equivalent nonparametric tests, such as the Kruskal-Wallis test, were used for comparison. Independent variables were included in a logistic regression model if significance was obtained in the bivariate analysis, allowing determination of factors defining a profile of adequate knowledge of inhaled therapy. These analyses were performed using IBM SPSS Statistics software version 19 (SPSS for Windows, Chicago, NY, USA). Statistical significance was set at a p value less than 0.05.
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community and family medicine departments and 38 (5.0%) were from pediatric departments. Among the 631 participants who worked at hospital centers, 404 (64.0%) were from pneumology departments, 135 (21.4%) were from allergy departments, 57 (9.0%) were from internal medicine departments, and 35 (5.5%) were from other health care departments. Six hundred and thirty surveys (44.0%) were provided by nursing professionals from Eastern Spain (Catalonia, Aragon, Levante, Balearic Islands, and Murcia). 300 (20.9%) were from Northern Spain (Galicia, Asturias, Cantabria, Basque Country, and La Rioja). 246 (17.2%) were from Central Spain (Castile-Leon, Castile-La Mancha, and Madrid). 193 (13.5%) were from Southern Spain (Andalusia and Extremadura), and 63 (4.4%) were from the Canary Islands, Ceuta, or Melilla. Table 1 shows the inhalation devices known and preferred by participants. The question about devices known was a multiple choice question with more than one acceptable answer. For this reason, the sum of percentages in column 1 exceeds 100. Only one answer was accepted for the question on preferred device (column 2). We found 3.1% knew of only one device and 8.7% knew of all twelve devices listed. The average number of familiar devices was 5.98 (3.06) and the median was 5 (Fig. 1). We found no correlation between participants, ages, and number of devices known or preferred (Kruskal-Wallis test p = 0.001). Overall, 65.4% of nurses preferred dry powder devices, while 34.7% preferred pMDI devices. Table 2 shows the results for questions 6, 8, 9, 11, and 12 in the overall sample and distributed according to speciality. Question 6 showed the source of knowledge about inhaled therapy came mainly from scientific society meetings and personal experience. The most important step in the use of a pMDI, firing the device after beginning inspiration (question 8), was answered correctly by 844 participants (59.6%). For question 9, on the most important step for correct DPI inhalation, the correct response was chosen (inhale deeply and forcefully) by 763 (53.5%). For question 10, ‘‘What variable do you consider most important when you prescribe an inhaler device?’’ 448 (32.3%) chose the response ‘‘Patient’s experience with device’’ rather than the
Results
A total of 1496 surveys (50.2%) were returned from the 2500 sent: 241 via e-mail and 1255 by postal mail. Fiftythree surveys were excluded from analyses: 9 were blank, 23 had 5 or more blank responses, 20 indicated the respondent was not familiar with any of the inhalation devices, and 1 was from a non-nursing professional. A total of 1443 surveys were finally evaluated: 1202 (83.3%) received by postal mail and 241 (16.7%) received by Internet. The mean age of respondents was 46.1 [standard deviation (SD) 9.4] years and 82.1% were women. From the total sample of 1443 participants, 1380 gave information concerning their work place: 777 (56.3%) worked at primary care centers, and 603 (43.7%) worked at hospitals. Of 1197 who specified the department where they worked, 566 were from primary care centers (47.3%), and 631 were from hospitals (52.7%). Among the participants who worked at primary care level, 528 (95.0%) were from
Table 3. Classification in ‘‘Poor’’ or ‘‘Adequate’’ Inhaled Therapy Knowledge for Sample after Excluding Nurses Who Work in Other Departments n (%) Zero points One point Two points Three points Four points TOTAL
Poor knowledge (0–2 points)
Good knowledge (3–4 points)
258 (18) 513 (35.7) 470 (32.6) – – 1241 (86.3)
– – – 192 (13) 10 (0.7) 202 (13.7)
Stratification was made after correct answers were pooled for items 8, 9, 10, and 11 (1 point for each correct answer [marked with an asterisk in Table 2]) in a new composite variable (general inhaled therapy knowledge). Values are shown the as mean with percentages in brackets.
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GINER ET AL.
Table 4. Knowledge Score ‘‘Odds ratio’’ Areas where nurses work Internal Medicine Primary Care Pneumology Allergy Age For each year
95% CI
P
1 0.64 2.53 1.16
0.26–1.59 1.05–6.10 0.43–3.16
0.404 0.036 0.807
1.02
1.00–1.04
0.048
Variable generate with questions 8, 9, 10, and 11.
correct response ‘‘Patient’s preferences,’’ which was the least chosen response, selected by 169 participants (12.2%). In question 11, ‘‘When you prescribe a new inhaler, do you or another health care worker assess the patient’s skills in its use?’’ the responses were varied and the correct response (‘‘Always’’) was the third most chosen option by 293 (20.4%), except for those who stated that they worked in pneumology departments, where the correct response was the second most chosen option, selected by 138 (34.5%). In question 12 on ‘‘Who trains the patients on the inhaler device technique at your centre’’, the most frequent response by 646 (45.0%) was ‘‘Either nurses or physicians,’’ with the exception of pneumology and internal medicine groups where the most frequent response was ‘‘Nurses,’’ 223 (55.3%) and 33 (60.0%). General knowledge about inhaled therapy (Table 3), a variable generated with questions 8, 9, 10, and 11, showed a mean value of 1.43 points (range 0–4) with a standard deviation of 0.95 and a median of 1 point. When grouped by speciality, the highest score, 1.75 (0.95), was obtained by the pneumology group, followed by allergy, 1.49 (0.91) and internal medicine 1.47 (0.89) groups. A significant difference was observed (Kruskal-Wallis test p = 0.001) between scores obtained according to the department where they carried out their care activity. General knowledge of inhaled therapy was classified according to the score obtained as adequate (‡3 points) or poor (£2 points). Table 3 shows that 14.0% (202 respondents) had an adequate general knowledge. The differences between groups were statistically significant, with the highest percentage (23.7%) of adequate knowledge (‡3 points) being found in the pneumology group.
Table 4 presents the multivariate analysis including variables that predict an adequate knowledge of inhaled therapy. Nurses in the respiratory group had a 2.53 odds ratio ( p = 0.036) for the item ‘‘general inhaled therapy knowledge’’ compared to nurses working in an internal medicine department. That is, respiratory nurses showed twice the probability of having adequate knowledge compared with internal medicine nurses. Age also played a role in predicting adequate knowledge, although the statistical significance was low. For each year of age, the probability of achieving adequate knowledge of inhaled therapy increased 2% (odds ration 1:02, p < 0.05). Discussion
The results of our survey show that the general level of knowledge regarding the use of inhalation devices is low among nurses working in this field in Spain. The variable level of knowledge (items 8, 9, 10, and 11) showed that only 14.0% of nurses who participated in the study had adequate knowledge about inhaled therapy. This result is directly comparable with the 14.2% found for the same item using this questionnaire in physicians in the OPTIM study.(12) Regarding the source of knowledge about inhaled therapy (question 6), it is surprising that 23.0% of participants stated that their knowledge came from personal experience, and that only 37.6% indicated that their source of knowledge was through scientific literature or scientific meetings. These figures reflect a lack of formal training in this field and may explain the poor general results, highlighting the need for education and training concerning inhaled therapy to be included in undergraduate study programs in nursing schools. Our results concerning who provides the training in the inhalation technique differed significantly from those in the OPTIM study.(12) Our findings indicated that training was done by either nurses or physicians in 45% of centers, by nurses in 42% of centers, and by physicians in 9.1%, contrasting with the 38.8%, 22.4%, and 34.6%, respectively, published in the OPTIM study.(12) These differences suggest a lack of coordination between these two groups of professionals, a situation that clearly affects the quality of our responses and patient knowledge. It is also of note that only one in five participants routinely checked the patients’ technique in inhalation therapy, a result similar to that in the OPTIM study.(12) In relation to the choice of device, most
Table 5. Results of Multivariate Analysis to Predict Adequate General Inhaled Therapy Knowledge’s Showing Significant Variables Included in Model Author
n
Evaluation
Device
% of good
Felez-1991 (17) Interiano-1993 (18) Hanannia-1994 (11) Jones-1995 (19) Plaza-1996 (20)
41 50
Demonstration Demonstration Demonstration Demonstration Theory Demonstration Demonstration Demonstration Demonstration Theory Demonstration
pMDI pMDI pMDI,Chamber,Turbuhaler pMDI Turbuhaler
32% 18% 82%,78%,12% 45% 2% 6% 54% 68%,50%,35% 29% 4 points/10 7.2, 5.0, 4.9 point/10
Chopra-2002 (10) Scarpaci-2007 (21) Dı´az-Lo´pez-2008 (22) Muchao-2008 (23) Basheti-2014 (24) CI = confidence interval.
75 50 10 47 144 33 40
pMDI pMDI,Chamber,Diskus Chamber Chamber MDI, Turbuhaler, Diskus
NURSE KNOWLEDGE ABOUT INHALED THERAPY
surveyed nurses and physicians chose the response ‘‘Patient’s experience with device,’’ and only a minority chose patient preferences, as would be desirable.(13,14) When we examined our results according to the type of center or department where participants worked, nurses working in a pneumology department showed significantly better scores for all items than nurses working in allergy, primary care, and internal medicine departments.(12) They also, therefore, showed better scores in the combined variable generated (general inhaled therapy knowledge). In the multivariate analysis, nurses from pneumology departments tripled the ‘‘odds ratio’’ (2.53) for ‘‘adequate knowledge’’ in inhaled therapy compared with other groups. We consider this finding is of particular concern, given the large volume of chronic respiratory patients attended at emergency rooms, internal medicine, and allergy departments, and primary care centers. Few studies to date have investigated knowledge and attitudes of nurses to inhaled therapy (Table 5).(10,11,17–24) Comparison with our findings is difficult due to the different research methods. Most previous studies involved a practical demonstration of technique, whereas our data were collected by a written questionnaire. Levels of knowledge in these studies are low however, like our own. The fact that we questioned respondents about their knowledge rather than their skill is a clear limitation of the study, possibly indicating a higher level of knowledge than the participant’s actual skills. Assessment of skills may have been a more reliable measure, but it would have been difficult to score results from a practical demonstration. Nevertheless, compared with a study in our setting in 1996, there appears to be a slight improvement in knowledge by nurses in Spain. The results obtained indicate that specific educational policies should be addressed to nurses working in inhalation therapy. Given our poor results in improving general inhalation therapy knowledge with traditional educational methods, novel strategies should be devised, such as workshops, better knowledge of guidelines, protocols agreed between doctors, and nursing coordination between primary care and specialist care, and especially the inclusion of curricula on inhaled therapy in undergraduate and postgraduate medical and nursery studies. One of these should be the inclusion of inhalation therapy as a topic in pre- and postgraduate training programs. Our study has several limitations. The main limitation is that it investigated theoretical knowledge only. In addition, our results reflect the knowledge of those who responded to the survey and do not necessarily represent all nurses in Spain. Another limitation is that we do not know exactly how many nurses received the web-based survey. To conclude, Spanish nurses managing patients with respiratory diseases continue to have poor knowledge about the use of inhaler devices and training and subsequent follow-up of inhalation techniques, despite the many activities carried out in recent years. New educational strategies specifically addressed to nursing training must be developed. Acknowledgments
The authors would like to thank Carolyn Newey for editorial assistance. The study was supported in part by an unrestricted grant from Chiesi (Spain).
91 Author Disclosure Statement
Ms. Jordi Giner declares that in the last 5 years she has received honoraria for participation in meetings, congresses, or research projects organized by the pharmaceutical or related companies: Chiesi, AstraZeneca, Boehringer-Ingelheim, Laboratorios Dr. Esteve, GlaxoSmithKline, MSD, Novartis, Sandoz, Pfizer, Teva, and Takeda. Ms. Carme Herna´ndez declares that in the last 5 years she has received honoraria for her participation in meetings, congresses, or research projects organized by BoehringerIngelheim, Menarini, Laboratorios Dr. Esteve, Teijin Healthcare, and AldoUnio´n. Ms. Ma Jesu´s Ferna´ndez declares that in the last 5 years she has received honoraria for her participation in meetings, congresses, or research projects organized by the following pharmaceutical or related companies: Chiesi, Laboratorios Dr. Esteve, Teijin Healthcare, Novartis, and Pfizer. Ms. Elena Lo´pez de Santa Marı´a declares that in the last 5 years she has received honoraria for her participation in meetings, congresses or research projects organized by Almirall, Boehringer-Ingelheim, Laboratorios Dr. Esteve, GlaxoSmithKline, MSD, and Novartis. Mr. Vicente Macia´n declares that in the last 5 years he has received honoraria for his participation in meetings, congresses or research projects organized Chiesi, Laboratorio Dr. Esteve, Teijin Healthcare, and Pfizer. Dr. Pere Roura declares that in the last 5 years he has participated in meetings and research projects from Chiesi and Pfizer. Dr. Eduard Tarragona received a stipend as a Medical Advisor from Chiesi. Dr. Vicente Plaza declares that in the last 5 years he received honoraria for speaking at sponsored meetings from AstraZeneca, Chiesi, GlaxoSmithKline, Merck, Novartis, and Pfizer, and as a consultant for Orion and Teva. He also received support for attending meetings from BoehringerIngelheim and for research projects from a variety of government agencies, not-for-profit foundations, and Chiesi, Menarini, and Merck. References
1. Freedman T: Medihaler therapy for bronchial asthma; a new type of aerosol therapy. Postgrad Med. 1956;20:667–673. 2. Sanchis J, Corrigan C, Levy ML, and Viejo JL: Inhaler devices—From theory to practice. Respir Med. 2013;107:495– 502. 3. Giraud V, and Roche N: Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J Off J Eur Soc Clin Respir Physiol. 2002;19:246–-251. 4. Melani AS, Canessa P, Coloretti I, DeAngelis G, DeTullio R, Del Donno M, Giacobbe R, Scarlato I, Serafini A, Barbato N, Vaghi A, and Sestini P; Educational Study Group of the Italian Association of Hospital Pulmonologists (AIPO): Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. Fisiopatologia e Riabilitazione Respiratoria, Policlinico Le Scotte, Azienda Ospedaliera Senese, Siena, Italy. [email protected]: Elsevier Ltd; 2011;105:930–938. 5. Global strategy for asthma management and prevention. Updated May 2014. http:// www.ginasthma.org/; accessed July 25, 2014.
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6. Plaza V, Fernandez M, Lopez A, Molina J, Navarro D, JA Quintano, Soler R, Go´mez F, Quirce S, and Villa JR: Spanish Guide for Asthma Management (GEMA 2009). Arch Bronconeumol. 2009;2:1–35. 7. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014. Global strategy for diagnosis, management, and prevention of COPD. Available at: http://www.goldcopd.org/ uploads/users/files/GOLD_Report_2014_Jan23.pdf. Last access: 7/25/14. 8. Giner J, Talamo C, Plaza V, Casan P, Lopez-Vin˜a A, Lopez de SantaMaria E, Fernandez MJ, Neffen H, and Rodrigo JG: SEPAR-ALAT Consensus on Inhaled Therapy. Arch Bronconeumo. 2013;49:1–14. 9. Laube BL, Janssens HM, de Jongh FH, Devadason SG, Dhand R, Diot P, Everard ML, Horvath I, Navalesi P, Voshaar T, and Chrystyn H; European Respiratory Society; International Society for Aerosols in Medicine: What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J Off J Eur Soc Clin Respir Physiol. 2011;37:1308–1331. 10. Chopra N, Oprescu N, Fask A, and Oppenheimer J: Does introduction of new ‘‘easy to use’’ inhalational devices improve medical personnel’s knowledge of their proper use? Ann Allergy, Asthma Immunol. 2002;88:395–400. 11. Hanania NA, Witmtman R, Kesten S, and Chapman KR: Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breathactuated dry powder inhalers. Chest. 1994;105:111–116. 12. Plaza V, Sanchis J, Roura P, Molina J, Calle M, Quirce S, Viejo JL, Caballero F, and Murio C. Physicians’ knowledge of inhaler devices and inhalation techniques remains poor in Spain. J Aerosol Med Pulm Drug Deliv. 2012;25:16–22. 13. Mar Institute of Medical Research Foundation. Granmo. Freeware sample calculation programme. http://www.imim .cat/ofertadeserveis/en_granmo.html. Last access: 3/23/15. 14. Lenney J, Innes JA, and Crompton GK: Inappropriate inhaler use: Assessment of use and patient preference of seven inhalation devices. EDICI. Respir Med. 2000;94:496–500. 15. Welch MJ, Nelson HS, Shapiro G, Bensch GW, Sokol WN, Smith JA, and Parasuraman BM: Comparison of patient preference and ease of teaching inhaler technique for Pulmicort Turbuhaler versus pressurized metered-dose inhalers. J Aerosol Med Pulm Drug Deliv. 2004;17:129–139. 16. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, and Vollmer WM, and the Better Outcomes of Asthma Treatment (BOAT) Study Group: Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010;181:566–577.
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17. Felez MA, Gonzalez Clemente JM, Cardona Q, Montserrat JM, and Picado C: Skill in the handling of aerosols by health care personnel. Rev Clin Esp. 1991;188:185–187. 18. Interiano B, and Guntupalli KK: Metered-dose inhalers. Do health care providers know what to teach? Arch Intern Med. 1993;153:81–85. 19. Jones JS, Holstege CP, Riekse R, White L, and Bergqvist T: Metered-dose inhalers: Do emergency health care providers know what to teach? Ann Emerg Med. 1995;26:308– 311. 20. Plaza V, Giner J, Go´mez J, Casan P, and Sanchis J: Health workers’ knowledge and skills regarding the use of the Turbuhaler inhaler. Arch Bronconeumol. 1997;33:113–17. 21. Scarpaci LT, Tsoukleris MG, and McPherson ML: Assessment of hospice nurses’ technique in the use of inhalers and nebulizers. J Palliat Med. 2007;10:665–679. 22. Dı´az-Lo´pez J, Cremades-Romero MJ, Carrio´n-Valero F, Maya-Martı´nez M, Fontana-Sanchı´s I, and Cuevas-Cebrian E: Evaluation of the management of inhalers by the nursing personnel in a reference hospital. An Med Interna. 2008;25:113–16. 23. Mucha˜o FP, Perı´n SL, Rodrigues JC, Leone C, and Silva Filho L: Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metereddose inhalers. J Bras Pneumol. 2008;34:4–12. 24. Basheti I, Qunaibi E, Hamadi S, and Reddel HK: Inhaler technique training and health-care professionals: Effective long-term solution for a current problem. Respir Care. 2014;59:1716–1725.
Received on November 27, 2014 in final form, April 8, 2015 Reviewed by: Arlene Smaldone Frans DeJongh Address correspondence to: Jordi Giner Donaire, MD Servei de Pneumologia Hospital de la Santa Creu i Sant Pau Sant Antoni M. Claret 167 08025 Barcelona Spain E-mail: [email protected]
(Appendix follows /)
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Appendix 1
1. Age (years) 2. Sex: Male/Female 3. Work place 3.1 Primary Care; 3.2 Hospital 4. Medical specialty: 4.1 Internal medicine 4.2 Primary care 4.3 Pneumology 4.4 Allergy 4.5 Pediatry 4.6 Other 5. Which area of Spain do you work in?: 5.1 North (Galicia, Asturias, Cantabria, Basque Country, Navarra, La Rioja) 5.2 Central (Castilla-Leon, Castilla-La Mancha, Madrid) 5.3 South (Extremadura, Andalucia) 5.4 East (Aragon, Catalonia, Valencia, Murcia, Baleares) 5.5 Canary Islands, Ceuta and Melilla 6. Your knowledge of inhaler use comes mainly from: 6.1 Attendance at meetings, courses, or workshops organized by scientific societies 6.2 Attendance at meetings, courses, or workshops organized by pharmaceutical industries 6.3 Reading articles or books specialized on the topic 6.4 Reading the leaflet included with the inhaler devices 6.5 Directly from personal clinical experience and common sense 7. In the column ‘‘a’’ indicated ALL devices that you known and in column ‘‘b’’ what is your preferred device (ONLY ONE) a) Turbuhaler, Accuhaler, pMDI, pMDI with inhalation chamber, pMDI Modulite system, Novolizer, Aerolizer, Handihaler, Easyhaler, Breezhaler, Respimat, Twisthaler b) Turbuhaler, Accuhaler, pMDI, pMDI with inhalation chamber, pMDI Modulite system, Novolizer, Aerolizer, Handihaler, Easyhaler, Breezhaler, Respimat, Twisthaler 8. The most important step for correct pMDI inhalation is: 8.1 Shake the device before inhalation 8.2 Exhale deeply before inhalation 8.3 Firing the device after beginning inspiration 8.4 Inhale deeply and forcefully 8.5 Continue deep, slow inspiration 9. The most important step for correct DPI inhalation is: 9.1 Shake the device before inhalation 9.2 Exhale deeply before inhalation 9.3 Firing the device after beginning inspiration 9.4 Inhale deeply and forcefully 9.5 Continue deep and slow inspiration 10. When you prescribe an inhaler device, which of the following variables do you consider most important? 10.1 The disease being treated 10.2 The patient’s preferences 10.3 The patient’s age 10.4 The patient’s previous experience using a specific inhaler 10.5 The patient’s cultural level 11. In your centre when is prescribed a new inhaler do you or another healthcare worker assess the patient’s skill with its use? 11.1 Always 11.2 Usually 11.3 Sometimes 11.4 Hardly ever 11.5 Never 12. Who trains the patients on the inhaler device technique at your center? 12.1 Doctor 12.2 Nurses 12.3 Either the nurse or doctor, it depends 12.4 Nobody, but we provide written information 12.5 Nobody, and we don’t give written information
Knowledge and Attitudes of Nurses in Spain about Inhaled Therapy: Results of a National Survey Jordi Giner, MSc, RN,1 Pere Roura, MB, MPH,2 Carme Herna´ndez, MSc, RN,3 Montserrat Torrejo´n, MSc, RN,1 Meritxell Peiro´, MSc, RN,1 M a Jesu´s Ferna´ndez, RN,4 Elena Lo´pez de Santa Marı´a, RN,5 M a Angeles Gimeno, MSc, RN,6 Vicente Macian, RN,7 Eduard Tarragona, MD,8 and Vicente Plaza, MD, PhD1
Abstract
Background: The main problem with inhalation therapy is incorrect use of inhalers. Nurses’ limited knowledge may contribute to this situation. This study aimed to assess the level of knowledge and attitudes of respiratory nurses about inhaled therapy. Methods: A 12-item multiple-choice questionnaire was sent to members in the Nursing Area of the Spanish Society of Pneumology and Thorax Surgery and to nurses working with respiratory patients using inhalers devices. The survey was voluntary, self-administered, and anonymous. It collected demographic characteristics, preferences, and knowledge and education about devices and inhalation technique. Results: A total of 1496 nurses completed the questionnaire correctly. Results showed 65.4% preferred dry powder inhalers (DPI), 8.7% were familiar with all 12 devices listed, 59.6% identified ‘‘firing the device after beginning inspiration’’ as the most important step when using the pressurized metered dose inhaler (pMDI), 53.5% identified ‘‘inhale deeply and forcefully’’ as the most significant step using DPI, and 20.4% ‘‘always checked a patient’s inhalation technique when a new inhaler was prescribed.’’ A composite, variable, general inhaled therapy knowledge pooled the correct answers related to knowledge and showed only 14% of nurses had adequate knowledge of inhaled therapy. Conclusions: In spite of recent training activities, knowledge concerning use of inhaler devices among Spanish nurses managing patients with respiratory diseases continues to be poor. Improvements are also needed in patient education and follow-up of inhalation techniques. Undergraduate and postgraduate educational programs need to be further developed. Key words: DPI, inhalation devices, inhalation technique, inhaled therapy, misuse of pMDI, nurse, pMDI though simpler and more effective devices have appeared since the first pressurized metered dose inhaler (pMDI), the Medihaler, was introduced in the 1950s,(1) the issue of their proper use persists. The main disadvantage of the inhaled route is that it demands a technique with which many patients are not familiar, compromising the effectiveness of this
Introduction
I
nhalation is the delivery route of choice for bronchodilator and anti-inflammatory drugs. Its main advantages are rapid onset of action, greater therapeutic effect with a smaller dose, and fewer side effects. However, al-
1 Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d’Investigacio´ Biome´dica Sant Pau (IIB Sant Pau), Universitat Auto`noma de Barcelona, Department of Medicine, Barcelona, Spain. 2 Service of Clinical Epidemiology, Hospital General de Vic, Barcelona, Spain. 3 Integrated Care Unit, Medical and Nursing Direction, Hospital Clı´nic, IDIBAPS, CIBER de Enfermedades Respiratorias (CIBERES), Universitat de Barcelona, Spain. 4 Lung Management Area, Central University Hospital of Asturias, Oviedo, Spain. 5 Pneumology Department, Hospital Universitario Cruces, Barakaldo, Basque Country, Spain. 6 Service of Pneumology, Hospital de Palamo´s, Palamo´s, Girona, Spain. 7 Service of Pneumology, Hospital Arnau de Vilanova, Valencia, Spain. 8 Medical Advisor of Medical Department Chiesi, L’Hospitalet del Llobregat, Barcelona, Spain.
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NURSE KNOWLEDGE ABOUT INHALED THERAPY
Table 1. Device Knowledge and Preferences Device Dry Powder Inhaler (DPI) Turbuhaler Accuhaler (Diskus) Handihaler Aerolizer Novolizer Breezhaler Easyhaler Respimat Twisthaler Metered Dose Inhaler (pMDI) pMDI pMDI + Chamber pMDI Modulite
(4a) Device (4b) Preferred knowledge (%) (%) 93.6 89.1
65.4 35.6 18.4
38 34.2 30.6 28.6 26.6 23.9 17.5
3.4 0.6 1.9 1.6 0.2 2.1 1.6 34,7
84.8 84.6 38.5
6.8 23.2 4.7
Device knowledge (4a): multiple choice; preferred (4b): only one device accepted.
approach. Studies show that the percentage of patients correctly using pMDIs ranges from 0% to 77%,(2) and in the case of dry powder inhalers (DPIs), it is from 0% to 66%.(2) Such indications of wide misuse may lead to poor control of both asthma and COPD.(3,4) For this reason, the main guidelines on asthma and COPD, such as GINA (Global Initiative for Asthma)(5) GEMA (Spanish guide to manage asthma, in its Spanish acronym),(6) and GOLD (Global Initiative for Chronic Obstructive Lung Disease),(7) recommend education and training in all stages of the disease. Training and follow-up in the use of inhaler devices are regarded as the most important steps in the education programs. Similarly, national societies, such as the Spanish Society of Pneumology and Thoracic Surgery (SEPAR)(8) and international societies such as the European Respiratory Society (ERS) and the International Society of Aerosol in Medicine (ISAM)(9) have developed guidelines and consensus for the use of inhaled therapy. But are healthcare personnel responsible for instructing patients in the use of inhalation devices competent and knowledgeable in the proper technique? Several studies have found that their level of knowledge is low, being 54%(10) for
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pMDIs and between 12% and 35%(11) for DPIs. Plaza et al.(12) recently published the results of the OPTIM survey on knowledge about inhaled therapy among 1514 respiratory disease physicians in Spain. The conclusions indicated that physicians’ knowledge about inhaler devices and inhalation remains inadequate. Since nurses in many settings provide a continuum of care and are responsible for teaching patients how to use inhalers, we would expect to find more favorable results. Using a survey and method similar to a previous study in physicians, our aim was to assess knowledge and attitudes about inhaler devices among nurses working directly with patients with asthma or COPD.(12) Material and Methods
We performed a multicenter study to assess knowledge, attitudes, and preferences regarding inhaled therapy among nurses providing training and follow-up of patients with asthma or COPD. Participants worked in pneumology, primary care centers, allergy, and internal medicine areas in Spain. They completed a self-administered questionnaire with 12 categorized multiple choice or numerical closed questions, similar to that used in the OPTIM study for physicians,(12) with the addition of question 4b (see Appendix 1). The questionnaire took less than 5 minutes to answer. Participation in the study was voluntary and anonymous. Between September and October 2012, a first set of webbased surveys was sent by email (Google-Drive) to the 257 members of the Nursing Area of SEPAR (The Spanish Society of Pneumology and Thoracic Surgery). They were asked to forward the survey to other nurses they knew working directly with patients receiving inhaled therapy. Between October 2012 and March 2013, a paper version of the questionnaire was distributed to other nurses in Spain who worked in relation to respiratory patients but had not been sent the survey by e-mail. All possible participants were specifically asked to return only one completed survey if they received it from more than one source. The questionnaire was identical in its e-mail and paper forms, and it had three parts. The first part, questions 1 to 5, was about sociodemographic data and the department where the participant worked. The second part, containing questions 6 to 9, asked participants about their knowledge of inhaled therapy, types of devices, their preferred device, and their technical knowledge about pMDIs, inhalation chambers, and
FIG. 1.
Percentage of known devices.
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Pneumology (n = 404)
Allergy (n = 135)
Primary care (n = 528)
Internal medicine (n = 57)
Values are shown as the mean with percentages in brackets. DPI = dry-powder inhaler; ns = not significant; pMDI = metered-dose inhaler; SD = standard deviation. *Correct answers for items 8, 9, 10, and 11 used to generate the composite variable general inhaled therapy knowledge.
Demographic Characteristics Age, mean (SD) 46.1 (9.4) 47.0 (9.5) 46.3 (10.4) 46.1 (9.1) 46.1 (8.5) Men/Women, % 18/82 12/88 10/90 22/78 16/84 Preferences ITEM 6. Your knowledge of inhaler use comes mainly from (valid surveys, n = 1,429) - Meetings by scientific societies 377 (26.4) 107 (27.1) 27 (20.1) 140 (26.6) 10 (18.2) - Meetings by industries 250 (17.5) 49 (12.4) 16 (11.9) 105 (19.9) 10 (18.2) - Reading scientific articles 160 (11.2) 56 (14.2) 13 ( 9.7) 58 (11.0) 7 (12.7) - Reading the leaflet device 139 ( 9.7) 21 (5.3) 13 ( 9.7) 68 (12.9) 7 (12.7) - Personal experience 328 (23.0) 99 (25.1) 46 (34.3) 106 (20.1) 15 (27.3) - Two or more sources of knowledge 175 (12.2) 63 (15.9) 19 (14.2) 50 ( 9.5) 6 (10.9) Issues Related to the Knowledge of Inhalation Techniques and Prescription ITEM 8:The most important step for correct pMDI inhalation is: (valid surveys, n = 1,415) - Shake the device before inhalation 147 (10.4) 33 (8.3) 14 (10.7) 58 (11.2) 3 (5.4) - Exhale deeply before inhalation 130 ( 9.2) 29 (7.3) 6 (4.6) 58 (11.2) 5 (8.9) - Firing the device after beginning inspiration* 844 (59.6) 281 (70.8) 80 (61.1) 280 (53.9) 36 (64.3) - Inhale deeply and forcefully 123 ( 8.7) 26 (6.6) 13 (9.9) 47 (9.1) 8 (14.3) - Continue deep, slow inspiration 171 (12.1) 28 (7.1) 18 (13.7) 76 (14.6) 4 (7.1) ITEM 9: The most important step for correct DPI inhalation is: (valid surveys, n = 1,426) - Shake the device before inhalation 48 (3.4) 8 (2.0) 5 (3.7) 17 (3.3) 6 (10.7) - Exhale deeply before inhalation 228 (16.0) 63 (15.9) 20 (14.8) 85 (16.3) 10 (17.9) - Firing the device after beginning inspiration 143 (10.0) 21 (5.3) 18 (13.3) 63 (12.1) 7 (12.5) - Inhale deeply and forcefully* 763 (53.5) 242 (61.0) 70 (51.9) 255 (48.9) 27 (48.2) - Continue deep, slow inspiration 244 (17.1) 63 (15.9) 22 (16.3) 101 (19.4) 6 (10.7) ITEM 10: When you prescribe an inhaler device, which of the following variables do you consider most important?: (valid surveys, n = 1,389) - Disease to treat 318 (22.9) 94 (24.5) 32 (25.2) 109 (21.2) 10 (18.9) - Patient’s preferences* 169 (12.2) 50 (13.0) 16 (12.6) 54 (10.5) 13 (24.5) - Patient’s age 364 (26.2) 72 (18.8) 28 (22.0) 160 (31.1) 9 (17.0) - Patient’s experience with device 448 (32.3) 155 (40.4) 38 (29.9) 153 (29.7) 17 (32.1) - Patient’s cultural level 90 ( 6.5) 13 (3.4) 13 (10.2) 39 (7.6) 4 (7.5) Issues Related to Education in Device Inhalation Techniques ITEM 11: In your centre when is prescribed a new inhaler, do you or another healthcare worker assess the patient’s skill in its use? (valid surveys, n = 1,434) - Always* 293 (20.4) 138 (34.5) 35 (26.3) 48 (9.1) 8 (14.0) - Usually 498 (34.7) 154 (38.5) 50 (37.6) 152 (28.9) 23 (40.4) - Sometimes 452 (31.5) 80 (20.0) 42 (31.6) 234 (44.5) 18 (31.6) - Hardly ever 134 ( 9.3) 26 (6.5) 5 (3.8) 60 (11.4) 8 (14.0) - Never 57 ( 4.0) 2 (0.5) 1 (0.8) 32 (6.1) 0 (0.0) ITEM 12: Who trains the patients on the inhaler device technique at your centre? (valid surveys, n = 1,435) - Physicians 130 (9.1) 14 (3.5) 16 (11.9) 55 (10.2) 3 ( 5.5) - Nurses 602 (42.0) 223 (55.3) 56 (41.8) 168 (32.0) 33 (60.0) - Either, nurses or physicians 646 (45.0) 162 (40.2) 61 (45.5) 262 (49.9) 19 (34.5) - Nobody, but written information is provided 21 ( 1.5) 2 (0.5) 1 (0.7) 10 (1.9) 0 (0.0) - Nobody, and written information is not provided 36 (2.5) 2 (0.5) 0 (0.0) 30 (5.7) 0 (0.0) GENERAL KNOWLEDGE (valid surveys, n = 1,443) - Poor (£2 points) 1,241 (86,0%) 308 (76,2%) 119 (88,1%) 488 (92,4%) 51 (89,5%) - Adequate (‡3 points) 202 (14,0%) 26 (23,8) 16 (11,9%) 40 (7,6%) 6 (10,5)
Total sample (n = 1,443)
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001 < 0.001
P (between groups)
Table 2. Results from Questionnaire for Whole Sample and Each Department Where Nurses Work (Excluding Other Departments)
NURSE KNOWLEDGE ABOUT INHALED THERAPY
DPIs. The third part, questions 10 to 12, addressed attitudes and activities in patient education regarding inhalation techniques (see Appendix 1). The level of knowledge about inhaled therapy was assessed by the sum of the correct responses to questions 8, 9, 10, and 11. Correct responses were 8.3, 9.4, 10.2, and 11.1, respectively (see Table 2), based on the recommendations for inhaled therapy.(8,9) Each correct response was scored 1 point. The resulting number generated a new variable, general knowledge about inhaled therapy. This variable was then arbitrarily stratified into two knowledge groups, poor (0, 1, or 2 points) and adequate (3 or 4 points). Quality control of questionnaires
The web-based questionnaire did not allow errors such as blank responses, multiple responses, or incoherent responses. Double data entry was performed for paper-based questionnaires (to detect a minimum of 5% of surveys with blank or unforeseen multiple responses) verifying and guaranteeing the quality of all questionnaires received. The data and values included in the databases therefore accurately reflect what was stated by those surveyed. Statistical analysis
Descriptive statistics were performed for the overall sample. The results for each question were expressed as percentages and compared between department groups. The Chi-square test was used between qualitative variables; analysis of variance (and Bonferroni adjustment) was used when comparisons were between quantitative variables following a normal distribution and qualitative variables. If quantitative variables did not follow a normal distribution, equivalent nonparametric tests, such as the Kruskal-Wallis test, were used for comparison. Independent variables were included in a logistic regression model if significance was obtained in the bivariate analysis, allowing determination of factors defining a profile of adequate knowledge of inhaled therapy. These analyses were performed using IBM SPSS Statistics software version 19 (SPSS for Windows, Chicago, NY, USA). Statistical significance was set at a p value less than 0.05.
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community and family medicine departments and 38 (5.0%) were from pediatric departments. Among the 631 participants who worked at hospital centers, 404 (64.0%) were from pneumology departments, 135 (21.4%) were from allergy departments, 57 (9.0%) were from internal medicine departments, and 35 (5.5%) were from other health care departments. Six hundred and thirty surveys (44.0%) were provided by nursing professionals from Eastern Spain (Catalonia, Aragon, Levante, Balearic Islands, and Murcia). 300 (20.9%) were from Northern Spain (Galicia, Asturias, Cantabria, Basque Country, and La Rioja). 246 (17.2%) were from Central Spain (Castile-Leon, Castile-La Mancha, and Madrid). 193 (13.5%) were from Southern Spain (Andalusia and Extremadura), and 63 (4.4%) were from the Canary Islands, Ceuta, or Melilla. Table 1 shows the inhalation devices known and preferred by participants. The question about devices known was a multiple choice question with more than one acceptable answer. For this reason, the sum of percentages in column 1 exceeds 100. Only one answer was accepted for the question on preferred device (column 2). We found 3.1% knew of only one device and 8.7% knew of all twelve devices listed. The average number of familiar devices was 5.98 (3.06) and the median was 5 (Fig. 1). We found no correlation between participants, ages, and number of devices known or preferred (Kruskal-Wallis test p = 0.001). Overall, 65.4% of nurses preferred dry powder devices, while 34.7% preferred pMDI devices. Table 2 shows the results for questions 6, 8, 9, 11, and 12 in the overall sample and distributed according to speciality. Question 6 showed the source of knowledge about inhaled therapy came mainly from scientific society meetings and personal experience. The most important step in the use of a pMDI, firing the device after beginning inspiration (question 8), was answered correctly by 844 participants (59.6%). For question 9, on the most important step for correct DPI inhalation, the correct response was chosen (inhale deeply and forcefully) by 763 (53.5%). For question 10, ‘‘What variable do you consider most important when you prescribe an inhaler device?’’ 448 (32.3%) chose the response ‘‘Patient’s experience with device’’ rather than the
Results
A total of 1496 surveys (50.2%) were returned from the 2500 sent: 241 via e-mail and 1255 by postal mail. Fiftythree surveys were excluded from analyses: 9 were blank, 23 had 5 or more blank responses, 20 indicated the respondent was not familiar with any of the inhalation devices, and 1 was from a non-nursing professional. A total of 1443 surveys were finally evaluated: 1202 (83.3%) received by postal mail and 241 (16.7%) received by Internet. The mean age of respondents was 46.1 [standard deviation (SD) 9.4] years and 82.1% were women. From the total sample of 1443 participants, 1380 gave information concerning their work place: 777 (56.3%) worked at primary care centers, and 603 (43.7%) worked at hospitals. Of 1197 who specified the department where they worked, 566 were from primary care centers (47.3%), and 631 were from hospitals (52.7%). Among the participants who worked at primary care level, 528 (95.0%) were from
Table 3. Classification in ‘‘Poor’’ or ‘‘Adequate’’ Inhaled Therapy Knowledge for Sample after Excluding Nurses Who Work in Other Departments n (%) Zero points One point Two points Three points Four points TOTAL
Poor knowledge (0–2 points)
Good knowledge (3–4 points)
258 (18) 513 (35.7) 470 (32.6) – – 1241 (86.3)
– – – 192 (13) 10 (0.7) 202 (13.7)
Stratification was made after correct answers were pooled for items 8, 9, 10, and 11 (1 point for each correct answer [marked with an asterisk in Table 2]) in a new composite variable (general inhaled therapy knowledge). Values are shown the as mean with percentages in brackets.
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Table 4. Knowledge Score ‘‘Odds ratio’’ Areas where nurses work Internal Medicine Primary Care Pneumology Allergy Age For each year
95% CI
P
1 0.64 2.53 1.16
0.26–1.59 1.05–6.10 0.43–3.16
0.404 0.036 0.807
1.02
1.00–1.04
0.048
Variable generate with questions 8, 9, 10, and 11.
correct response ‘‘Patient’s preferences,’’ which was the least chosen response, selected by 169 participants (12.2%). In question 11, ‘‘When you prescribe a new inhaler, do you or another health care worker assess the patient’s skills in its use?’’ the responses were varied and the correct response (‘‘Always’’) was the third most chosen option by 293 (20.4%), except for those who stated that they worked in pneumology departments, where the correct response was the second most chosen option, selected by 138 (34.5%). In question 12 on ‘‘Who trains the patients on the inhaler device technique at your centre’’, the most frequent response by 646 (45.0%) was ‘‘Either nurses or physicians,’’ with the exception of pneumology and internal medicine groups where the most frequent response was ‘‘Nurses,’’ 223 (55.3%) and 33 (60.0%). General knowledge about inhaled therapy (Table 3), a variable generated with questions 8, 9, 10, and 11, showed a mean value of 1.43 points (range 0–4) with a standard deviation of 0.95 and a median of 1 point. When grouped by speciality, the highest score, 1.75 (0.95), was obtained by the pneumology group, followed by allergy, 1.49 (0.91) and internal medicine 1.47 (0.89) groups. A significant difference was observed (Kruskal-Wallis test p = 0.001) between scores obtained according to the department where they carried out their care activity. General knowledge of inhaled therapy was classified according to the score obtained as adequate (‡3 points) or poor (£2 points). Table 3 shows that 14.0% (202 respondents) had an adequate general knowledge. The differences between groups were statistically significant, with the highest percentage (23.7%) of adequate knowledge (‡3 points) being found in the pneumology group.
Table 4 presents the multivariate analysis including variables that predict an adequate knowledge of inhaled therapy. Nurses in the respiratory group had a 2.53 odds ratio ( p = 0.036) for the item ‘‘general inhaled therapy knowledge’’ compared to nurses working in an internal medicine department. That is, respiratory nurses showed twice the probability of having adequate knowledge compared with internal medicine nurses. Age also played a role in predicting adequate knowledge, although the statistical significance was low. For each year of age, the probability of achieving adequate knowledge of inhaled therapy increased 2% (odds ration 1:02, p < 0.05). Discussion
The results of our survey show that the general level of knowledge regarding the use of inhalation devices is low among nurses working in this field in Spain. The variable level of knowledge (items 8, 9, 10, and 11) showed that only 14.0% of nurses who participated in the study had adequate knowledge about inhaled therapy. This result is directly comparable with the 14.2% found for the same item using this questionnaire in physicians in the OPTIM study.(12) Regarding the source of knowledge about inhaled therapy (question 6), it is surprising that 23.0% of participants stated that their knowledge came from personal experience, and that only 37.6% indicated that their source of knowledge was through scientific literature or scientific meetings. These figures reflect a lack of formal training in this field and may explain the poor general results, highlighting the need for education and training concerning inhaled therapy to be included in undergraduate study programs in nursing schools. Our results concerning who provides the training in the inhalation technique differed significantly from those in the OPTIM study.(12) Our findings indicated that training was done by either nurses or physicians in 45% of centers, by nurses in 42% of centers, and by physicians in 9.1%, contrasting with the 38.8%, 22.4%, and 34.6%, respectively, published in the OPTIM study.(12) These differences suggest a lack of coordination between these two groups of professionals, a situation that clearly affects the quality of our responses and patient knowledge. It is also of note that only one in five participants routinely checked the patients’ technique in inhalation therapy, a result similar to that in the OPTIM study.(12) In relation to the choice of device, most
Table 5. Results of Multivariate Analysis to Predict Adequate General Inhaled Therapy Knowledge’s Showing Significant Variables Included in Model Author
n
Evaluation
Device
% of good
Felez-1991 (17) Interiano-1993 (18) Hanannia-1994 (11) Jones-1995 (19) Plaza-1996 (20)
41 50
Demonstration Demonstration Demonstration Demonstration Theory Demonstration Demonstration Demonstration Demonstration Theory Demonstration
pMDI pMDI pMDI,Chamber,Turbuhaler pMDI Turbuhaler
32% 18% 82%,78%,12% 45% 2% 6% 54% 68%,50%,35% 29% 4 points/10 7.2, 5.0, 4.9 point/10
Chopra-2002 (10) Scarpaci-2007 (21) Dı´az-Lo´pez-2008 (22) Muchao-2008 (23) Basheti-2014 (24) CI = confidence interval.
75 50 10 47 144 33 40
pMDI pMDI,Chamber,Diskus Chamber Chamber MDI, Turbuhaler, Diskus
NURSE KNOWLEDGE ABOUT INHALED THERAPY
surveyed nurses and physicians chose the response ‘‘Patient’s experience with device,’’ and only a minority chose patient preferences, as would be desirable.(13,14) When we examined our results according to the type of center or department where participants worked, nurses working in a pneumology department showed significantly better scores for all items than nurses working in allergy, primary care, and internal medicine departments.(12) They also, therefore, showed better scores in the combined variable generated (general inhaled therapy knowledge). In the multivariate analysis, nurses from pneumology departments tripled the ‘‘odds ratio’’ (2.53) for ‘‘adequate knowledge’’ in inhaled therapy compared with other groups. We consider this finding is of particular concern, given the large volume of chronic respiratory patients attended at emergency rooms, internal medicine, and allergy departments, and primary care centers. Few studies to date have investigated knowledge and attitudes of nurses to inhaled therapy (Table 5).(10,11,17–24) Comparison with our findings is difficult due to the different research methods. Most previous studies involved a practical demonstration of technique, whereas our data were collected by a written questionnaire. Levels of knowledge in these studies are low however, like our own. The fact that we questioned respondents about their knowledge rather than their skill is a clear limitation of the study, possibly indicating a higher level of knowledge than the participant’s actual skills. Assessment of skills may have been a more reliable measure, but it would have been difficult to score results from a practical demonstration. Nevertheless, compared with a study in our setting in 1996, there appears to be a slight improvement in knowledge by nurses in Spain. The results obtained indicate that specific educational policies should be addressed to nurses working in inhalation therapy. Given our poor results in improving general inhalation therapy knowledge with traditional educational methods, novel strategies should be devised, such as workshops, better knowledge of guidelines, protocols agreed between doctors, and nursing coordination between primary care and specialist care, and especially the inclusion of curricula on inhaled therapy in undergraduate and postgraduate medical and nursery studies. One of these should be the inclusion of inhalation therapy as a topic in pre- and postgraduate training programs. Our study has several limitations. The main limitation is that it investigated theoretical knowledge only. In addition, our results reflect the knowledge of those who responded to the survey and do not necessarily represent all nurses in Spain. Another limitation is that we do not know exactly how many nurses received the web-based survey. To conclude, Spanish nurses managing patients with respiratory diseases continue to have poor knowledge about the use of inhaler devices and training and subsequent follow-up of inhalation techniques, despite the many activities carried out in recent years. New educational strategies specifically addressed to nursing training must be developed. Acknowledgments
The authors would like to thank Carolyn Newey for editorial assistance. The study was supported in part by an unrestricted grant from Chiesi (Spain).
91 Author Disclosure Statement
Ms. Jordi Giner declares that in the last 5 years she has received honoraria for participation in meetings, congresses, or research projects organized by the pharmaceutical or related companies: Chiesi, AstraZeneca, Boehringer-Ingelheim, Laboratorios Dr. Esteve, GlaxoSmithKline, MSD, Novartis, Sandoz, Pfizer, Teva, and Takeda. Ms. Carme Herna´ndez declares that in the last 5 years she has received honoraria for her participation in meetings, congresses, or research projects organized by BoehringerIngelheim, Menarini, Laboratorios Dr. Esteve, Teijin Healthcare, and AldoUnio´n. Ms. Ma Jesu´s Ferna´ndez declares that in the last 5 years she has received honoraria for her participation in meetings, congresses, or research projects organized by the following pharmaceutical or related companies: Chiesi, Laboratorios Dr. Esteve, Teijin Healthcare, Novartis, and Pfizer. Ms. Elena Lo´pez de Santa Marı´a declares that in the last 5 years she has received honoraria for her participation in meetings, congresses or research projects organized by Almirall, Boehringer-Ingelheim, Laboratorios Dr. Esteve, GlaxoSmithKline, MSD, and Novartis. Mr. Vicente Macia´n declares that in the last 5 years he has received honoraria for his participation in meetings, congresses or research projects organized Chiesi, Laboratorio Dr. Esteve, Teijin Healthcare, and Pfizer. Dr. Pere Roura declares that in the last 5 years he has participated in meetings and research projects from Chiesi and Pfizer. Dr. Eduard Tarragona received a stipend as a Medical Advisor from Chiesi. Dr. Vicente Plaza declares that in the last 5 years he received honoraria for speaking at sponsored meetings from AstraZeneca, Chiesi, GlaxoSmithKline, Merck, Novartis, and Pfizer, and as a consultant for Orion and Teva. He also received support for attending meetings from BoehringerIngelheim and for research projects from a variety of government agencies, not-for-profit foundations, and Chiesi, Menarini, and Merck. References
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6. Plaza V, Fernandez M, Lopez A, Molina J, Navarro D, JA Quintano, Soler R, Go´mez F, Quirce S, and Villa JR: Spanish Guide for Asthma Management (GEMA 2009). Arch Bronconeumol. 2009;2:1–35. 7. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014. Global strategy for diagnosis, management, and prevention of COPD. Available at: http://www.goldcopd.org/ uploads/users/files/GOLD_Report_2014_Jan23.pdf. Last access: 7/25/14. 8. Giner J, Talamo C, Plaza V, Casan P, Lopez-Vin˜a A, Lopez de SantaMaria E, Fernandez MJ, Neffen H, and Rodrigo JG: SEPAR-ALAT Consensus on Inhaled Therapy. Arch Bronconeumo. 2013;49:1–14. 9. Laube BL, Janssens HM, de Jongh FH, Devadason SG, Dhand R, Diot P, Everard ML, Horvath I, Navalesi P, Voshaar T, and Chrystyn H; European Respiratory Society; International Society for Aerosols in Medicine: What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J Off J Eur Soc Clin Respir Physiol. 2011;37:1308–1331. 10. Chopra N, Oprescu N, Fask A, and Oppenheimer J: Does introduction of new ‘‘easy to use’’ inhalational devices improve medical personnel’s knowledge of their proper use? Ann Allergy, Asthma Immunol. 2002;88:395–400. 11. Hanania NA, Witmtman R, Kesten S, and Chapman KR: Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breathactuated dry powder inhalers. Chest. 1994;105:111–116. 12. Plaza V, Sanchis J, Roura P, Molina J, Calle M, Quirce S, Viejo JL, Caballero F, and Murio C. Physicians’ knowledge of inhaler devices and inhalation techniques remains poor in Spain. J Aerosol Med Pulm Drug Deliv. 2012;25:16–22. 13. Mar Institute of Medical Research Foundation. Granmo. Freeware sample calculation programme. http://www.imim .cat/ofertadeserveis/en_granmo.html. Last access: 3/23/15. 14. Lenney J, Innes JA, and Crompton GK: Inappropriate inhaler use: Assessment of use and patient preference of seven inhalation devices. EDICI. Respir Med. 2000;94:496–500. 15. Welch MJ, Nelson HS, Shapiro G, Bensch GW, Sokol WN, Smith JA, and Parasuraman BM: Comparison of patient preference and ease of teaching inhaler technique for Pulmicort Turbuhaler versus pressurized metered-dose inhalers. J Aerosol Med Pulm Drug Deliv. 2004;17:129–139. 16. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, and Vollmer WM, and the Better Outcomes of Asthma Treatment (BOAT) Study Group: Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010;181:566–577.
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17. Felez MA, Gonzalez Clemente JM, Cardona Q, Montserrat JM, and Picado C: Skill in the handling of aerosols by health care personnel. Rev Clin Esp. 1991;188:185–187. 18. Interiano B, and Guntupalli KK: Metered-dose inhalers. Do health care providers know what to teach? Arch Intern Med. 1993;153:81–85. 19. Jones JS, Holstege CP, Riekse R, White L, and Bergqvist T: Metered-dose inhalers: Do emergency health care providers know what to teach? Ann Emerg Med. 1995;26:308– 311. 20. Plaza V, Giner J, Go´mez J, Casan P, and Sanchis J: Health workers’ knowledge and skills regarding the use of the Turbuhaler inhaler. Arch Bronconeumol. 1997;33:113–17. 21. Scarpaci LT, Tsoukleris MG, and McPherson ML: Assessment of hospice nurses’ technique in the use of inhalers and nebulizers. J Palliat Med. 2007;10:665–679. 22. Dı´az-Lo´pez J, Cremades-Romero MJ, Carrio´n-Valero F, Maya-Martı´nez M, Fontana-Sanchı´s I, and Cuevas-Cebrian E: Evaluation of the management of inhalers by the nursing personnel in a reference hospital. An Med Interna. 2008;25:113–16. 23. Mucha˜o FP, Perı´n SL, Rodrigues JC, Leone C, and Silva Filho L: Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metereddose inhalers. J Bras Pneumol. 2008;34:4–12. 24. Basheti I, Qunaibi E, Hamadi S, and Reddel HK: Inhaler technique training and health-care professionals: Effective long-term solution for a current problem. Respir Care. 2014;59:1716–1725.
Received on November 27, 2014 in final form, April 8, 2015 Reviewed by: Arlene Smaldone Frans DeJongh Address correspondence to: Jordi Giner Donaire, MD Servei de Pneumologia Hospital de la Santa Creu i Sant Pau Sant Antoni M. Claret 167 08025 Barcelona Spain E-mail: [email protected]
(Appendix follows /)
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Appendix 1
1. Age (years) 2. Sex: Male/Female 3. Work place 3.1 Primary Care; 3.2 Hospital 4. Medical specialty: 4.1 Internal medicine 4.2 Primary care 4.3 Pneumology 4.4 Allergy 4.5 Pediatry 4.6 Other 5. Which area of Spain do you work in?: 5.1 North (Galicia, Asturias, Cantabria, Basque Country, Navarra, La Rioja) 5.2 Central (Castilla-Leon, Castilla-La Mancha, Madrid) 5.3 South (Extremadura, Andalucia) 5.4 East (Aragon, Catalonia, Valencia, Murcia, Baleares) 5.5 Canary Islands, Ceuta and Melilla 6. Your knowledge of inhaler use comes mainly from: 6.1 Attendance at meetings, courses, or workshops organized by scientific societies 6.2 Attendance at meetings, courses, or workshops organized by pharmaceutical industries 6.3 Reading articles or books specialized on the topic 6.4 Reading the leaflet included with the inhaler devices 6.5 Directly from personal clinical experience and common sense 7. In the column ‘‘a’’ indicated ALL devices that you known and in column ‘‘b’’ what is your preferred device (ONLY ONE) a) Turbuhaler, Accuhaler, pMDI, pMDI with inhalation chamber, pMDI Modulite system, Novolizer, Aerolizer, Handihaler, Easyhaler, Breezhaler, Respimat, Twisthaler b) Turbuhaler, Accuhaler, pMDI, pMDI with inhalation chamber, pMDI Modulite system, Novolizer, Aerolizer, Handihaler, Easyhaler, Breezhaler, Respimat, Twisthaler 8. The most important step for correct pMDI inhalation is: 8.1 Shake the device before inhalation 8.2 Exhale deeply before inhalation 8.3 Firing the device after beginning inspiration 8.4 Inhale deeply and forcefully 8.5 Continue deep, slow inspiration 9. The most important step for correct DPI inhalation is: 9.1 Shake the device before inhalation 9.2 Exhale deeply before inhalation 9.3 Firing the device after beginning inspiration 9.4 Inhale deeply and forcefully 9.5 Continue deep and slow inspiration 10. When you prescribe an inhaler device, which of the following variables do you consider most important? 10.1 The disease being treated 10.2 The patient’s preferences 10.3 The patient’s age 10.4 The patient’s previous experience using a specific inhaler 10.5 The patient’s cultural level 11. In your centre when is prescribed a new inhaler do you or another healthcare worker assess the patient’s skill with its use? 11.1 Always 11.2 Usually 11.3 Sometimes 11.4 Hardly ever 11.5 Never 12. Who trains the patients on the inhaler device technique at your center? 12.1 Doctor 12.2 Nurses 12.3 Either the nurse or doctor, it depends 12.4 Nobody, but we provide written information 12.5 Nobody, and we don’t give written information
