Knowledge,Attitudes,and Practices of Intensive Care Unit Nurses Regarding Oral Care for Intubated Patients in Hebron Hospitals,Palestine

Abstract

Introduction

Oral care in intubated patients is essential to prevent ventilator-associated pneumonia and other complications. Intensive care unit (ICU) nurses play a vital role in implementing oral care protocols effectively for intubated patients.

Objective

This study aimed to assess the knowledge, attitudes, and practices (KAP) of ICU nurses in Hebron hospitals, Palestine, regarding oral care for intubated patients.

Methods

A cross-sectional survey was conducted among 108 ICU nurses using a structured questionnaire that covered demographic data, KAP.

Results

Of the participants, 43.45% demonstrated good knowledge, while 56.55% had poor knowledge. Positive attitudes were reported by 77.5% of the nurses, and good practices were observed in 46.5% of them. No significant correlation was found between demographic variables and KAP (p > 0.05). However, a statistically significant positive correlation was found between knowledge and practice (r = 0.474, p < 0.001).

Conclusion

Although most ICU nurses exhibited positive attitudes toward oral care, substantial gaps were identified in their knowledge and clinical practice. These findings highlight the need for continuous education and the implementation of standardized oral care protocols to enhance the quality of care in ICUs.

Keywords

ICU nurses oral care intubated patients knowledge attitudes practices

Introduction

Oral care has been defined as “the science and technology for the prevention of oral diseases, improvement of treatment outcomes, promotion of patient rehabilitation, and enhancement of quality of life (QOL)” (Tang et al., 2022). It is considered one of the fundamental nursing procedures with a significant impact on patient well-being and overall health. Oral hygiene refers to maintaining the cleanliness of the oral cavity, including the gums, teeth, tongue, lips, and dentures (Blessy & Balasubramaniam, 2020).

In intensive care units (ICUs), oral care plays a critical role in influencing patient outcomes. The primary goals of oral care include promoting oral hygiene, reducing dental plaque and microbial colonization in the oropharynx, and preventing aspiration of contaminated secretions (Al-Falahi et al., 2022). Intensive care unit patients are often unable to maintain their own oral hygiene due to their critical conditions. Poor oral hygiene has been associated with colonization of respiratory pathogens, particularly in dental plaque and oral mucosa, which increases the risk of infection (Tang et al., 2022). Additionally, critically ill patients are often immunocompromised and more susceptible to oral infections, such as dry mouth due to medications and oral candidiasis resulting from extensive antibiotic use (Kim et al., 2022).

Mechanical ventilation is a lifesaving intervention for patients with critical illnesses and respiratory failure. It is estimated that more than 300,000 patients receive mechanical ventilation each year. These individuals are at elevated risk for complications such as ventilator-associated pneumonia (VAP), which can lead to prolonged ventilation, extended ICU and hospital stays, increased healthcare costs, and higher morbidity and mortality rates (Ranzani et al., 2022).

The incidence of VAP can be reduced through early intervention and timely diagnosis (Lin et al., 2020). Ventilator-associated pneumonia is a type of hospital-acquired pneumonia that commonly affects patients who are intubated and mechanically ventilated, typically developing within 48–72 h of intubation (Al-Falahi et al., 2022). It affects approximately 5%–40% of patients who are mechanically ventilated for more than two days, with variations depending on country, ICU type, and diagnostic criteria (Papazian et al., 2020).

Nurses play a vital role in providing oral care, particularly for patients who are unable to perform basic self-care. In ICU settings, most patients rely entirely on nurses for oral hygiene due to physical limitations or impaired consciousness (Lombardo et al., 2022). Unfortunately, oral care is often undervalued or deprioritized, and when provided, it is commonly limited to swabbing the mouth with gauze and saline merely for comfort (Asadi & Jahanimoghadam, 2024). It is essential to reframe oral care as a clinical necessity rather than a comfort measure (Blessy & Balasubramaniam, 2020). Since the oral cavity is a major source of upper respiratory infections in ICU patients, oral care should be prioritized to improve patient outcomes and overall QOL (Jun, 2021).

Therefore, ICU nurses’ knowledge, attitudes, and practices (KAP) regarding oral care are critical in preventing complications and delivering high-quality care. The ability to provide effective oral care depends on nurses’ knowledge, skills, and perceptions of its importance (Andersson et al., 2019). The purpose of this study is to evaluate the KAP of ICU nurses regarding oral care for intubated patients.

Aim of the Study

The aim of this study is to evaluate the KAP of ICU nurses in Hebron hospitals, Palestine, regarding the provision of oral care to intubated patients, with the goal of identifying gaps and informing future training and protocol development.

Review of Literature

Prior research has demonstrated that the oral microbiomes of intubated patients undergo significant changes, including an increase in gram-negative bacteria and the emergence of highly aggressive organisms associated with VAP (Asadi & Jahanimoghadam, 2024; Chen et al., 2020). The use of certain medications can reduce saliva production, disrupt the oral environment, and increase the risk of biofilm formation (Oliveira et al., 2014). Maintaining dental hygiene is therefore critically important for mechanically intubated patients, as dental plaque can serve as a reservoir for respiratory pathogens (Ranzani et al., 2022).

Although oral care is typically included in foundational nursing curricula, it is often undervalued—particularly regarding its significance for intubated patients (Sole et al., 2004). Multiple studies have identified several barriers that hinder nurses from performing adequate oral care for critically ill patients. These barriers include the deprioritization of oral hygiene in clinical routines, the lack of standardized oral care protocols for intubated patients, the absence of oral hygiene assessment tools, and insufficient education and training related to oral care (Jun, 2021; Tewelde et al., 2024).

Methodology

Study Design

This study employed a cross-sectional survey design to assess the KAP of ICU nurses in Hebron, Palestine, regarding oral care for intubated patients. A multistage cluster sampling method was used to select the study participants. In the first stage, all hospitals in Hebron were included. In the second stage, all ICUs within these hospitals were selected. In the third stage, a proportionately stratified random sample of ICU nurses was drawn from each unit.

Based on the results of a pilot study, the required sample size was calculated using a 95% confidence level and a 1.5% margin of error. A standard deviation of 10 and an estimated 15% dropout rate were also factored in. The estimated minimum sample size was determined to be 141 ICU nurses.

Research Question

What are the levels of KAP of ICU nurses in Hebron hospitals regarding oral care for intubated patients?

Population Sample

This study targeted all nurses working in the ICUs of hospitals in the Hebron Governorate, including both governmental and private institutions. The total number of ICU nurses in these hospitals was 141, which constituted the study's target population. After applying the inclusion and exclusion criteria, a final sample of 108 ICU nurses from Hebron hospitals was selected.

The study adopted a positivist paradigm, which assumes that reality is objective and can be measured through empirical observation. This approach emphasizes the use of quantifiable data and statistical analysis, aligning with the structured survey methodology employed in this research.

The required sample size was calculated using the G*Power software (version 3.1.9.7), based on a regression analysis with a statistical power of 0.90, an alpha level of 0.05, a medium effect size (0.10), and 10 predictors. The minimum sample size determined was 141. A total of 120 questionnaires were distributed to eligible nurses, and 108 were returned fully completed, resulting in a response rate of 86.4%.

Inclusion Criteria

The inclusion criteria for participation in this study were: (1) currently working as a nurse in an adult ICU, and (2) having prior experience in providing oral care to intubated patients. Nurses were excluded if they were uncooperative, failed to complete more than five questions on the questionnaire, or were on leave during the data collection period.

To facilitate data collection, the head nurse or supervisor in each ICU was responsible for distributing the questionnaires to eligible participants. Completed surveys were collected after three days.

Ethical Approval

Ethical approval for this study was obtained from the affiliated university and the participating hospitals. The research team met with hospital administrators and the head nurses of each ICU to explain the study's purpose and to coordinate an appropriate schedule for data collection. Informed consent was obtained from each participant after a comprehensive explanation of the study's objectives, procedures, and potential implications. Written consent was signed by all participants. Confidentiality was strictly maintained, and participants were informed of their right to withdraw from the study at any point without any consequences. This assurance was clearly stated in the questionnaire documentation.

Study Tools

A self-administered questionnaire was used as the primary tool for data collection in this study. Permission to use the questionnaire was obtained from its original author, Lin et al. (2011). This instrument was selected due to its practicality and comprehensiveness, particularly for assessing oral care practices among ICU nurses caring for intubated patients. It includes detailed questions on the use of oral disinfectant solutions, as well as a grading scale to assess oral hygiene routines—making it both effective and relevant for the study's objectives.

The questionnaire comprised four main sections:

Section One: Demographic information, including age, gender, level of nursing education, and years of work experience. This section also included two additional questions: (1) “Is there an oral care protocol for intubated patients, in the hospital where you are currently working?” and (2) “Do you follow any oral care protocol for intubated patients in the ICU?”

Section Two: Six multiple-choice questions assessing knowledge about oral care cleaning solutions. Participants who answered more than 50% of the questions correctly were categorized as having “good knowledge”; those scoring 50% or less were categorized as having “poor knowledge.”

Section Three: Two questions measuring attitudes. Intensive care unit nurses were asked to rate the importance of oral care in daily physical care activities and as part of therapeutic nursing interventions on a 10-point Likert scale. Scores of 6–10 indicated a “positive attitudes,” while scores of 0–5 indicated a “negative attitudes.”

Section Four: Four questions assessing practice related to oral care. These included: (1) frequency of removing oral secretions, (2) maintaining oral moistness, (3) performing oral care using a toothbrush, and (4) performing oral care using a cotton swab or foam swab. A score above 50% was considered indicative of “good practice,” while scores below this threshold reflected “poor practice.”

To assess the questionnaire's clarity and simplicity, a pilot test was conducted with 25 ICU nurses. Each nurse was asked to rate the clarity of the items on a scale from 1 (not understandable) to 5 (completely understandable). All items received ratings of 4 or 5 from all participants, indicating a high level of clarity. Additionally, four experts in the field evaluated the content validity of the questionnaire using a four-point relevance scale (1 = not relevant, 4 = highly relevant). Their evaluations confirmed the content appropriateness of the instrument.

Validation and Reliability

The validity and reliability of the finalized questionnaire were assessed using test–retest reliability and Cronbach's alpha. To evaluate reliability, a group of 35 ICU nurses completed the questionnaire and were asked to complete it again after two weeks. The intra-class correlation coefficients for the questionnaire items ranged from 0.86 to 0.93, indicating high test–retest reliability. Additionally, internal consistency was measured using Cronbach's alpha, with values of 0.82, 0.85, and 0.88 reported for the KAP sections, respectively—demonstrating strong reliability across all components.

Content validity was evaluated by calculating the Content Validity Index (CVI) for each item. Responses rated as 3 (moderately relevant) or 4 (highly relevant) on a four-point scale were considered acceptable. The CVI for each item was determined by dividing the number of experts who assigned a rating of 3 or 4 by the total number of experts (Boparai et al., 2016).

The average CVI scores for each section were as follows:

Knowledge section: 0.97; attitudes section: 0.92; Practice section: 0.96

These high CVI values confirm the questionnaire's strong content validity and relevance for assessing ICU nurses’ KAP toward oral care for intubated patients.

Data Collection Procedure

Data collection commenced following ethical approval from both the affiliated university and the participating hospitals. The research team visited the ICUs of the targeted hospitals and met with the head nurses to explain the study objectives and obtain permission to distribute the questionnaires.

The self-administered questionnaires were then distributed to eligible ICU nurses. During distribution, the researchers provided a clear explanation of the study's purpose and obtained informed consent from each participant. Data collection took place over a two-week period in each hospital, specifically during the transition between morning and evening shifts—an interval during which nurses were more likely to be available and free from immediate clinical duties.

Participants were encouraged to complete the questionnaire honestly and voluntarily. The estimated time required to complete the survey was 15–20 min. Upon submission, the researchers reviewed each questionnaire to ensure completeness and data quality.

Statistical Analysis

Data analysis was conducted using the Statistical Package for the Social Sciences, version 20. Both descriptive and inferential statistics were utilized. A significance level of 5% was set, with a p-value of less than 0.05 considered statistically significant.

Descriptive statistics, including frequencies and percentages, were used to summarize categorical variables such as gender, level of education, and hospital type. Continuous variables—including age, number of years working in the ICU, and total years of nursing experience—were reported using means and standard deviations. The Chi-square test was employed to examine associations between categorical variables.

Results

Sample Characteristics

The sample consists of 108 ICU nurses from Hebron Hospitals, 53.3% of them are males and 46.7% are female. With average age 29 years and average years of experience 10 years. According to educational level; 59.8% of the nurses have bachelor degree, 29% diploma and 11.2% of them have master degree; 81.3% of them follow oral care protocol for intubated patients in ICU, as in Table 1.

Table 1.

Results of Analyzing the Sample Characteristics.

Variable	Options	CountN = 107	Percentage %
ICU nurses characteristics
Age (mean ±STD)		29.177 ± 6
Gender	Male	57	53.3%
	Female	50	46.7%
Level of education	Diploma Degree	31	29.0%
	Bachelor Degree	64	59.8%
	Master Degree	12	11.2%
Hospital type	Governmental	39	36.4%
	Private	68	63.6%
Hospital name	Hebron governmental Hospital	25	23.4%
	Al-Hasn governmental Hospital	8	7.5%
	Al-Ahli Hospital	54	50.5%
	Al-Mizan specialized Hospital	14	13.1%
	Dura governmental Hospital	6	5.6%
In the hospital where you are currently working, is there an oral care protocol?	No	17	15.9%
	Yes	89	83.2%
	I don't Know	1	0.9%
Do you follow any oral care protocol for intubated patients in intensive care unit?	No	20	18.7%
	Yes	87	81.3%
Years of Experience ((Mean ±STD))	10.0327 ± 17.81142
Total years of experience in ICU (Mean ±STD)	8.3692 ± 17.82612

The Level of ICU Nurses Knowledge Toward Oral Care for Intubated Patient

The researchers ask the ICU nurses to answer some questions to evaluate their Knowledge toward oral care for intubated patient. And table and figure show the summaries of their answers, as in Table 2.

Table 2.

Results of ICU Nurses Knowledge Toward Oral Care for Intubated Patient.

Question	Correct		Incorrect
Question	Answer		Answer
What are the characteristics of ideal oral cleaning Solution?	52	48.6%	55	51.4%
Answer: Maintains oral moistness	52	48.6%	55	51.4%
What are the characteristics of chlorhexidine as oral cleaning solution?	35	32.7%	72	67.3%
Answer: Decreases viscosity of oral mucus	35	32.7%	72	67.3%
What are the characteristics of sodium chloride as oral cleaning solution?	53	49.5%	54	50.5%
Answer: Eliminates debris attached to oral mucus	53	49.5%	54	50.5%
What are the characteristics of hydrogen peroxide as oral cleaning solution?	47	43.9%	60	56.1%
Answer: Remove bad odors	47	43.9%	60	56.1%
What are the characteristics of sodium bicarbonate as oral cleaning solution	48	44.9%	59	55.1%
Answer: Increases viscosity of oral mucus	48	44.9%	59	55.1%
All of the following is oral care effective supplies and equipment for removing dental plaque for intubated patient except?	44	41.1%	63	58.9%

Answer: Toothbrush
Total (Mean of percentage)		43.45%		56.55%

The Level of Attitudes Toward Oral Care for Intubated Patient

To measure the level of attitudes of ICU nurses toward oral care for intubated patient, the researchers ask ICU nurses about the importance of oral care as a nursing activity in the daily activities of physical care, and the importance of it as a therapeutic nursing activity (Table 3).

Table 3.

The Level of Attitudes of ICU Nurses Toward Oral Care for Intubated.

Question	N	Minimum	Maximum	Mean	Std. deviation
What is the importance of oral care as a nursing activity in the daily activities of physical care?	107	3.00	10.00	8.2991	1.74407
What is the importance of oral care as a therapeutic nursing activity?	107	2.00	10.00	7.2523	2.32741
Total				7.77

The results showed that the importance of oral care as a nursing activity in the daily activities of physical care is high with mean 8.2, and the mean of the importance of oral care as a therapeutic nursing activity is 7.2. This is clear in the above table.

The Level of Practice of ICU Nurses Toward Oral Care for Intubated

To measure the level of Practice of ICU nurses toward oral care for intubated, the researchers ask the nurses some questions. The following table displays the results in Table 4.

Table 4.

The Level of Practice of ICU Nurses Toward Oral Care for Intubated.

Question	Good practice		Poor practice
	Count	Percentage	Count	Percentage
		(%)	(%)	(%)
How often do you remove patients’ oral secretions?	51	47.7%	56	52.3%
Answer: once every 8–12 h	51	47.7%	56	52.3%
How often do you maintain patients’ oral moistness?	44	41.1%	63	58.9%
Answer: once every 8–12 h	44	41.1%	63	58.9%
How often do you perform oral care with a toothbrush?	50	46.7%	57	53.3%
Answer: once a day	50	46.7%	57	53.3%
How often do you perform oral with a cotton swab or foam swab?	54	50.5%	53	49.5%
Answer: once every 8–12 h	54	50.5%	53	49.5%
Total (Mean of percentage)		46.5%		53.5%

Hypothesis No.1: There is no significant association between demographic data (age, level of education, and working experience) and the KAP of oral care among ICU nurses in Hebron Hospitals.

Spearman's correlation conducted to check the association between demographic data (age, level of education, and working experience) and the KAP of oral care among ICU nurses in Hebron Hospitals in Table 5.

Table 5.

The Results of Spearman's Correlation Between Demographic Data and the Knowledge, Attitudess, and Practices of Oral Care among ICU Nurses.

Variable			Age	Years of experience	Level of education
Spearman's rho	Knowledge	Correlation coefficient	−0.150	−0.070	−0.048
		p-Value	0.122	0.472	0.625
		N	107	107	107
	Attitudes	Correlation coefficient	0.158	0.091	−0.030
		p-Value	0.103	0.350	0.763
		N	107	107	107
	Practice	Correlation coefficient	0.032	−0.015	−0.018
		p-Value	0.744	0.881	0.852
		N	107	107	107

Hypothesis No.2: There are no significant differences in the level of KAP of oral care among ICU nurse, according to hospital type.

Mann–Whitney test was conducted to check the differences in the level of KAP of oral care among ICU nurse, according to hospital type.

The analysis showed that there is no association between demographic variables (age, level of education, and working experience) and the knowledge, Attitudess, and practices of oral care among ICU nurses in Hebron Hospitals with p-values more than the significance level α = .05.

Hypothesis No.3: There is no significant correlation between knowledge and practices of oral care among ICU nurses in Hebron Hospital.

Spearman's correlation was conducted to check the correlation between knowledge and practices of oral care among ICU nurses in Hebron Hospital (Table 5).

The analysis showed that there is a positive significant correlation r =.474, between the between knowledge and practices of oral care among ICU nurses in Hebron Hospital, with p-value 0.000 which is less than the significance level α = .05. This is clear in Table 6.

Table 6.

The Results of Spearman's Correlation Between the Knowledge and Practices of Oral Care among ICU Nurses.

Variable			Practice
Spearman's rho	Knowledge	Correlation coefficient	.474**
		p-Value	0.000
		N	107

**Correlation is significant at the 0.01 level (two tailed).

Discussion

Nurses play a vital role in delivering care to critically ill patients, bridging clinical expertise with compassionate support. Understanding ICU nurses’ KAP regarding oral care for intubated patients is essential for improving patient outcomes and refining clinical care protocols. This discussion presents the key findings of the current study in relation to previous research on this topic.

The results indicated that nurses’ knowledge and attitudes were not significantly influenced by demographic variables such as education level and work experience. However, the findings did show that nurses’ practices improved with increased knowledge and positive attitudes, suggesting that enhancing knowledge can have a direct effect on care quality.

In terms of knowledge, the study revealed that only 43.45% of participating nurses’ demonstrated good knowledge regarding oral care for intubated patients, while 56.55% exhibited poor knowledge. These findings are inconsistent with those reported by Asadi and Jahanimoghadam (2024) and Lin et al. (2011), where the average knowledge score among 205 nurses was 58.8%. This discrepancy points to possible gaps in the availability of educational resources and standardized training in the study setting.

Supporting this concern, studies by Al-Falahi et al. (2022) and Al-Zaru et al. (2020) have emphasized that many nurses worldwide may lack adequate understanding of evidence-based oral care protocols for mechanically intubated patients. Given the critical importance of knowledge in ensuring high-quality nursing care, it is imperative that healthcare institutions implement continuous education initiatives and standardized training programs to enhance ICU nurses’ competency in this area (Qtait, 2025).

Level of Attitudes among Participants Toward Oral Care for Intubated Patients

This study revealed that 77.5% of nurses maintain a positive attitudes toward oral care for intubated patients. This figure highlights a general recognition of the importance of proper oral care among healthcare providers. A study conducted by Lin et al. (2011) was in harmony with the study findings, which reported that the level of Attitudes among nurses was 79.4%. Positive attitudes may stem from an intrinsic motivation to provide high-quality care, aligning with findings from (Bijarania et al., 2024). However, positive attitudes alone are not sufficient to guarantee effective practice if knowledge and skill levels are not appropriately addressed. A study conducted in Hong Kong was in harmony with the findings shown there is a strong relationship between KAP toward oral care (Wong, 2020). Another study shown that a relationship between attitudes-practice indicated a positive significant correlation (Sumampouw et al., 2019).

Level of Practice among Participants Toward Oral Care for Intubated Patients

Despite the prevalence of positive attitudes, only 46.5% of nurses showed good practice in providing oral care to intubated patients. This gap between attitudes and practice points to a persistent disconnect between intention and implementation. Research by Blessy and Balasubramaniam (2020) and Haghighat et al. (2019) indicates that factors such as job status, age, burnout, and recent training can affect how care is provided. For instance, contract nurses often receive more current training, while younger nurses may have improved practices due to reduced burnout. Our findings highlight the importance of aligning KAP through consistent protocols and ongoing training.

This study shows that there are no significant relationships between level of education and nurses’ experience in terms of KAP (p ≥ 0.05). Further comparative studies did not support these findings and added depth to our understanding of this issue. One study emphasizes the impact of education and professional experience on the attitudes and practices of nurses regarding oral care in ICU settings. Nurses with more recent training and experience with established protocols tend to perform better in providing consistent oral care (Hoben et al., 2017).

Another significant factor is the availability of resources and standardized guidelines. A review found that the absence of standardized protocols and the inconsistency in available resources, like appropriate oral care tools, contribute to the variability in care practices. Nurses often rely on foam sticks and oral swabs instead of recommended small, soft-bristle brushes with suction capabilities, leading to suboptimal care (Zainib et al., 2024; Cabrita-Xavier et al., 2023).

This study found a significant positive correlation (r = 0.474) between ICU nurses’ knowledge and their practices regarding oral care. This means that as nurses become more knowledgeable about oral care for intubated patients, their adherence to effective practices improves. This relationship aligns with the World Health Organization (WHO) that emphasizing the importance of a well-educated workforce for optimal patient care (WHO, 2022).

Al-Falahi et al. (2022) identified a direct link between knowledge and oral care practices among nurses in Sana'a, Yemen. Nurses who were more knowledgeable followed proper oral care protocols more consistently, while those with less knowledge often did not adhere to the recommended practices. A finding aligns with this study’s findings that understanding appropriate oral care guidelines directly affects how nurses apply them in clinical settings.

Bijarania et al. (2024) emphasized that nurses with more advanced educational backgrounds demonstrated better oral care practices for intubated patients in India. Their findings suggest that continuous professional education is essential for bridging the gap between knowledge and practice. However, in contrast to their results, the current study found no statistically significant differences in knowledge, attitudes, or practice based on nurses’ educational levels. This indicates that, in the present sample, factors other than formal education may be influencing oral care behaviors.

In comparison with findings from Vucelić et al. (2024) and Jun (2021), the present study suggests that ICU nurses in Palestine may be more aware of the critical importance of oral care for intubated patients. However, it is important to note that different tools were used across studies, which may account for discrepancies in the reported outcomes. Other recent research has also shown varied levels of knowledge. For instance, Jahani and Poursangbor (2022) reported that a large proportion of ICU nurses in Korea lacked formal education in oral care and had never received any structured training.

These findings collectively highlight the urgent need to implement structured oral care programs and ongoing professional development initiatives in ICU settings. Such programs are especially critical for nurses with limited clinical experience, as they can enhance both knowledge and attitudes toward oral care. Developing and implementing evidence-based training tailored to ICU environments could significantly improve nurses’ practice and ultimately contribute to better patient outcomes.

Limitations

While the use of a self-administered questionnaire allows for rapid data collection and respondent convenience, it is vital to recognize the method's possible limits in dependability. Respondents may understand questions differently, resulting in varying levels of answer accuracy. Furthermore, the lack of direct researcher interaction during completion may lead to a preference for socially acceptable comments rather than actual reflections, particularly on sensitive issues. To address these problems, future research may include follow-up interviews or triangulate data-gathering techniques to improve the validity of findings.

The best research method for this study was observational using structured interviews to collect data instead of self-administered questionnaires, but since no approval was obtained from hospitals to conduct structured interviews, self-administered questionnaires.

A small sample size can minimize the generalizability of the study findings. Not all nurses cooperated in completing the questionnaire for the included hospitals.

Implication for Practice

The findings of this study have important implications for clinical practice in ICUs. Although most ICU nurses demonstrated positive attitudes toward oral care for intubated patients, significant gaps in knowledge and actual practice were identified. These discrepancies highlight the urgent need to enhance nurses’ competencies through structured, evidence-based training programs. Developing and implementing standardized oral care protocols across all hospitals are essential to ensure consistency and adherence to best practices. These guidelines should provide clear instructions regarding techniques, frequency, and appropriate supplies for oral hygiene. Furthermore, hands-on workshops and simulation-based training can help nurses effectively apply these protocols in real clinical settings. Integrating oral care education into nursing curricula and ICU orientation programs can further reinforce the importance of this aspect of care. Regular audits, supervision, and feedback mechanisms should also be introduced to monitor compliance and support continuous quality improvement. By addressing the identified knowledge and practice gaps, healthcare institutions can reduce the risk of VAP, improve patient outcomes, and strengthen the overall quality of critical care nursing.

Conclusion

In summary, the evaluation of KAPs surrounding oral care for intubated patients reveals that while most nurses maintain a positive attitude, there are still areas for improvement in their knowledge and practices. Closing this gap demands a multifaceted strategy, including thorough training, standardized care protocols, and consistent professional development for nurses.

By focusing on these measures, healthcare organizations can help nurses convert their positive attitudes into effective practices, leading to better outcomes for patients.

Footnotes

Acknowledgments

The authors acknowledge the midwives who participated in the study.

ORCID iDs

Nesreen Alqaissi

Mohammed Qtait

Ethical Approval and Consent to Participate

Ethics approval was obtained from the University Ethics review committee (ppu.nur-48/01/24). Informed consent was obtained from each participant with an assurance of anonymity and confidentiality.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data for this study would be available upon reasonable request from the principal investigator.

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