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Abstract

Introduction

Patients who have experienced a stroke are at risk of developing aspiration pneumonia. The risk of aspiration pneumonia is often attributed to dysphagia, which is a condition observed in stroke patients due to the weakening of the muscles involved in swallowing. Nursing care related to oral hygiene, feeding, positioning, and mobilization can reduce the risk of aspiration pneumonia in poststroke patients. This study aims to explore nurses’ experiences with prevention practices for aspiration pneumonia in poststroke patients.

Methods

This study employed a qualitative, exploratory, descriptive design. Twelve registered nurses were recruited from the stroke unit of a Teaching Hospital in Accra, Ghana. Data were collected through in-depth, face-to-face, semi-structured interviews, using an interview guide. The data were transcribed and analyzed using thematic analysis.

Results

The findings revealed two main themes and five subthemes about nurse practice to prevent aspiration pneumonia in poststroke patients. They included prevention practices, describing what participants thought were prevention practices for aspiration pneumonia. The second theme, attitudes towards prevention practices, generated the participants’ beliefs and attitudes as they related them to carrying out various prevention practices. Highlights of the findings included the participants’ detailed descriptions of the preventative measures they utilized and their positive attitudes towards the various patient-centered prevention practices they detailed. These encompassed a dynamic process of care, attentiveness to signs and symptoms of aspiration in poststroke patients, and perceptions of the negative aspects of prevention practices.

Conclusions

Nursing practice should place strong emphasis on the critical role nurses play in preventing respiratory complications, particularly aspiration pneumonia, in poststroke patients. In addition, further research into the burden of pneumonia among stroke survivors and the effectiveness of nurse-led preventive interventions is essential for enhancing the quality of poststroke care.

Keywords

aspiration pneumonia prevention nurses nursing practices stroke

Introduction

A stroke is a neurological condition that occurs when blood flow to the brain is blocked or sudden bleeding causes damage to brain cells (NHLBI, 2022). Globally, stroke is the second leading cause of death and the third leading cause of death and disability combined (Feigin et al., 2022). Patients with stroke may experience aspiration pneumonia (AP) due to swallowing problems.

Prevention practices for AP in patients with stroke are within the fundamentals of nursing practice. Nurses have the most interactions with patients and are best equipped to implement preventive care practices to reduce the incidence of AP among patients with stroke (Wilkinson et al., 2021). However, nurses require appropriate training, educational opportunities, and workplace support to implement screening protocols effectively in the prevention of AP (Green et al., 2021; Hines et al., 2016). Nevertheless, preventive care can be influenced by the nurse's culture or beliefs surrounding stroke recovery and prevention of complications (Opoku et al., 2020). Therefore, this outlines how nursing interventions can contribute to the prevention of AP.

Review of Literature

Aspiration is the outcome of impaired swallowing, which permits inhalation of oropharyngeal (oral) or upper gastrointestinal (stomach) contents into the airway (Mandell & Niederman, 2019; Neill & Dean, 2019). This can lead to AP, a respiratory illness caused by various bacteria that can enter the lungs (Musher et al., 2017; Suzuki et al., 2021). AP can be difficult to diagnose formally because of the mechanisms of the condition and the tendency for symptoms to range from overt to occurring silently (Mandell & Niederman, 2019; Pekacka-Egli et al., 2021).

According to Yoshimatsu et al. (2020), neurological health conditions such as stroke can contribute to the development of AP. As of 2019, the World Stroke Organization reported there were 12.2 million new cases of stroke and 6.55 million deaths. Feigin et al. (2022) reported that the stroke burden is increasing rapidly and negatively impacting the adult population in low- and middle-income countries (LMICs), where 90% of the stroke burden currently resides. The neurological effects of stroke impair swallowing, a condition known as dysphagia, which causes a poor gag reflex and reduces the affected person's ability to clear oral secretions (Feng et al., 2019; Yoshimatsu et al., 2020). Consequently, stroke patients may aspirate and develop pneumonia, leading to longer hospital stays and higher rates of morbidity and mortality, with a substantial economic effect on healthcare resources (Eltringham et al., 2020; Teh et al., 2018; Teuschl et al., 2018), which may be significant in LMICs.

Stroke-associated pneumonia (SAP) is normally considered secondary to aspiration (Hannawi et al., 2013). SAP describes pulmonary infections that occur in nonventilated patients with stroke within the first week after the onset of the condition. As a common complication following stroke, some of the main risk factors for SAP include the severity of the stroke, dysphagia, female sex, advanced age, and disturbances of consciousness, in addition to comorbidities such as coronary artery disease and chronic obstructive pulmonary disease (Eltringham et al., 2020; Liu et al., 2022; Tinker et al., 2021). Although there are multiple causes of SAP, a combination of dysphagia leading to oropharyngeal aspiration and gastric contents into the lungs, and stroke-induced immunosuppression due to acute cerebral ischemia, has been proposed as a possible mechanism (Eltringham et al., 2020; Teh et al., 2018). The risk of SAP may be three times higher among patients with dysphagia, with an increasing risk in patients diagnosed with aspiration (Eltringham et al., 2020).

SAP is a potentially preventable respiratory complication if patients are identified early and interventions are implemented to reduce the risk of infection (Teh et al., 2018). Hence, early recognition of high-risk patients of SAP may help healthcare professionals, including nurses, to monitor the condition and ensure timely management, which is needed to reduce the risk of SAP (Zhang et al., 2022; Liu et al., 2022; Li et al., 2014). Nurses can contribute to preventing AP by ensuring proper oral care to prevent oral infections, positioning patients correctly, and using safe feeding techniques during meals, especially when nasogastric tubes (NGTs) are in place. Encouraging early mobilization during hospitalization also helps (Lyons & Kollef, 2018; Mandell & Niederman, 2019; Tamburri et al., 2020). According to Hines et al. (2016), nurses play a key role in screening patients for dysphagia and monitoring their progress or decline in swallowing ability. Additional studies have shown that implementing a dysphagia screening tool upon hospital admission can lower patients’ risk of developing AP (Palli et al., 2017; Yoo et al., 2021a).

To provide the best respiratory-based care to patients following a stroke, nurses must strive to maintain both technical (i.e., swallow assessment) and non-technical (oral care) skills by seeking opportunities to modify ward-based practices as needed (Johnson & Smith, 2016). For patients with stroke who are experiencing dysphagia, the condition must be identified early, and aspiration must be prevented to reduce the risk of further respiratory complications (Chang et al., 2022; Yoo et al., 2021b). Early speech and language specialist screening of dysphagia and swallow assessment may reduce the risk of SAP. However, these specialists are few in Ghana, and in their absence, general nursing staff can provide quality care for patients with dysphagia (Baatiema et al., 2017; Pandian et al., 2020).

Numerous studies from countries in Sub-Saharan Africa have shown that AP accounts for 33%–39.4% of stroke-related complications in hospitals and is the only factor influencing 30-day mortality in poststroke patients (Abubakar & Jamoh, 2017; Asgedom et al., 2020; Diendéré et al., 2021; Fekadu et al., 2019; Youkee et al., 2021). However, the literature on the role of nurses in preventing AP among stroke patients in Ghana is limited. Some argue that preventive practices are effective because intervention studies have shown little to no change in pneumonia rates after these practices were implemented, especially regarding enteral feeding and oral care (Brogan et al., 2015; Campbell et al., 2020). Does this mean nurses should avoid engaging in these practices? The evidence supporting these preventive measures indicates that nurses should continue to incorporate them into their care for stroke patients to improve recovery and prevent respiratory infections. Therefore, this study aimed to examine the prevention practices for AP in poststroke patients among nurses, to identify the various practices nurses use to prevent AP, and to explore their attitudes regarding prevention in the stroke unit of a teaching hospital in Accra.

Methods

Study Design

This study used a qualitative research method with an exploratory descriptive design. The use of a qualitative method helps develop an understanding of participants’ views of a phenomenon by describing and interpreting the meaning of their work experiences (Polit & Beck, 2014). Again, a qualitative study was chosen to explore diverse perspectives, describe the phenomenon (prevention of AP) in detail, contextualize attitudes and preventive practices among nurses, and capture the unique voices of the participants. An exploratory descriptive design was suitably selected for this study to explore and describe nurses’ day-to-day practices, perspectives, and experiences with preventing AP in poststroke patients. Data was collected using an interview guide through in-depth, face-to-face, semi-structured interviews and analyzed using thematic analysis (Braun & Clarke, 2006; DeJonckheere & Vaughn, 2019).

Setting and Participants

This study was conducted in a stroke unit at the Teaching Hospital in Accra, Ghana, a tertiary healthcare facility. The hospital stroke unit offers comprehensive care with a trained multidisciplinary team to assist in improving stroke management (Hammond, 2014; Korle Bu Teaching Hospital, n.d.). Completing the study in a stroke unit allowed the researchers to interview nurses who were knowledgeable about prevention practices for AP in patients with stroke. A purposive sampling technique was used to select twelve (12) eligible participants. Registered nurses who had practiced for at least one year on the stroke unit, ensured availability, and agreed to participate in the study were included, and nurses who were on annual leave and secondment to the unit were excluded (Polit & Beck, 2014).

Before starting the recruitment and data collection process, permission was obtained from the unit manager after receiving ethical clearance. The researcher (YSF) was then allowed to access staff members, speak with them one-on-one, and provide an information sheet. Further explanation of the study was given to the target population that met the inclusion criteria. During this phase, potential participants received a copy of the consent form and had two days to thoroughly review the information sheet before deciding whether to participate. Informed written consent was obtained from all participants who agreed to take part in the study. Interviews were then scheduled individually with each participant.

Data Collection

Data for the study were collected through in-depth, face-to-face interviews using a semi-structured interview guide, with participants selecting their preferred time and place. All interviews were conducted in English because it is the official language of communication, and the study participants were educated professional nurses. The first author, a nurse researcher with a master's degree in nursing, conducted the interviews and used an audio recorder. Field notes were also taken to highlight emergent findings, important points, or nonverbal behaviors that could enrich data analysis. Some questions, such as “Please share your views about aspiration pneumonia in patients post-stroke, what comes to mind when you think about prevention practices for aspiration pneumonia in post-stroke patients? Tell me about the practices you use to prevent aspiration pneumonia in post-stroke patients. What is done on the unit to identify stroke patients who are at risk for aspiration?” was used to gather information about participants’ practices in preventing AP among stroke patients. Each interview lasted 40–60 min. Data collection continued until data saturation was reached (Braun & Clarke, 2021). All interviews took place in the nurse managers’ offices, which were free from intrusion and environmental noise, creating a conducive setting. The researchers had no prior relationship with the participants.

Data Analysis

The analytical method used in this study was Braun and Clarke's (2006) thematic analysis technique. The process began with organizing all audio and written field notes for preparation. The second and fifth authors, both nursing academics and PhD holders, transcribed the interviews verbatim, thoroughly reviewed them, and familiarized themselves with the data to accurately identify similar or contrasting ideas. The two authors then started coding key phrases, ensuring that similar thoughts or words from the data were highlighted and grouped into distinct subcategories and categories (Lester et al., 2020). The relationships between the developed categories were further examined and organized into main themes. After identifying the main themes, all researchers independently reviewed and refined the themes and their subthemes to ensure clarity and accuracy, leading to the final presentation of the findings.

Trustworthiness

Lincoln and Cuba's (1985) criteria were used to establish rigor: credibility, transferability, dependability, and confirmability. Credibility was ensured by submitting the study guide to an Institutional Review Board for approval before its use, spending more time with participants during data collection, and performing member checking for data accuracy. This was done by playing back the audio recordings to participants after each interview. To ensure transferability, detailed descriptions of the setting, methods, and participant characteristics were provided to help readers determine whether the findings could apply to different settings or populations (Korstjens & Moser, 2018). Dependability was ensured by clearly outlining the methods guiding the study and properly auditing (tracking and recording) the data collection process (Forero et al., 2018). Confirmability was achieved by transcribing participant responses verbatim and generating themes from their direct quotes (Eldh et al., 2020).

Ethical Considerations

Before recruitment and data collection, ethical clearance was obtained from the hospital's Institutional Review Board. Formal consent was obtained from the department head of the hospital's Medicine and Therapeutics Center and the unit manager of the stroke unit to ensure easy access to the unit and flexibility in the work schedule for the participants. The study was explained to all participants. The benefits, risks, and discomfort associated with the study were explained to them, and they were assured of anonymity and confidentiality. Participation was voluntary, and participants were informed that they could withdraw from the study without any penalties. The participants provided verbal and written consents. Identification codes were assigned to each participant to ensure their anonymity. Data were managed appropriately and kept safe, under lock for hard copies, and double password-protected for soft copies, with accessibility only to researchers. Study data would be retained for five years.

Results

Demographics of the Participants

The participants’ ages ranged from 26 to 45 years. The study included six males and six females. Seven participants had worked at the Stroke Unit for 1–5 years, while five had worked there for 6–10 years. All 12 participants were registered general nurses: four completed nursing at the diploma level, and eight at the degree level. All participants were Ghanaians, and they incidentally identified with the Christian faith. This reflects the trend observed in Ghana's 2021 Population and Housing Census, which found that most people living in urban areas like Accra, where the study was conducted, identify as Christian (Ghana Statistical Service, 2021). The demographics of the participants are summarized in Table 1.

Table 1.

Demographics of the Participants.

Participant ID	Age (Years)	Gender	Religion	Marital Status	Occupation	Level of Education	Years of Experience on Stroke Unit
Participant 01	26	Female	Christian	Married	RGN	Degree	1
Participant 02	31	Female	Christian	Single	RGN	Degree	2
Participant 03	27	Female	Christian	Single	RGN	Degree	3
Participant 04	35	Male	Christian	Married	RGN	Degree	8
Participant 05	34	Male	Christian	Married	RGN	Degree	6
Participant 06	33	Male	Christian	Single	RGN	Diploma	6
Participant 07	26	Female	Christian	Single	RGN	Degree	1
Participant 08	45	Male	Christian	Married	RGN	Diploma	8
Participant 09	34	Female	Christian	Single	RGN	Diploma	1.5
Participant 10	32	Male	Christian	Married	RGN	Degree	5
Participant 11	34	Female	Christian	Married	RGN	Diploma	2
Participant 12	30	Male	Christian	Married	RGN	Degree	7

Note. RGN = registered general nurse.

Themes and Subthemes

Two main themes emerged from this study. The first theme, prevention practices, described what participants thought to be prevention practices for AP. The subthemes included nurses’ practices, attentiveness to signs and symptoms, and dynamic processes. The second theme, attitudes towards care, generated the participants’ beliefs and attitudes as they related to carrying out various prevention practices. The subthemes were positive attitudes and negative attitudes towards aspects of prevention practices. The themes and subthemes are shown in Table 2.

Table 2.

Themes and Subthemes Generated.

Themes	Subthemes
Prevention practices	Nurses practices
	Attentiveness to signs and symptoms
	A dynamic process
Attitude towards care	Positive attitudes
Attitude towards care	Negative attitudes

Prevention Practices

As the first major theme of this study, respondents gave vivid details about what exactly nurses do to prevent AP in poststroke patients, revealing their specific prevention practices and the use of assessment skills to guide their practices.

Nurses Practices

For nurses to provide care to patients, they must proactively use their knowledge and skills in nursing practice. The nurses spoke in depth about providing oral care, completing swallowing tests, assisting patients with positioning and feeding, and finally, suctioning.

Most nurses explained the process of providing oral care with what they described as using a padded spatula. Toothbrushes and toothpaste were used by patients who did not experience neurological side effects of stroke, such as dysphagia. Furthermore, the nurses described how the padded spatula not only helped nurses clean patients’ teeth but also assisted them in keeping their mouths open so that they could access all areas of the mouth to support complete oral health.

What we normally do is if a patient is not able to spit out, like the ones that I said are having problems with swallowing. What we do is not use the normal toothbrush or the toothpaste … we use um, a mouthwash. We dilute it because it's a bit strong … Then, we use a spatula with gauze around it. Then, we used a tongue depressor, which is a spatula. To bring the tongue down. Then we clean the teeth, in, out, then we clean the tongue also.—Participant 06

For patients who are conscious but cannot swallow, respondents indicated that using the padded spatula and mouthwash can also prevent choking events that may occur should a patient aspirate.

Most of them are unconscious. So, you use a padded spatula … that would be the best way to do the oral care because when you do that, there's no more liquid going inside because with the padded spatula and then the, the mouthwash you squeeze it out {gestures squeezing out gauze to kind of dry it}.—Participant 03

Participants reported frequent drooling due to dysphagia, a swallowing issue, as a side effect of the stroke. Nurses suctioned secretions to prevent choking and adjusted patient positions to prevent excess drool from entering the airway.

One participant explained this as follows:

They hypersecrete their saliva, and it is common with stroke patients… we do, um, the regular suctioning … we do change their positions a lot … however, we put them, we target the chin, the whole head, and the mouth … that is how we manage to prevent the oral secretions from choking them.—Participant 02

All 12 participants mentioned the use of the swallowing test to prevent AP in poststroke patients. This swallowing test is described by the participants as a baseline test used to determine what type of feeding patients can tolerate poststroke, either enteral feeding through nasogastric tube (NGT) or oral feeding.

Maybe the stroke has affected the patient's ability to, uh, swallow, or is he able to swallow? Therefore, when we perform this assessment, we are okay that, well, the patient can tolerate um, orals, and then we continue with oral feeding. But if the patient cannot, then we pass an NGT.—Participant 10

Participants indicated that swallowing tests were performed in three stages, highlighting the type of liquid or food tested at each stage. Within each stage, a specific procedure helped nurses determine whether they could continue with the test. Some nurses recounted some of the local food dishes that patients could tolerate by mouth if they could pass through to the stage of the swallowing test.

So, we give you a teaspoon of water to drink. If the patient can swallow it without coughing, choking, or holding the water in the mouth, it means the patient has passed the first stage. Then, we gave them half a glass of water. (…), then, move on to the next stage, the next stage is something like something that is in a paste form, but not so thick. Something that you can use a spoon to fetch, and after dropping, you get some sticking on the spoon. We sometimes use Cerelac, but we don't make it in a paste form … If the patient can swallow, that means the patient has passed the second stage.—Participant 08

Stage three, which is a very thick meal like, um, uh, in our local terms we have what we call “Mpoto Mpoto.” Like it's a mashed potato or yam, but it is made in a porridge form or a little bit thicker (…). So, we perform the swallowing test in these three stages, so depending on the level at which the patient passes, we will know which meal to feed him or her.—Participant 07

“Mpoto Mpoto” is a Ghanaian food made with mashed yam. The addition of other ingredients, such as palm oil, soups, and water, can alter the dish to the appropriate texture that patients post-stroke can tolerate in the second or third stage of the swallowing test.

Prevention practices for feeding are centered around safety with oral feeding and with other forms of feeding that are commonly used in stroke patients, such as NGT feeding. All interventions of feeding safety described by the nurses were also linked to the appropriate positioning of the patients, which not only applies to times when patients were being fed but also needed to remain slightly elevated so that they do not regurgitate after feeding. The nurses explained as follows:

So, you prop the patient up in bed, and you set up the tray and everything. Then, the patient is fed at regular intervals or intermittently. Therefore, when you put the patient's feed into the mouth. You make sure whatever is in the mouth is gone, the patient has swallowed everything before you give another one.—Participant 04

(…), if the patient is not feeding, the patient is in the lateral position. You elevate your head slightly. Let us say 30 °high. We don't go so flat.—Participant 09

Nurses also recognized feeding via the nasogastric route as a preventive practice. Feeding via the nasogastric route involves the insertion of a feeding tube through the patient's nose, down the throat, and into the stomach. Consequently, patients can receive a liquid diet through the tube.

We do more of nasogastric tube here … they give their consent, and we pass it. … so that is a way of us preventing it (aspiration pneumonia) because we don't want to force food in the patient's mouth for the aspiration risk.—Participant 02

Attentiveness to Signs and Symptoms

In monitoring and assessing patients poststroke, the findings revealed that nurses paid close attention to different signs and symptoms to identify patients who may have aspirated. Some nurses discussed the importance of paying attention to new-onset coughing.

We look out for certain things. Therefore, if you see red lights, we stop. Patients can easily aspirate and change their condition. The red light, I am referring to coughing, choking, seeing that the patient is in distress … So, with that one, we have to just monitor the patient and see if it is from the food. Has the patient aspirated?—Participant 11

In addition to coughing as an indicator that patients may have aspirated, one nurse described patients having a hoarse voice when oral contents in the mouth may have entered the lungs. She stated that:

You hear this hoarse kind of {makes example of hoarse sound} like the whole food is not going there. The food is going somewhere I do not like. Then, the body will bring out some hoarse, hoarse sound, or, how do you say, some kind of sound. So, you have to monitor all that, it's just not about feeding?—Participant 03

When an NGT is dislodged, it can put patients at risk of developing AP. Any liquid entering the tube can regurgitate or bypass the throat, causing patients to cough and possibly inhale fluid into the lungs. A Participant stated the following:

We observe them for some, you know, signs of, uh, the tube dislodging. Sometimes, the patients may cough, a very serious problem sign … The moment you introduce something through the nasogastric tube. Just a little goes in and then the patient starts coughing, immediately we stop, (…). That's a very paramount thing.—Participant 02

Nurses found that the facial expressions of the patients may indicate that they were experiencing pain. One nurse stated that:

Sometimes they're able to swallow, but they have some, they have some facial expression that shows that they're in pain.—Participant 08

In addition, one participant explained that other signs and symptoms, such as fever and respiratory distress, may indicate that the consequences of impaired swallowing have already occurred.

If the patient is spiking temperature a lot, the patient is, um, having distress in breathing, there are certain signs you might see that give you a clue that this might be aspiration pneumonia.—Participant 01

A Dynamic Process

Nurses’ practices highlight the dynamic nature of poststroke prevention practices, as patients recover and change in status unpredictably throughout their hospital stay. The participants spoke of continuously assessing patients’ swallowing and diet choices, ensuring that they adapt to changes in patient status.

It's not as if when we come, you come and then we do it (swallowing test) and put on an NG tube and that ends it. The following day, we will try to see whether you will still be able to swallow. If you are not, the NGT remains, but for some, you try, and then the person can swallow it. You just monitor for a day or two, and you just take off the tube.—Participant 12

You don't know what's going on in the brain at some points. (…), You give water, and the patient is coughing. You give water, the patient brings it back. You know, you passed the NGT. You wait, three to four, five days, like, then you do the swallowing assessment again. Because at that time, the body's still healing, right?—Participant 03

This comprehensive understanding allowed participants to anticipate potential aspiration events and intervene appropriately.

One nurse stated that:

We (the nurses) consider them for admission, as they're going home, at home, we do continuity of care there. They come for review and all that, in all we have those preventive measures.—Participant 02

When it comes to the prevention of aspiration, nurses explained that they were continuously assessing poststroke patients so that the care plan could be modified, even on discharge and postreview management.

Attitudes Towards Care

The second major theme relates to the findings on nurses’ attitudes toward prevention practices for AP in poststroke patients. Two subthemes spawned nurses’ positive and negative attitudes towards these practices.

Positive Attitudes

As the nurses shared their experiences on various prevention practices, it was evident that their positive attitudes centered on ensuring safety, following routines, and understanding the importance of preventing infection in poststroke patients.

Every morning …we carry out oral care … we carry out oral care for all patients that cannot do it on their own, but those that can also do it on their own. So, there will not be any, um, infections or gems growing up in their mouths.—Participant 10

A lot of them drool a lot. So, if you do not do it (oral care), the saliva, you cannot even go close to the patient … So, when I am also working on the patient, I feel very comfortable and very relaxed, and then I do what I am supposed to do. Now, if a patient smells bad, and I go close to him, the smell alone will put me off, and then when I go to work on a patient, I will just be in a hurry to do it, and then leave the patient's side. Do you get it?—Participant 11

Another nurse mentioned that the swallowing test results were as follows:

A normal thing to do in the ward, and to prevent the patient from going into such complications, you must do it. … I don't want to put the patient in, in a situation whereby we have to deal with other things, aside from the stroke, because when these complications set in, they make the treatment more complicated … aspiration pneumonia can take the patient.—Participant 04

Nurses had positive attitudes towards the use of NGT to prevent AP and to ensure that proper practices are being utilized while the tube is in place.

So, you're coming to feed, you must observe for elongation of the tube, or when you're coming to feed, you can check for bubbles, you have to put the tip of the NG tube in water. To check for bubbling.—Participant 07

Another nurse held the view that

Some groups of thought are moving away from that (bubbling method mentioned above) because they say the patient can aspirate the water. … So, normally, what we use here we are using the stethoscope to listen to the gastric sound. So, you place the stethoscope on the stomach, and then you push air into the tube. You hear the whoops sound if it is in the stomach, then you know that it's in.—Participant 08

Lastly, nurses had positive attitudes towards feeding with percutaneous endoscopic gastrostomy (PEG) tubes because they felt that it was the safest and most manageable option for enteral feeding.

Percutaneous endoscopic gastrostomy, which is done under endoscopy … for that one, mostly it's the safest and the best cause feeding goes directly to the stomach.—Participant 04

Overall, the findings highlighted one of the many benefits of having specialized care for stroke patients. The nurses understood the complexities of this patient population, and their attitudes and beliefs about prevention practices reflected this.

Negative Attitudes

In trying to identify any negative attitudes, not much was explicitly revealed. Instead, the nurses described their attitudes towards some of the negative aspects of performing the different prevention practices, which was important to report among the findings. In the few instances where nurses had negative attitudes towards any of the prevention practices, most times they would quickly support their statements with dialogue about the need to still carry out the prevention practice despite the negative aspect of it.

For the nurses, when providing oral care, the main negative attitude towards this practice was that, at times, the patients may not cooperate or comply with the process. Despite this, nurses still stressed the importance of keeping the mouth clean. They believed that their training and use of different tactics needed to be used in the face of difficulties to have success in carrying out prevention practices.

Sometimes these patients are unconscious and then all of a sudden there's something in their minds, I don't even know what's going on in there. She might just bite it (the padded spatula) …. um, some won't even open their mouth well, so, you know, there are lots of techniques we do just to make their mouths a bit open … you can't get a hundred percent, but like, at least if you can get the mouth clean a bit, the better.—Participant 03

When it came to feeding patients by the oral route, the nurses felt that at times it could be a long process.

The only challenge is sometimes when they are feeding at a very slow pace, that means you need to spend more time with the patients to feed.—Participant 01

With repositioning, some nurses complained about the strenuous nature of the task. For example, a patient's behavior or presentation may be impacted by the severity of the stroke a patient has had. Despite this, nurses believed that repositioning patients and keeping them mobile should remain a priority.

Most of my colleagues complain of backache a lot. It's not easy, you know, some patients are heavy, others way more than 300 pounds … but you have to, yeah. That is it. You have to, it's, it's tedious sometimes. Um, but you have to, so it's either you call in for help, more hands to position the patients. Yeah. You have to, you don't have an excuse, that is it. Yeah. Though it's hard, but you have to.—Participant 03

Discussion

The participants identified various prevention practices for AP in patients after a stroke. The nursing practices described, starting with the provision of oral care, align with some recommendations suggested by Campbell et al. (2020), including toothbrushing, use of fluoride-based toothpaste, mouth rinsing, and tongue cleansing. The nurses understood that performing oral care for patients was a daily task for preventing patients from developing infections like pneumonia (Odgaard & Kothari, 2019). The significance of nurses’ practices is also supported by previous studies showing that aspiration of oral pathogens from the oral cavity can enter the lungs and cause pneumonia (Khadka et al., 2021; Yuan et al., 2020). Another notable finding related to oral care is the nurses’ implementation of regular oral cavity suctioning. Nurses reported using suctioning and positioning the head and neck to prevent the aspiration of harmful oral contents. These findings are consistent with current evidence indicating that conservative measures like suctioning or using toothbrushes as part of oral care can help manage drooling and potentially prevent infection (Giuliano et al., 2021; McGeachan & McDermott, 2017).

Participants in this study practiced swallowing screening for patients poststroke, to assess for possible swallowing difficulties, as a means to prevent AP. This was seen as a positive attitude of care, and some participants held that performing the test is necessary for the well-being and respiratory health of patients (Chang et al., 2022). Their description of the screening test was similar to the Gugging Swallowing Screen (GUSS), which is nurse-led (Oliveira et al., 2019; Sherman et al., 2021). These findings are important and suggest that the nurses in this facility were capable of screening patients to keep them safe in the absence of a speech and language specialist. Further highlighting the importance of focused care to prevent aspiration. Such competencies are recommended by Pandian et al. (2020) as necessary to sustain stroke care services in LMICs.

Again, participants had positive attitudes towards safe feeding as of great importance. Oral feeding practices were related to safety as outlined by Nazarko (2017) and Seedat and Strime (2022), and included good positioning, feeding at a good pace, and watching for proper swallowing of food. The nurses’ descriptions of how they associate the texture of food the patient can tolerate with local dishes (mashing solid foods) are also very important for the findings’ usefulness in the Ghanaian context. However, because most of their patient population are admitted with swallowing difficulties, weakness, or a low level of consciousness, nurses in this study suggested the use of NGT for their patients.

It was a means of preventing AP, being mindful to check the correct position of the NGT before feeding, to prevent AP (Rabaut et al., 2022). This means that when oral feeding is not safe, NGT feeding may be the means for patients with stroke to get nutrition and medications (Gong et al., 2021). Participants also had a positive attitude towards the use of PEG tubes as safer for feeding patients who require enteral feeding long-term (Kamran et al., 2022; Molina Villalba et al., 2019). Feeding practices by the participants, in patients poststroke, were consistent with other studies (Borglin et al., 2020; Benjapornlert et al., 2020; Yoshikawa et al., 2021).

Confirming NGT placement by monitoring changes in the length of the tube is an acceptable practice and reflects the practices of the nurses as described in this study (Judd, 2020). Although checking NGT placement with an x-ray or testing aspirated stomach contents with litmus paper is considered best practice, however, this may not be feasible in all healthcare facilities in less health-resource countries, including Ghana.

Noticeably, study participants did not mention mobilizing patients with stroke as a prevention practice, overtly to prevent AP. However, the nurses reported that most of their patients are weak or bedbound; therefore, any movement like walking with patients is usually guided by physiotherapy or, at times, not encouraged because of the patient's condition. Although mobilization of the patient with a stroke was not an issue, the participants were focusing more on positioning as it relates to AP. Consequently, any form of positioning or low-intensity mobilization was associated with feeding practices, and not all forms of mobilization, to conclude that the participants believed it was a prevention practice.

The findings again highlight the nurses’ attentiveness to signs and symptoms as prevention practices of aspiration or suspected AP; the common ones being coughing. Specifically, coughing that has a sudden onset or coughing that occurs during oral and enteral feeding. This finding aligns with a study that determined coughing frequency, in addition to the risk for aspiration, is a predictor of pneumonia in stroke survivors with dysphagia (Pekacka-Egli et al., 2021). Participants also indicated that pain in the throat, change in facial expression when swallowing, and hoarseness were some of the signs of dysphagia in patients with stroke and should be closely monitored (Green et al., 2021).

Although the nurses in this study were not using other screening tools apart from GUSS, the signs and symptoms they assessed for anticipating aspiration risk in patients poststroke are comparable to other studies (Olesen et al., 2021; Umay et al., 2022). Furthermore, Yoshimatsu et al. (2020) concluded that hoarseness of the voice is a chronic sign related to the development of AP. Significantly, the participants’ attentiveness to signs and symptoms demonstrates their concern and awareness of how patients with stroke may present if they have dysphagia, which can lead to AP. The above, therefore, suggests that the participants in this study described a positive attitude in practices to prevent AP in their patients. Although previous studies among Ghanaian nurses in some healthcare facilities concluded suboptimal use of scientific evidence in practice, with participants citing workload and lack of policies as barriers (Anaman-Torgbor et al., 2022; Atakro et al., 2020). Nonetheless, the findings of this study contribute to suggestions about prevention practices for AP being used by nurses on a stroke unit and can be used to improve practices for other care areas in a broader context.

Participants of this study did not reveal many negative attitudes towards the prevention practices of AP in patients with stroke explicitly. However, some participants described negative experiences of sometimes encountering difficult and unpleasant resistance when trying to help patients with oral care. Regardless, the nurses still had the desire to perform these prevention practices, understanding the risks involved if they did not (Weening-Verbree et al., 2021; Ferguson et al., 2020).

The next negative aspect is that some participants, although few, recounted negative attitudes about prevention practices regarding the time it takes to feed a patient who can be fed orally, which contrasts with the study by Seedat and Strime (2022). Yet again, other participants believed that repositioning patients was strenuous at times but needed to be done to support patient safety (Chaplin & McLuskey, 2020). Nevertheless, participants in this study agreed that caring for patients with stroke in the context of preventing AP is a continuous process through assessment from admission to postreview management. The findings in this study regarding nurses’ attitudes towards prevention practices in the care of patients with stroke are significant because their perspectives and experiences with these practices suggest that they may have a stronger willingness to engage in them daily. Experience (years) working solely with stroke patients appears to give the nurses a comprehensive understanding of poststroke patients’ behaviors. From what the nurses described, this allows them not only to care for stroke patients using preventive practices, but also to anticipate possible aspiration events and intervene appropriately before they occur.

Strengths and Limitations

This study had certain limitations. Using a qualitative approach, the findings are mainly interpretative and influenced by the researchers’ perspectives; therefore, they may not be immediately applicable to different cultural or professional settings. Additionally, although the number of participants and their narratives may not be directly generalizable to nursing staff and other stroke units, since the study was conducted in one tertiary hospital in Ghana's capital city. Nonetheless, the findings support the development of a thematic understanding that is relevant to nursing practices in caring for poststroke patients in LMICs with limited healthcare resources.

Implications for Practice

Nurses providing care for patients who have experienced a stroke should evaluate their work setting to determine whether their practices conform to standard protocols and are being implemented on the ward. The regulatory authorities should ensure regular training for nurses caring for patients with stroke, update their procedure manual regularly, and make them aware of providing mouth care, oral, and enteral feeding. Leadership at all levels should ensure that proper procedures and hospital protocols are understood by nursing staff and followed accordingly. This can not only help with issues of patient safety, but the understanding of the risk involved with unsafe practices can also improve nurses’ attitudes towards prevention practices.

Conclusion

The study explored nurses’ prevention practices for AP in poststroke patients within a Ghanaian context. Prevention practices identified by the nurses were the provision of oral care, suctioning, swallow screening for all patients, ensuring feeding safety, and repositioning of patients. The findings indicated that nurses had positive attitudes towards prevention practices for AP, even when dealing with the negative aspects of those same practices.

Ultimately, this research contributed knowledge about the nurse's role in preventing AP for stroke patients and provided insight into nurses’ experiences and perspectives in the Ghanaian context. The information revealed in the study could be used to develop country-specific guidelines that align with the resources available. This can be helpful not only in the Ghanaian context but in other sub-Saharan countries with similar resource limitations.

Supplemental Material

sj-docx-1-son-10.1177_23779608251399966 - Supplemental material for Exploration of Nurses’ Preventive Practices for Aspiration Pneumonia Among Poststroke Patients at a Teaching Hospital in Ghana: A Qualitative Study

Supplemental material, sj-docx-1-son-10.1177_23779608251399966 for Exploration of Nurses’ Preventive Practices for Aspiration Pneumonia Among Poststroke Patients at a Teaching Hospital in Ghana: A Qualitative Study by Yaa Serwaa Frimpong, Menford Owusu Ampomah, Cecilia Eliason, Dorcas Yvonne Berko, Luke Laari and Paul Kolbugri in SAGE Open Nursing

Supplemental Material

sj-docx-2-son-10.1177_23779608251399966 - Supplemental material for Exploration of Nurses’ Preventive Practices for Aspiration Pneumonia Among Poststroke Patients at a Teaching Hospital in Ghana: A Qualitative Study

Supplemental material, sj-docx-2-son-10.1177_23779608251399966 for Exploration of Nurses’ Preventive Practices for Aspiration Pneumonia Among Poststroke Patients at a Teaching Hospital in Ghana: A Qualitative Study by Yaa Serwaa Frimpong, Menford Owusu Ampomah, Cecilia Eliason, Dorcas Yvonne Berko, Luke Laari and Paul Kolbugri in SAGE Open Nursing

Footnotes

Acknowledgments

The authors would like to thank the management of the Teaching Hospital and the staff at the Stroke Unit for participating in this study and for their cooperation.

ORCID iDs

Yaa Serwaa Frimpong

Menford Owusu Ampomah

Cecilia Eliason

Dorcas Yvonne Berko

Luke Laari

Paul Kolbugri

Ethics Approval and Consent to Participate

This research was approved by the Korle-Bu Teaching Hospital's Institutional Review Board (KBTH-IRB 000155/2022). Informed written consent was obtained from all study participants. This study was conducted in accordance with the Declaration of Helsinki. All participants were also assured of the anonymity and privacy of their personal information.

Consent to Participate

Informed written consent was obtained from all study participants.

Authors’ Contributions

Yaa Serwaa Frimpong—the conception of the study, data collection, management, and analysis; and initial write-up. Menford Owusu Ampomah—conception and supervision of the study. Reviewed write-up Menford Owusu Ampomah, Cecilia Eliason, Dorcas Yvonne Berko, Luke Laari, and Paul Kolbugri—were all involved in the data analysis, core data interpretation, and analysis shaping. All the authors critically reviewed the manuscript before submission. All the authors critically reviewed and edited the manuscript before submission. All authors approve of the manuscript's content for submission.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

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

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request and in consultation with study participants.

Supplemental Material

Supplemental material for this article is available online.

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