Current state and influencing factors in airbag management among emergency department nurses: A multicenter study

Abstract

BACKGROUND

The emergency department (ED) plays a critical role in establishing artificial airways and implementing mechanical ventilation. Managing airbags in the ED presents a prime opportunity to mitigate the risk of ventilator-associated pneumonia. Nonetheless, existing research has largely overlooked the understanding, beliefs, and practical dimensions of airway airbag management among ED nurses, with a predominant focus on intensive care unit nurses.

AIM

To investigate the current status of ED nurses' knowledge, beliefs, and practical behaviors in airway airbag management and their influencing factors.

METHODS

A survey was conducted from July 10^th to August 10^th, 2023, using convenience sampling on 520 ED nurses from 15 tertiary hospitals and 5 sary hospitals in Shanghai. Pathway analysis was utilized to analyze the influencing factors.

RESULTS

The scores for ED nurses' airway airbag management knowledge were 60.26 ± 23.00, belief was 88.65 ± 13.36, and behavior was 75.10 ± 19.84. The main influencing factors of airbag management knowledge included participation in specialized nurse or mechanical ventilation training, department, and work experience in the department. Influencing factors of airbag management belief comprised knowledge, department, and participation in specialized nurse or mechanical ventilation training. Primary influencing factors of airbag management behavior included knowledge, belief, department, participation in specialized nurse or mechanical ventilation training, and professional title. The belief in airbag management among ED nurses acted as a partial mediator between knowledge and behavior, with a total effect value of 0.513, and an indirect effect of 0.085, constituting 16.6% of the total effect.

CONCLUSION

ED nurses exhibit a positive attitude toward airbag management with relatively standardized practices, yet there remains room for improvement in their knowledge levels. Nursing managers should implement interventions tailored to the characteristics of ED nurses' airbag management knowledge, beliefs, and practices to enhance their airbag management proficiency.

Key Words: Artificial airway management, Health knowledge, Attitudes, Practice, Airbag management, Pathway analysis, Nurses

Core Tip: The emergency department (ED) serves as a critical setting for establishing artificial airways and implementing mechanical ventilation. Managing airbags in the ED presents a prime opportunity to mitigate the risk of ventilator-associated pneumonia. Research findings reveal that ED nurses generally harbor a positive attitude toward airbag management, and their practical behaviors are moderately standardized. Nevertheless, there remains a need for enhancing their knowledge levels. This study offers theoretical underpinning for delivering pertinent training and fostering the development of specialized nursing programs tailored to ED settings. Furthermore, it underscores the necessity for implementing targeted improvement strategies.

INTRODUCTION

As medical technology advances, establishing an artificial airway for mechanical ventilation has become a crucial intervention for critically ill patients. Ventilator-associated pneumonia (VAP), as one of the common complications of mechanical ventilation, stands as a significant contributor to patient mortality. Statistics reveal that approximately 28% of mechanically ventilated patients experience VAP, with mortality rates ranging between 25% and 50%[1,2]. Furthermore, the occurrence of VAP prolongs hospital stays and escalates medical expenses[3]. Within mechanical ventilation, the role of the airbag is paramount. Situated on the outer wall at the end of the tracheal tube or tracheostomy tube, the airbag ensures effective positive pressure ventilation and prevents aspiration of oral and gastric contents when appropriately pressurized[4]. Insufficient airbag pressure could lead to a gap between the airway and airbag, compromising ventilation efficacy and allowing upper respiratory pathogens to enter the lower airways[5]. Conversely, overinflation of the airbag may result in ischemic mucosal damage or even necrosis of the airway[6]. Recent studies both domestically and internationally have confirmed that maintaining airbag pressure within an optimal range significantly reduces the incidence of VAP in patients[7-9]. The probability of patients developing VAP reaches 34.6% without standardized airbag monitoring and management[10]. Therefore, implementing effective airbag management for critically ill patients holds paramount importance in reducing the incidence of VAP, shortening hospital stays, and expediting patient recovery.

Emergency department (ED) is critical in treating severely ill patients, where mechanical ventilation is an essential intervention. Research indicates[11] that the utilization rate of mechanical ventilation in ED has increased to 27%. Consequently, implementing airbag management strategies in ED offers a significant opportunity to reduce the risk of VAP infections[12]. Previous studies have predominantly concentrated on intensive care unit (ICU) nurses' understanding and practices related to airbag management, with less attention given to ED nurses[13,14]. Therefore, drawing on the knowledge-attitude-practice (KAP) theory, this study explores the knowledge, beliefs, and practices of ED nurses regarding airbag management. By analyzing the influencing factors and their pathways, this study aims to identify gaps in airbag management, support the development of specialized training and education for nurses, and establish targeted improvement strategies. This approach seeks to enhance patient care quality, decrease the incidence of VAP, and accelerate patient recovery in ED.

MATERIALS AND METHODS

Subjects

A total of 520 ED nurses from 15 tertiary hospitals and 5 sary hospitals in Shanghai were recruited for the study conducted between July 10^th and August 10^th, 2023. Inclusion criteria included holding a valid registered nurse practicing certificate, having a minimum of 1 year of work experience in the emergency resuscitation room or emergency ICU (EICU), and voluntary participation in the survey. Exclusion criteria encompassed individuals on leave or absent during the survey period and nurses currently engaged in further education or specialized training. Ethical approval for the study was obtained from the hospital's ethics committee (No. 2022-075-01).

Research tools

General questionnaire: The researchers designed the questionnaire for this section after reviewing previous studies and consulting with experts. It encompassed various demographic and professional aspects, including gender, grade of working hospital, education status, professional title, department: Emergency resuscitation room or EICU, work experience in the department, and participation in specialized nurse or mechanical ventilation training.

The ICU healthcare workers' artificial airway airbag management KAP questionnaire: The questionnaire was originally designed in 2020[15], comprising three dimensions: Knowledge, attitude/belief, and behavior, totaling 42 multiple-choice questions. In this investigation, the Cronbach's alpha coefficients for the questionnaire were calculated as 0.983, 0.926, and 0.956, corresponding to the dimensions of knowledge, attitude/belief, and behavior, respectively. Specifically, the questionnaire addressed knowledge inquiry, encompassing 19 items graded on a scale from 1 (no understanding) to 5 (complete mastery), with a total score ranging from 19 to 95. A higher score reflects a superior comprehension of airbag management and its associated knowledge. The attitude inquiry comprised 8 items graded from 1 (disagree) to 3 (completely agree), with a total score ranging from 8 to 24. A higher score indicates a more favorable attitude and belief toward airbag management. The behavior inquiry involved 15 items rated from 1 (never) to 5 (always), with a total score ranging from 15 to 75. A higher score indicates a higher level of execution of airbag management in clinical practice. The total score of the questionnaire was 194 points, categorized into three levels based on different total scores: Total score < 116 points categorized as poor, 116 ≤ total score < 155 points categorized as fair, and total score ≥ 155 points categorized as good. For ease of comparison of knowledge, belief, and behavior scores, standardized scores were calculated for each dimension and the total score using the formula: Standardized score = (actual score on the questionnaire/total score on questionnaire) X 100[16].

Data collection

The study utilized the questionnaire star platform for conducting online surveys. Initially, researchers sought consent from nurse supervisors in each hospital's ED to participate in the study. Subsequently, nurse supervisors distributed the questionnaire link to WeChat groups of various ED units, enabling ED nurses to independently and anonymously complete the survey. The open online survey period lasted from July 10 to August 10, 2023, allowing each account to complete the questionnaire only once. Following data collection, a two-person check was conducted to ensure completeness and clarity. Respondents were contacted for clarification if any items were found unanswered or unclear.

Statistical analysis

This study utilized SPSS 26.0 to perform statistical analyses. Quantitative data adhering to a normal distribution were described using the mean ± SD, and evaluated through univariate analyses employing independent sample t-tests and analysis of variance. Qualitative data were summarized by frequencies (percentages). Additionally, Pearson correlation analysis was conducted to examine relationships between variables. For a more in-depth analysis, variables that showed statistical significance in the univariate analysis were selected as independent variables for path analysis using Mplus 8.3. P < 0.05 was considered to indicate statistical significance.

RESULTS

The general information of the survey participants

In this survey, a total of 520 questionnaires were distributed, out of which 487 were considered valid, leading to an effective response rate of 93.7%. Table 1 provides comprehensive details on the general information about the survey participants.

Table 1 The general information of the survey participants, n (%).

Characteristics variables	Frequency	Characteristics variables	Frequency
Sex		Professional title
Male	53 (10.9)	Nurse	99 (20.3)
Female	434 (89.1)	Nurse practitioner	271 (55.6)
Grade of a working hospital		Chief nurse practitioner	112 (23.0)
Grade 3, Class A	256 (52.6)	Deputy chief nurse practitioner	5 (1.0)
Grade 3, Class B	134 (27.5)	Work experience in the department
Grade 2, Class A	97 (19.9)	1 yr-3 yr	107 (22.0)
Educational status		4 yr-6 yr	88 (18.1)
Specialized secondary school	5 (1.0)	7 yr-10 yr	91 (18.7)
Junior college	124 (25.5)	11 yr-15 yr	111 (22.8)
Bachelor's degree	354 (72.7)	16 yr-20 yr	59 (12.1)
Master's degree and above	4 (0.8)	More than 21 yr	31 (6.4)
Department (of work)		Participation in specialized nurse or mechanical ventilation training
Emergency resuscitation room	256 (52.6)
Emergency intensive care unit	231 (47.4)	Yes	300 (61.6)
		No	187 (38.4)

The scores of ED nurses' knowledge, attitude, and practice regarding airbag management

The study revealed that ED nurses exhibited varied levels of competence in airbag management. Their knowledge score was 57.24 ± 21.85 points, indicating a wide range of proficiency. Approximately 47.4% of the participants demonstrated good to fair levels of knowledge in this domain. Regarding their beliefs, the score was 21.28 ± 3.21 points. Impressively, 99.4% of the nurses held beliefs falling within the good to fair range. In terms of behavior, the score stood at 56.33 ± 14.88 points, suggesting moderate consistency. Notably, 80.4% of the nurses displayed good to fair behavior in managing airbags. Table 2 provides detailed distributions of standardized scores and levels across dimensions.

Table 2 The scores of emergency department nurses' knowledge, attitude, and practice regarding airbag management, n (%).

Project	Score (points, mean ± SD)	Standardized score (points, mean ± SD )	Grade (frequency): Poor, Fair, Good
Knowledge	57.24 ± 21.85	60.26 ± 23.00	256 (52.6)	100 (20.5)	131 (26.9)
Belief	21.28 ± 3.21	88.65 ± 13.36	3 (0.6)	118 (24.2)	366 (75.2)
Practice	56.33 ± 14.88	75.10 ± 19.84	94 (19.3)	162 (33.3)	231 (47.4)

The three lowest-scoring items in the dimensions of knowledge, attitude, and behavior regarding airbag management among ED nurses

In the domain of ED nurses' competence in airbag management, the three areas scoring the lowest in knowledge include item 5, "Understanding venous pressure on the airway wall" (2.49 ± 1.40); item 4, "Understanding arterial pressure on the airway wall" (2.54 ± 1.41); and item 7, "Understanding factors that increase airbag pressure" (2.83 ± 1.27). Similarly, the lowest scores in beliefs about airbag management are item 8, "Agreement with the regular assessment of airbag pressure monitoring" (2.52 ± 0.56); item 2, "Proactive learning about artificial airway airbag management" (2.58 ± 0.52); and item 3, "Participation in airbag-related training" (2.61 ± 0.50). In practices, the lowest scores are item 8, "Flushing fluid accumulation from the airbag during airway management" (3.08 ± 1.52); item 2, "Measuring airbag pressure before and after oral care and nasogastric feeding" (3.40 ± 1.33); and item 15, "Using an airbag leak test to assess upper airway patency before extubation" (3.44 ± 1.40). Please refer to Table 3 for detailed information.

Table 3 The three lowest-scoring items in the dimensions of knowledge, attitude, and behavior regarding airbag management among emergency department nurses.

Project	Score (points, mean ± SD)
The three entries with the lowest knowledge scores
Item 5 "Understanding venous pressure on the airway wall"	2.49 ± 1.40
Item 4 "Understanding arterial pressure on the airway wall"	2.54 ± 1.41
Item 7 "Understanding factors that increase airbag pressure"	2.83 ± 1.27
The three entries with the lowest belief scores
Item 8 "Agreement with the regular assessment of airbag pressure monitoring"	2.52 ± 0.56
Item 2 "Proactive learning about artificial airway airbags management"	2.58 ± 0.52
Item 3 "Participation in airbag-related training"	2.61 ± 0.50
The three items with the lowest practical scores
Item 8 "Flushing fluid accumulation from the airbag during airway management"	3.08 ± 1.52
Item 2 "Measuring airbag pressure before and after oral care and nasogastric feeding"	3.40 ± 1.33
Item 15 "Using an airbag leak test to assess upper airway patency before extubation"	3.44 ± 1.40

Comparison of airbag management knowledge, attitude, and practice among ED nurses with different characteristics

Statistically significant differences were observed in airbag management knowledge scores among nurses based on their educational level, department of work, work experience in the department, and participation in specialized nurse or mechanical ventilation training (P < 0.05). Variations in belief scores were noted based on the department of work and participation in specialized nurse or mechanical ventilation training (P < 0.05). Similarly, differences in behavior scores were significant concerning educational level, professional title, department of work, and participation in specialized nurse or mechanical ventilation training in the ED (P < 0.05). Please refer to Table 4 for detailed information. Positive correlations were found between ED nurses' knowledge and belief, knowledge and behavior, and belief and behavior regarding airbag management (r = 0.452, 0.582, 0.463 respectively; P < 0.01).

Table 4 Comparison of airbag management knowledge, attitude, and practice among emergency department nurses with different characteristics.

Project	Knowledge score	Test statistic	P value	Belief score	Test statistic	P value	Practical score	Test statistic	P value
Sex		-0.2912	0.772		-1.2982	0.195		0.4592	0.647
Male	56.32 ± 24.75			20.74 ± 3.38			57.32 ± 16.92
Female	57.35 ± 21.50			21.34 ± 3.18			56.21 ± 14.63
Grade of a working hospital		2.7841	0.063		2.4881	0.084		1.8201	0.163
Grade 3, Class A	55.55 ± 21.79			21.00 ± 3.25			55.96 ± 15.04
Grade 3, Class B	57.25 ± 20.43			21.42 ± 3.14			55.22 ± 15.03
Grade 2, Class A	61.68 ± 23.46			21.81 ± 3.13			58.82 ± 14.11
Educational status		2.6711	0.047		1.3661	0.253		3.1881	0.024
Specialized secondary school	53.40 ± 24.74			22.80 ± 1.79			61.40 ± 17.56
Junior college	60.80 ± 21.98			21.24 ± 3.32			59.38 ± 13.71
Bachelor's degree	55.84 ± 21.67			21.23 ± 3.19			55.09 ± 15.14
Master's degree and above	76.25 ± 14.38			24.00 ± 0.00			64.50 ± 9.68
Professional title		1.6071	0.187		2.3001	0.077		3.4081	0.018
Nurse	55.80 ± 21.77			21.47 ± 3.22			60.14 ± 13.65
Nurse practitioner	56.15 ± 21.90			20.96 ± 3.25			54.68 ± 15.54
Chief nurse Practitioner	60.79 ± 21.72			21.83 ± 3.03			56.99 ± 13.89
Deputy chief nurse practitioner	65.60 ± 19.50			22.20 ± 3.03			55.00 ± 11.34
Department		-4.4882	< 0.001		-4.5182	< 0.001		-6.9092	< 0.001
Emergency resuscitation room	53.10 ± 21.17			20.67 ± 3.36			52.14 ± 15.56
Emergency intensive care unit	61.83 ± 21.73			21.95 ± 2.90			60.97 ± 12.59
Work experience in the department		2.3291	0.042		1.4751	0.196		2.0041	0.077
1 yr-3 yr	55.31 ± 23.00			21.29 ± 3.32			58.48 ± 14.88
4 yr-6 yr	54.73 ± 21.45			20.61 ± 3.40			55.24 ± 15.09
7 yr-10 yr	54.34 ± 21.81			21.22 ± 3.06			52.57 ± 16.15
11 yr-15 yr	58.38 ± 21.16			21.32 ± 3.09			57.05 ± 13.80
16 yr-20 yr	62.95 ± 19.49			21.81 ± 3.20			58.41 ± 13.01
More than 21 yr	64.65 ± 23.35			22.06 ± 2.94			56.45 ± 13.50
Participation in specialized nurse or mechanical ventilation training		9.6352	< 0.001		5.7992	< 0.001		7.9382	< 0.001
Yes	63.87 ± 21.69			21.94 ± 2.95			60.31 ± 13.53
No	46.61 ± 17.51			20.21 ± 3.33			49.94 ± 14.76

¹F value.

²t value.

Path analysis of factors influencing knowledge, attitude, and behavior of ED nurses regarding airbag management

Utilizing the KAP theory, we conducted path analysis, as illustrated in Figure 1, considering variables with statistically significant effects from single-factor analysis as independent variables, and knowledge, attitude, and behavior scores as dependent variables. Table 5 presents the model fit parameters, with values indicating a good fit. In Table 6, we highlight that out of 13 research hypotheses, our study supported 10, did not support 2, and found a negative effect in 1 hypothesis. Specifically, the department of work, work experience, and participation in specialized nurse or mechanical ventilation training directly influenced the knowledge score of ED nurses regarding airbag management. Additionally, knowledge, department of work, participation in specialized nurse or mechanical ventilation training, and professional title directly influenced the belief score. Furthermore, knowledge, belief, department of work, participation in specialized nurse or mechanical ventilation training, and professional title had direct effects on the behavior score of ED nurses. Notably, belief acted as a partial mediator between knowledge and behavior. The total effect was 0.513, with an indirect effect of 0.085, constituting 16.6% of the total effect (refer to Table 7).

Figure 1 Path analysis of influencing factors of airbag management knowledge, attitude, and practice among emergency department nurses.

Table 5 The fitting indexes of the path analysis model.

Fit indices	χ2	DF	χ2/DF	Root mean square error of approximation	Comparative fit index	Tucker-Lewis index	Standardized residual mean root
Fitted values	3291.278	1003	3.281	0.068	0.907	0.901	0.047
Reference value	—	—	1-5	< 0.08	> 0.90	> 0.90	< 0.05

DF: Degrees of freedom.

Table 6 Path analysis and hypothesis testing results.

Hypothesis	Relationship between variables	Estimate	Standard error	T value	P value	Decision
H1	Knowledge: Belief	0.387	0.044	8.764	< 0.01	Accepted
H2	Knowledge: Practice	0.428	0.040	10.587	< 0.01	Accepted
H3	Belief: Practice	0.219	0.041	5.338	< 0.01	Accepted
H4	Educational status: Knowledge	-0.038	0.042	-0.884	0.376	Rejected
H5	Department: Knowledge	0.200	0.041	4.911	< 0.01	Accepted
H6	Work experience in the department: Knowledge	0.131	0.042	3.104	< 0.01	Accepted
H7	Participation in specialized nurse or mechanical ventilation training: Knowledge	0.366	0.039	9.472	< 0.01	Accepted
H8	Department: Belief	0.119	0.043	2.781	< 0.01	Accepted
H9	Participation in specialized nurse or mechanical ventilation training: Belief	0.091	0.046	1.999	< 0.05	Accepted
H10	Educational status: Practice	-0.024	0.039	-0.609	0.543	Rejected
H11	Professional title: Practice	-0.097	0.039	-2.482	< 0.05	Significant negative correlation
H12	Department: Practice	0.147	0.037	4.015	< 0.01	Accepted
H13	Participation in specialized nurse or mechanical ventilation training: Practice	0.122	0.038	3.208	< 0.01	Accepted

Table 7 Path analysis effect decomposition of factors influencing airbag management knowledge, attitude, and practice among emergency department nurses (standardized path coefficient).

Dependent variable	Independent variable	Direct effect	Overall effect ranking
Knowledge	Participation in specialized nurse or mechanical ventilation training	0.366	1
	Department	0.200	2
	Work experience in the department	0.131	3
Belief	Knowledge	0.387	1
	Department	0.119	2
	Participation in specialized nurse or mechanical ventilation training	0.091	3
Practice	Knowledge	0.428	1
	Belief	0.219	2
	Department	0.147	3
	Participation in specialized nurse or mechanical ventilation training	0.122	4
	Professional title	-0.97	5

DISCUSSION

The level of knowledge mastery in managing airbags among ED nurses is generally moderate, with beliefs and behaviors being relatively positive

According to the KAP theory, knowledge serves as the foundation for behavioral change. In the realm of airbag management for critically ill patients, mastering this knowledge is crucial. Within the clinical practice of ED nurses, frequent procedures involving endotracheal intubation and mechanical ventilation are imperative. A deficiency in relevant knowledge may result in improper procedures, subsequently escalating the incidence of VAP. This study unveiled that the knowledge level of ED nurses in airbag management mostly ranged from good to fair, with 47.4% of respondents categorized as having fair to good levels, consistent with previous studies[13,17]. However, attention is warranted regarding poorly performing items within the knowledge score, particularly in comprehending factors such as venous pressure, arterial pressure, and increased airbag pressure. This inadequacy might be linked to limited opportunities for ED nurses to partake in relevant training. Hence, structured theoretical courses and practical guidance could assist in enhancing nurses' knowledge of airbag management[18,19]. Furthermore, studies by Higgs et al[20] demonstrated that adherence to evidence-based guidelines in airbag management can significantly mitigate complications. Therefore, future training programs could tailor training based on evidence-based guidelines, targeting the identified weaknesses in ED nurses' knowledge.

Regarding airbag management beliefs, ED nurses showcased relatively positive attitudes, with 99.4% classified in the fair to good range, consistent with prior research[21]. Nevertheless, attention should be directed towards certain belief items with lower scores, including regular assessment of airbag pressure monitoring, active engagement in learning-related knowledge, and participation in relevant training. This might be influenced by the demanding nature of ED nursing work and the pressure of assessments, reducing their willingness to actively engage in learning and training. Hence, administrators could enhance nurses' training enthusiasm by optimizing training formats and improving training management systems.

In terms of airbag management behavior, 80.4% of ED nurses exhibited good to fair levels, contrary to findings in a previous study[22]. This difference might be attributed to the growing emphasis on nursing care practices in airbag management, with departments establishing nursing quality control units for supervision. However, specific attention should be given to certain behaviors with lower scores, such as flushing fluid accumulation from the airbag during airway management, measuring airbag pressure before and after oral care and nasogastric feeding, and using an airbag leak test to assess upper airway patency before extubation. Past research indicates that bedside skills training through plan-do-check-act methodologies can significantly enhance nurses' bedside skills in standardized airbag management, consequently reducing VAP incidence[23]. Therefore, we propose using quality management approaches to improve the standardization of nurses' airbag management. Additionally, considering the adoption of new instruments and technologies, such as dynamic airbag pressure monitoring systems or portable electronic airbag pressure monitoring devices[24-26], could further enhance airbag management practices.

Factors influencing the level of knowledge in airbag management among ED nurses

The results of path analysis highlighted the positive direct impact of specialized nurse or mechanical ventilation training on the airbag management knowledge scores of ED nurses, aligning with previous research[27]. Consequently, it is advisable to strengthen education and training concerning airbag management in clinical settings, by establishing quality control groups for artificial airway airbag management. This measure aims to ensure the timely dissemination of research advancements and cutting-edge knowledge in this field[28]. Furthermore, a noticeable discrepancy in airbag management knowledge was observed between nurses in the EICU and those in the emergency resuscitation room, possibly indicating a lack of emphasis on airbag management in the latter. Many hospitals have yet to implement standardized airbag management measures in emergency resuscitation rooms. Therefore, we propose active knowledge exchange between departments to enhance the airbag management knowledge level of all nurses in the hospital. Lastly, our research findings suggest that years of work experience significantly impact nurses' airbag management knowledge scores, consistent with prior studies[13]. Nurses with more experience generally possess richer clinical experience and a higher level of airbag management knowledge. Hence, administrators should prioritize and provide additional training opportunities for nurses with less experience to improve their airbag management knowledge levels.

Factors influencing the level of beliefs in airbag management among ED nurses

Path analysis results revealed that the knowledge of airbag management among ED nurses significantly impacts their belief scores, consistent with previous findings[15]. This discovery likely demonstrates how the extensive knowledge of nurses in airbag management positively influences their beliefs in this domain. Additionally, nurses stationed in emergency resuscitation units and those lacking specialized training in nursing or mechanical ventilation tended to hold relatively pessimistic views regarding airbag management. This tendency could arise from a deficiency in emphasis on airway management within emergency resuscitation units and a lack of specialized training, potentially resulting in a lower level of proficiency in airbag management knowledge. Therefore, it is recommended to prioritize interventions targeting nurses with lower levels of airbag management knowledge, particularly those deployed in emergency resuscitation units and those lacking specialized training. The goal is to augment their awareness and commitment to actively participate in airbag management practices.

Factors influencing the level of behavior in airbag management among ED nurses

The path analysis results underscored the significant and direct impact of airbag management knowledge on behavior. Moreover, both airbag management knowledge and beliefs directly shaped airbag management behavior, with airbag management beliefs serving as a mediator between knowledge and behavior, aligning with previous research[15]. This suggests that enhanced knowledge and positive beliefs regarding airbag management can promote stricter adherence to practices among nurses. Research conducted by Hu et al[29] further validates the efficacy of educational interventions in cultivating positive beliefs among nurses, offering a viable approach to enhancing airbag management behavior. However, nurses working in emergency resuscitation units and those lacking specialized training in nursing or mechanical ventilation exhibited comparatively inferior airbag management behavior. Previous studies[12,30,31] have also revealed elevated airbag pressures in mechanically ventilated patients within ED and pre-hospital settings, indicating a need for improvement in airbag management practices, particularly in critical care scenarios. This highlights the importance for management to prioritize quality control in ED airbag management to bolster nurses' adherence to proper practices. Additionally, the path analysis revealed a negative correlation between airbag management behavior and nurses holding higher professional titles. This phenomenon may be attributed to fewer airbag management-related tasks being performed by nurses with higher professional titles, often delegated to lower-ranking colleagues. Consequently, management must enhance training and assessment protocols for nurses in emergency resuscitation units, those lacking specialized training, and those with higher professional titles, thereby providing adequate support and fostering improvement in airbag management behavior.

CONCLUSION

The study highlights a positive attitude and relatively standardized practices among ED nurses regarding airbag management. However, there is room for improvement in their knowledge levels. To enhance nurses' knowledge of airbag management for mechanically ventilated patients and reduce the incidence of VAP, managers can develop scientifically feasible training strategies based on the knowledge, beliefs, and practice characteristics of ED nurses and influencing factors. Improvements to specialized training systems can be implemented to enhance nurses' adherence to airbag management measures.

There are some advantages of our study. Firstly, the innovative approach of shifting the research focus from the ICU to the ED for airbag management studies presents a novel perspective. Secondly, conducting a multicenter, large-sample survey in Shanghai, China, ensures a comprehensive and diverse dataset, yielding insightful observations. Thirdly, the inclusion of in-depth analyses, such as pathway analysis and effect decomposition, enhances the overall understanding of the subject.

We also acknowledged some limitations of this study. First, The cross-sectional design of the study poses challenges in establishing causal relationships between variables. Additionally, the exclusive reliance on data from ED nurses in Shanghai, China, may constrain the generalizability of the findings. To enhance the universal applicability of research outcomes, future endeavors should consider broadening the study scope to include samples from diverse regions and healthcare institutions. Despite these limitations, the study provides a robust foundation for future research aiming to refine and broaden the understanding of airbag management practices among ED nurses.