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Year : 2019  |  Volume : 33  |  Issue : 2  |  Page : 86-90

The effect of single educational intervention on improving nurses' proficiency in using different inhaler devices in a tertiary care setting

1 Department of Community Medicine and Central Research Services, Pramukh Swami Medical College, Karamsad, Gujarat, India
2 Departments of Respiratory Medicine, Pramukh Swami Medical College, Karamsad, Gujarat, India
3 Department of Paediatrics, Pramukh Swami Medical College, Karamsad, Gujarat, India
4 Department of Paediatrics and Central Research Services, Pramukh Swami Medical College, Karamsad, Gujarat, India

Date of Submission27-Jun-2019
Date of Acceptance25-Oct-2019
Date of Web Publication28-Jan-2020

Correspondence Address:
Dr. Ravish Manmohan Kshatriya
Opd No 109, Department of Respiratory Medicine, Pramukh Swami Medical College, Karamsad, Anand, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijaai.ijaai_22_19

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CONTEXT: Inhalation medications are administered by different inhalers such as pressurized metered-dose inhaler (pMDI) with or without the spacer, dry-powder inhaler (DPI), and nebulizer. Many health-care providers including nurses may have deficiencies in knowledge about using inhalers. This can result in improper techniques of using inhalers adapted by patients, which may lead to wastage of time, medicine, and money and thereby poor outcome in terms of relief.
AIMS: The aim is to study the proficiency of inhalers in nurses and the effect of educational intervention to improve the same.
SETTINGS AND DESIGN: It was a hospital-based educational interventional type of study.
SUBJECTS AND METHODS: Technique of usage of inhalers in 87 nurses was assessed. The steps assessed were as follows (1) Preparation, (2) Administration, (3) Inhalation, (4) Coordination, and finally, (5) Instructions given to patients. Important and necessary steps such as able to identify empty device, advising mouth gargles after administration of the drug via the inhaler device and proper breath holding were also assessed. After an initial assessment, nurses were given an individualized educational session regarding the correct usage of various inhaler devices. They were again reevaluated after one month for the same.
STATISTICAL ANALYSIS USED: The proportion of the participants performing the steps properly before and after the intervention was calculated and compared with Z-test for proportions. The relationship between the years of experience and score for task post intervention was seen through Karl Pearson's correlation coefficient (r).
RESULTS: After the intervention, the proficiency of nurses with the use of each device improved as follows: for pMDI from 21.8% to 36.8%, for DPI from 21.8% to 62.18%, for pMDI with spacer from 2.3% to 21.%, and for nebulizer from 33.3% to 53.21%. For important steps such as identification of empty MDI, only 28.7% of the nurses did it correctly, which improved to 64.4% after the intervention. For proper holding of the device, the proficiency of nurses increased from 29.9% to 69.7%. For proper coordination, the proficiency increased from 18.39% to 67.1%. About 11.4% of the nurses held breath correctly before, which improved to 60.5% after teaching. About 40.2% of the nurses advised gargles after using inhalers before the intervention, which improved to 86.8% afterward.
CONCLUSIONS: Our individualized training has made a difference and improved knowledge as well as skills regarding the use of different inhaler devices in nurses, although there is still a lot of scope for further improvement.

Keywords: Educational intervention, inhalers, nurses, proficiency

How to cite this article:
Ganjiwale J, Kshatriya RM, Joshi Y, Nimbalkar S. The effect of single educational intervention on improving nurses' proficiency in using different inhaler devices in a tertiary care setting. Indian J Allergy Asthma Immunol 2019;33:86-90

How to cite this URL:
Ganjiwale J, Kshatriya RM, Joshi Y, Nimbalkar S. The effect of single educational intervention on improving nurses' proficiency in using different inhaler devices in a tertiary care setting. Indian J Allergy Asthma Immunol [serial online] 2019 [cited 2023 Feb 8];33:86-90. Available from: https://www.ijaai.in/text.asp?2019/33/2/86/276951

  Introduction Top

As asthma and chronic obstructive pulmonary disease (COPD) both are chronic inflammatory airway diseases, it is utmost important that patients of these diseases take inhaler therapy properly for the better management of their condition. These medications are often administered as pressurized metered-dose inhaler (pMDI), dry-powder inhaler (DPI), or with nebulizer. The pMDI, DPI, and nebulizer devices are the preferred pulmonary drug delivery methods, as the patients are able to use them on their own with minimal assistance if they are taught well.[1] Although both pMDI and DPI are relatively simple devices to operate, their proper use is not entirely intuitive, and each has technical limitations that can limit their effectiveness.[1] Each type of inhaler is different, with device-specific instructions for use. In some cases, the steps can be confused between devices, resulting in severe reductions in drug available to patients.[2] When the technique of inhalation is poor, the drugs are often not delivered appropriately to the site of action, leading to poor treatment outcomes. Poor inhalation technique leads to insufficient medication effects and to the prescription of more or additional medication with a higher probability of side effects and to increased costs.[3] A major limitation to the effective use of inhaled medications is the inability of many patients to use various inhaler devices correctly. However, other clinicians, nurses, pharmacists, and other health-care providers should be conversant with the correct sequence of inhaler use, as they are required to check and recheck the correctness of the technique during patients' initial and subsequent follow-up visits.[4] Patients are often given the medications without proper detailing/instructions on the correct technique of use because the provider may not be conversant with the technique.[5],[6] In large tertiary hospitals, nurses are involved quite a lot in dispensing medications in emergency, in routine day care, as well as while discharging the patients with various inhaler devices. It is of the utmost importance that nurses must know proper technique and how to use them and to educate them regarding the same. Lopej et al. suggested in a study that, the health-care provider must have essential level of training to correctly instruct the patient because the efficacy of inhaled treatment greatly depends on the adequacy of techniques. He has also observed that the percentage of mistakes by nursing staff was quite high.[7]


  1. To evaluate the proficiency regarding the use of four inhaler devices: DPI, pMDI, pMDI with spacer, and nebulizer among nursing staff
  2. To evaluate the effect of individualized educational training about proper usage of the inhaler devices on the nurses' knowledge.

  Subjects and Methods Top

It was an interventional study, which was conducted in the hospital nursing staff of a tertiary care center in Western India. The technique of usage of inhaler devices in 87 nurses was assessed with structured assessment sheet by the investigator on one-to-one basis. The investigator was first trained by experts concerned with the subject regarding the correct and necessary steps of the usage of various inhaler devices. The steps assessed were as follows: (1) preparation of device, (2) administration, (3) inhalation, (4) coordination, and (5) general instructions given to the patients by the nurses. Each step performed correctly fetched 1 point, while 0 was awarded for the steps performed wrongly. Thus, the total score was calculated from 5 and the proficiency was assessed as per the score achieved [Table 1]. Important and necessary steps while using inhaler devices such as the ability to identify the empty device, advising mouth gargles after inhaler use, and proper breath holding were also assessed separately [Table 2]. These were also assessed similarly, that is for each step performed correctly, the participant was awarded 1 point and was awarded 0 for the step performed incorrectly. A placebo was used in the devices for the assessment and also the demonstration.
Table 1: Assessment sheet for the proficiency of different inhalers

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Table 2: Assessment sheet of necessary and important steps

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The nurses were then provided individualized feedback regarding their proficiency in the primary assessment and were also provided with an individualized educational session regarding the correct use of inhalers by the same investigator. Nurses were given demonstration regarding the correct steps of usage of same inhalers by the same investigator on one-to-one basis immediately after primary assessment and feedback.

The 76 nurses were reevaluated after about a month by the same investigator with the same methodology. The rest 11 nurses were lost to follow-up.

The proportion of the participants performing the steps properly before and after the intervention was calculated and compared with Z-test for proportions. The relationship between the years of experience and score for task post intervention was seen through Karl Pearson's correlation coefficient (r).

  Results Top

Of 87 participants in initial assessment, 19 (21.8%) nurses were proficient in using pMDI, 19 (21.8%) nurses were proficient with the DPI, 2 (2.3%) nurses were well versed with the use of pMDI with spacer, and 29 (33.3%) nurses were proficient with the use of nebulizer.

After the educational intervention, the proficiency of the nurses regarding the use of each inhaler device showed improvement. Of 76 nurses in the second assessment after intervention, 28 (36.8%) nurses showed improvement in proficiency in using pMDI, 47 (62.18%) nurses were proficient in using DPI, and 16 (21%) nurses showed improvement in the usage of pMDI with the spacer. Similarly, the improvement in the usage of nebulizer was found in 45 (59.2%) nurses after training as compared to 29 (33.3%) in initial assessment [Figure 1].
Figure 1: Proficinecy of various inhalers among nurses

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Regarding important and necessary steps such as identification of empty MDI, only 25 (28.74%) nurses did it correctly, which improved to 49 (64.47%) after health education. For proper holding of the device, it was increased from 26 (29.88%) nurses to 53 (69.74%) nurses. As far as proper coordination, efficiency was increased from 16 (18.39%) nurses to 51 (67.11%) nurses. Ten (11.4%) nurses held breath correctly before, which improved to 48 (60.5%) after teaching. Thirty-five (40.2%) nurses advised gargles after using inhalers before the intervention, which improved to 66 (86.8%) afterward [Figure 2].
Figure 2: Improvement in various steps of inhalers after intervention

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When correlation was found between the experience at work among nurses in the months with the scores achieved in the post intervention scores, there were no good correlations observed (r = 0.166) for MDI use, r = 0.005 for MDI with spacer, r = 0.169 for DPI, and r = 0.262 for nebulizer. Thus, there was no correlation between experience in number of months and proficiency of various inhaler devices.

Overall, it was observed that before the intervention, only 2 of 87 nurses were able to perform all the steps of all inhaler devices appropriately. After the intervention, this number improved to 14 out of 76 (11 participants were lost to follow-up), although the proportion has improved from 2.25% to 15.56%, which is statistically significant (P = 0.003 by applying Z-test for proportion).

  Discussion Top

Inhaler therapy is the most important aspect of the treatment of COPD and asthma. Patients require adequate training and education to optimize the use of inhalers. Many asthma and COPD patients get hospitalizations so frequently that nurses play an important role in providing them the treatment through inhalers. Nurses play an important role to provide the treatment to the patients when they are hospitalized.

In our study, we have found that only 0.02% of the nurses were completely proficient in using all of the above four inhaler devices. After the individualized training, the percentage of nurses using the devices improved to 15%, which is still unacceptable. In spite of the provision of individualized training to the nurses, the improvement has not been remarkable. Various methods such as one-on-one education, web-based education, unit-based education, or hospital-wide competency-based education can improve the knowledge and skills regarding the use of inhalers in health-care professionals.[8]

Previous research in developing educational models in the psychomotor domain suggested that to learn a technique effectively, there should be five transitional phases to the educational intervention (imitation, manipulation, precision, articulation, and naturalization), which would allow motor skill development from the unperfected to the proficient level.[9],[10],[11] To improve such important psychomotor skills, repeated training with hands-on demonstration and periodic assessment of health care provide can be planned. We planned only single mode of intervention, but it could be better if repeated interventions with feedback and reinforcement may be implemented.

The study conducted in the same institute regarding the proficiency of the use of various inhaler devices among the interns revealed that interns were also less proficient in the usage of inhalers (34% for MDI and MDI with spacer, 64% for DPI, and 61% for nebulizer).[12] Thus, nurses and interns both should be trained to use inhalers properly to provide better outcome in asthma and COPD patients at primary level. House staff and nursing staff were also found less proficient in the proper use of the metered-dose inhaler in one study.[13] Another study conducted in Mumbai in India concluded that doctors and nurses also made multiple errors in using inhalers. Although the scores of doctors were significantly better as compared to nurses and patients, it was still quite inadequate compared to the total score (mean score for doctors – 6.35/10). The nurses, in fact, had almost as wrong technique as the patients themselves (4.70 vs. 4.65).[14]

Exhalation up to Functional Residual Capacity (FRC) before inhalation, slow and deep inhalation while using MDI, fast and forceful inhalation while using DPI along with adequate breath hold, and normal tidal breathing during neutralization are recommended for proper inhaler use,[15],[16],[17],[18] but in our study, nurses had very less knowledge and skills to deliver inhaler device up to certain acceptable level. These errors were also found in another study of our institute.[15],[16],[17],[18]

In our study, it was found that nurses were more proficient in using nebulizer as compared to MDI with spacer (2.3% vs. 33.8%). This might be due to wildly use of nebulizer in indoor or hospitalized patients. However, regarding efficacy, MDI with a spacer is quite comparable with the nebulizer and cost-effective too. One study conducted by Chong Neto et al. revealed that the nebulizer was more expensive and used more medicine, showing the same efficiency as compared to spacer.[19] Thus, we need to increase proper and effective use of pMDI with spacer in hospitalized patients comparable to nebulizer which may reduce resources and cost of the treatment.

We have found that there was no correlation between the experience of nursing in terms of number of years and proficiency regarding the usage of inhalers. Hence, each and every nursing staff should be evaluated and provided individualized training for the same. In our study, after providing individualized educational intervention to nurses, there is an improvement in their knowledge and skills to use inhalers more proficiently.

  Conclusions Top

The proficiency of using inhalers in nurses was found to be suboptimal in our study. A single time individualized intervention, although showed some improvement, was not substantial practically. Therefore, we feel the need to reinforce the intervention more frequently, and the proficiency also should be evaluated periodically for improvement.


The authors would like to thank all the participants.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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De Tratto K, Gomez C, Ryan CJ, Bracken N, Steffen A, Corbridge SJ, et al. Nurses' knowledge of inhaler technique in the inpatient hospital setting. Clin Nurse Spec 2014;28:156-60.  Back to cited text no. 8
Dave RH. Psychomotor Levels in Developing and Writing Objectives. Tuscon: Educational Innovators Press; 1970.  Back to cited text no. 9
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Kshatriya RM, Khara NV, Paliwal RP, Patel SN. Evaluation of proficiency in using different inhaler devices among intern doctors. J Family Med Prim Care 2016;5:362-6.  Back to cited text no. 12
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]

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