Abstract
Introduction
Nurses in intensive care units (ICUs) are vulnerable to sick building syndrome (SBS), which can affect their health, performance, and patient safety. Understanding SBS is crucial in healthcare to protect both staff and patients. However, many ICU nurses lack knowledge about this condition and the necessary detection tools.
Objectives
This study aimed to describe ICU nurses’ knowledge about SBS and the need of an instrument to detect the signs and symptoms of SBS.
Methods
A cross-sectional study was conducted with a sample of 100 ICU nurses, recruited through simple random sampling from the Critical Care Indonesia Nurse Association. The study focused on nurses’ knowledge of SBS and the need for an instrument to detect it. Research instruments included basic respondent characteristics, nurses’ knowledge, and the need for an SBS detection tool. Data were analyzed using descriptive statistics.
Results
The majority of respondents exhibited a good level of knowledge (66%), yet many answered questions incorrectly regarding SBS etiology, symptoms, and effects. This was exemplified by incorrect responses attributing noise and chemicals as causes of SBS, overlooking fatigue as a symptom, and inaccurately assessing the physical effects of SBS. Notably, nurses demonstrated strong knowledge regarding SBS prevention (71%) and treatment (94%). Respondents unanimously supported the necessity of an instrument capable of detecting SBS among ICU nurses (71%), with an electronic instrument being the preferred option over other forms.
Conclusion
ICU nurses possess a good level of knowledge about SBS. It is recommended to develop and investigate an electronic-based instrument for detecting SBS. Additionally, implementing an e-learning educational program could further enhance the knowledge and management of SBS among healthcare professionals.
Background
Sick building syndrome (SBS) is a collection of nonspecific symptoms of pain or discomfort stemming from exposure to harmful factors associated with building use (Niza et al., 2023). Nurses who work 24 hr in the intensive care unit (ICU) are prone to SBS due to several factors: constant noise from monitors and life support machines, lack of airflow, fluctuating room temperature, too much light, light reflections, dust, number of people in the room, humidity, and contact with static electric (Jafakesh et al., 2019). Knowledge regarding SBS is very important for ICU nurses so that they can take preventive measures or seek appropriate treatment if they experience SBS (Jafakesh et al., 2019). Despite the importance, initial research involving five ICU nurses revealed that most of them lack knowledge about SBS. However, these nurses mentioned that they experienced some of the symptoms of SBS. Need assessment related to instruments to detect SBS in nurses has not been carried out.
In a study on ICU nurses, some nurses experienced SBS symptoms which were thought to be caused by wrong eating or stress (Zamani-Badi et al., 2019). The results of this study are in line with an exploration in Iran which found that almost half (47.2%) of 144 ICU nurses and more than half (55%) of ICU and operating room nurses experienced SBS symptoms (Dulger et al., 2018). To the best of the researchers’ knowledge, research on nurses’ knowledge related to SBS has not been found. Nurses’ knowledge about SBS needs to be known so that the empowerment of nurses in preventing and overcoming SBS can be done with the knowledge of nurses as the basis. The initial stage of empowerment is knowing/identifying signs and symptoms of whether a nurse is experiencing SBS with an instrument/tool.
Review of Literature
Previous studies show that SBS can be experienced by workers, occupants of a building, or students who live in a particular building (Adiningsih & Hairuddin, 2021; Ardian & Sudarmaji, 2010; Asri et al., 2019; Fu et al., 2021; Huo et al., 2020; Jafakesh et al., 2019; Shan et al., 2016; Sun et al., 2019; Suzuki et al., 2021; Thach et al., 2019; Vafaeenasab et al., 2015; Zamani-Badi et al., 2019). Health workers who work in hospitals can also experience SBS, including nurses, where the most common symptoms are headache, difficulty in concentrating, and dry skin (Keyvani et al., 2003; Vafaeenasab et al., 2015). Nurses who work in the ICU are at a very high risk of experiencing SBS because of the closed ICU room model with constant noise from monitoring and patient life support machines which is one of the factors associated with the incidence of SBS among nurses (Keyvani et al., 2003).
Previous findings indicate that factors related to the incidence of SBS include temperature and humidity (Hanifah et al., 2020), along with other environmental determinants (Afifah & Diyanah, 2021; Ardian & Sudarmaji, 2010). Additional factors related to SBS in ICU nurses include insufficient airflow, fluctuating room temperatures, excessive light, light reflections, dust, the number of people in the room, humidity, and contact with static electricity (Dulger et al., 2018; Jafakesh et al., 2019). A study in Iran found that almost half (47.2%) of 144 ICU nurses (Jafakesh et al., 2019) and more than half (55%) of ICU and operating room nurses (Zamani-Badi et al., 2019) experienced SBS symptoms. SBS can affect both physical and emotional well-being (Huo et al., 2020; Nduka et al., 2018); if this happens to nurses, it may negatively impact their work efficiency and health. Disturbance of psychological wellness of nurses was found to have impact on nurses’ productivity and nursing work life (Pujiyanto et al., 2017) whereby nursing work life has an impact on both nursing performance and job satisfaction (Pujiyanto et al., 2017), including nurses’ adherence to patient safety measures (Asmoro et al., 2022). This, in turn, may affect nursing work life and nurses’ performance on duty and job satisfaction (Winasih et al., 2015). Therefore, SBS can be very dangerous for both nurses and the safety of critically ill patients who depend entirely on health workers.
To date, there has been no research on nurses’ knowledge of SBS. Several studies have investigated incidence of SBS among employees, but currently existing research is related to the prevalence of SBS and the distribution of symptoms experienced by nurses. Overview of nurses’ knowledge about SBS is important to be explored; a need assessment about an instrument to evaluate SBS among ICU nurses also needs to be explored because to date no such instrument exists. The purpose of this study was to describe the knowledge of ICU nurses about SB syndrome and the need of an instrument to detect SBS among ICU nurses.
Methods
Study Design
The research design was a cross-sectional study. The design was chosen because it allows the investigation of numerous ICU nurses’ characteristics at a single point of time (Jacobsen, 2020). The design also enables researchers to gather information about what is happening in a current population in relation to SBS, to be able to achieve the research objectives.
Research Questions
What is the level of knowledge about SBS among ICU nurses?
What is the perceived need for an instrument to detect SBS among ICU nurses?
Sample and Settings
The study population consisted of ICU nurses who were members of a branch of the Critical Care Indonesia Nurses Association/Himpunan Perawat Critical Care (HIPERCCI) in Indonesia. Using Slovin's formula (Peat, 2002), a sample of 100 ICU nurses was recruited by simple random sampling from a population of 132 nurses, with a margin of error of 0.05. The sample size was calculated using an online Slovin's formula calculator. Inclusion criteria included working in the ICU for 30 hr per week or more and not being on sick leave. Nurses on leave were excluded from the study. This study was conducted in Indonesia.
Variables/Instruments
There were two variables of interest: nurses’ knowledge related to SBS and the need for an SBS detection instrument. The research instruments comprised basic characteristics of the respondents, nurses’ knowledge related to SBS, and the assessment of the need for an instrument to detect SBS among nurses. All instruments were self-administered questionnaires.
The basic characteristics questionnaire, developed by the researchers, included both multiple choice (five questions) and short answer (four questions) formats to gather data on respondents’ age, gender, education, and length of work in the ICU. The nurses’ knowledge questionnaire was modified from Vafaeenasab et al. (2015), which was originally used to identify SBS among ICU nurses in a Persian setting. The original questionnaire measured SBS symptoms and associated factors, while the modified version focused on nurses’ knowledge related to SBS. It included five indicators: etiology, signs and symptoms, effects, prevention, and treatments of SBS. This questionnaire consisted of 17 multiple choice questions and a checklist of SBS signs and symptoms affecting the eyes, nose, chest and throat, skin, and other areas.
The questionnaire assessing the need for an SBS detection instrument was developed by the researchers and included four questions with indicators on the need for early detection of SBS, the frequency of instrument use among nurses, and the type of instrument considered most suitable and comfortable for ICU nurses.
A back translation was conducted for the nurses’ knowledge questionnaire modified from Vafaeenasab et al. (2015) because the original questionnaire was in English. The back translation process involved two bilingual translators (English-Indonesian) and the researcher. The steps were as follows: the researcher first translated the original instrument text from English to Indonesian. Then, the first translator retranslated the researcher's translation from Indonesian to English. Next, the second bilingual translator translated the English research instrument back into Indonesian. Finally, the original instrument text (English) was compared with the second translator's translation, and the final translation was completed from the original language to Indonesian.
Prior to data collection, the instruments were tested for validity and reliability with a sample of 20 ICU nurses. Instrument validity refers to its ability to measure the variable of interest (Polit & Beck, 2021). The validity of the instrument was tested using the Pearson Product Moment correlation to test the correlation between scores of each item and its total scores. The decision on validity was based on the calculated r value compared to the r table with a correlation coefficient limit (r) of 0.30–0.50. If r count > r table, then Ho was rejected, indicating validity; if r count < r table, Ho was accepted, indicating invalidity (Polit & Beck, 2021). The validity test yielded an r table (Pearson Correlation), Sig. 2-tailed (α = 0.05) value of 0.361. The corrected item-total correlations (r count) ranged from 0.81 to 0.88 for the basic characteristics questionnaire, 0.58 to 0.88 for the nurses’ knowledge questionnaire, and 0.76 to 0.84 for the assessment of the needs for an SBS detection instrument questionnaire, showing that all questionnaires were valid.
Instrument reliability refers to its ability to yield consistent data between measurements (Polit & Beck, 2021). Internal consistency of the instruments was evaluated using Cronbach's alpha coefficients. An instrument was considered reliable if the Cronbach's alpha was 0.7 or more. The reliability test yielded Cronbach's alpha coefficients of 0.88, 0.87, and 0.81, respectively, for the basic characteristics, nurses’ knowledge related to SBS, and the assessment of the need for an SBS detection instrument questionnaire, indicating that all instruments were reliable.
Data Collection and Analysis
Data collection was conducted using Google Forms, which were distributed to ICU nurses who were members of HIPERCCI in East Java. Data collection took place in August 2022 by research team members, without research assistants. Each member involved in the writing of this scientific article had specific roles. The corresponding author contributed substantially to the conception and design of the study, as well as to all parts of the study, manuscript writing, and revisions. Another author was responsible for data acquisition, analysis, and interpretation, while other authors were involved in drafting the article, critically revising it for important intellectual content, and providing final approval for the version to be published. Respondents received explanations regarding the purpose and benefits of the study, the procedures to be followed, potential risks, and their right to withdraw. Additionally, the researchers obtained informed consent from each respondent.
After data collection, the data underwent several steps: cleansing, editing, scoring, coding, tabulating, data entry, and cleaning. The data were then analyzed using IBM SPSS Statistics version 25 (IBM Corporation, New York, USA). Descriptive statistics were employed, including measures such as frequency and percentage distributions were used to describe categorical variables. The results were summarized and presented in tables to facilitate interpretation and draw conclusions.
Ethical Consideration
The protocol of this study had passed an ethical review and was approved by the Institutional Review Board members of the Faculty of Nursing, Universitas Airlangga, with Ethical Approval No. 2548-KEPK. All participants were given information about the study and subsequently provided their consent to participate.
Results
Out of 100 recruited critical nurses, 71% are female and 87% are married. In terms of educational background, more than half (56%) have vocational nursing education. Approximately three-quarters (76%) are rotation nurses, and around 60% work 40–50 hr per week. Additionally, approximately three-quarters (76%) are clinical nurses, and 59% have less than 10 years of working experience (Table 1).
Respondent Characteristics (n = 100).
Table 2 describes the respondents’ level of knowledge regarding SBS. It highlights that the majority (66%) have a good level of knowledge about SBS. Table 3 elaborates on these findings by detailing both correct and incorrect answers regarding various aspects of SBS. The majority of respondents answered incorrectly about SBS etiology (82%), SBS symptoms (93%), and SBS effects (75%). Specifically, most nurses answered incorrectly about the noise, light, dust, and chemicals that may cause SBS. Questions about SBS symptoms, such as unspecified weaknesses, were also answered incorrectly. Moreover, the effects of SBS on the eyes, nose, throat, chest, skin, and work performance were commonly answered incorrectly. Interestingly, the nurses showed good knowledge of SBS prevention (71%) and SBS treatment (94%). For example, they correctly identified that good humidity and indoor air quality can prevent SBS and were able to identify treatments to alleviate SBS.
Level of Knowledge Related Sick Building Syndrome Among ICU Nurses (n = 100).
ICU = intensive care unit.
Knowledge Indicators of Sick Building Syndrome (n = 100).
SBS = sick building syndrome.
Table 4 describes the need for an instrument capable of detecting SBS. According to the table, 71% of respondents agreed on the necessity of such an instrument for ICU nurses. Additionally, 31% of respondents believe that SBS signs and symptoms should be assessed monthly. Nearly half of the respondents (48%) chose an electronic instrument as a convenient tool for detecting SBS.
SBS Detection Tool Needs Analysis (n = 100).
SBS = sick building syndrome.
Discussion
Nurses’ Knowledge About SBS
This study shows that the majority of ICU nurses who were members of HIPERCCI in East Java, Indonesia, had good knowledge regarding SBS. However, most could not correctly identify the factors that can cause someone to experience SBS. Knowledge about SBS plays an important role in the prevention and management of SBS. Knowledge is crucial for hazard precautions in the workplace, including understanding SBS, as it enables employees to identify risks and implement preventive measures like proper ventilation and avoiding harmful chemicals. In healthcare settings, particularly among ICU nurses, this knowledge helps protect both staff and patients by maintaining a healthy indoor environment (Aluko et al., 2016; Gebreeyessus, 2022; Shaheen et al., 2023). With an increasing understanding of SBS among ICU nurses, they will become more aware of its causes and risk factors. Studies of health workers in Nigeria and Pakistan indicate that knowledge is one of the factors that enable healthcare workers to identify hazards and prevent occupational incidents in healthcare settings (Aluko et al., 2016; Shaheen et al., 2023). These studies reported that nurses practiced hand hygiene to prevent cross-infection, completed their immunizations, and complied with standard operating procedures to enhance work safety (Aluko et al., 2016). These findings are consistent with previous study which found that knowledge was significantly associated with attitude and practices regarding occupational health and safety principles among cleaners working in a referral hospital in Addis Ababa, Ethiopia (Gebreeyessus, 2022). The rational model of health promotion posits that high knowledge will translate to a positive attitude and subsequently good behavior (Mitic et al., 2012). Thus, it can be concluded that increasing knowledge will increase awareness of threats, including SBS.
This survey also reveals that ICU nurses were unaware of the symptoms of SBS. Insufficient knowledge may lead to improper treatment of SBS symptoms experienced by ICU nurses, which may include headaches, mental fatigue, mucosal irritation, skin irritation, and respiratory disorders. Investigations in various settings show consistent findings regarding these symptoms among different populations: office workers (Asri et al., 2019), building residents (Huo et al., 2020; Nduka et al., 2018), pregnant health workers (Gómez-Acebo et al., 2011), and ICU nurses (Jafakesh et al., 2019). These variations may stem from differences in environment, climate, and building type. This survey was conducted in Indonesia, which has a humid, monsoon climate, differing from studies conducted in countries with four seasons. Additionally, as shown in Table 1, the majority of respondents work 40 hr per week, and the rest of their time is likely spent at home, typically in nonapartment buildings, as is common in Indonesia. This might explain why the majority of respondents were unaware of SBS symptoms, as the symptoms they experienced may have been mild.
The symptoms, despite likely to cause great harm to human productivity and health, may be interpreted or diagnosed with other disease or psychological distress. This can consequently prolong the symptoms of SBS, which causes low nurse productivity at work and increased absenteeism from work. This raises the issue of the importance of a detection tool or instrument that is able to detect SBS among ICU nurses. Conducting SBS detection in ICU nurses is carried out as a preventive measure to reduce the risk of SBS occurring. From the data obtained, respondents agreed on the necessity of an instrument that is able to detect SBS from ICU nurses. Identifying risk factors and symptoms can be beneficial as an SBS prevention measure among ICU nurses. To optimize early detection of SBS in nurses, identification needs to be carried out regularly.
Need Assessment About Instrument to Assess SBS
From this research, most respondents agreed on the necessity of an instrument capable of detecting SBS among ICU nurses, as previous studies show a high incidence rate of SBS in healthcare workers. For instance, a study in Iran found that almost half (47.2%) of 144 ICU nurses (Jafakesh et al., 2019) and more than half (55%) of ICU and operating room nurses in Kashan (Zamani-Badi et al., 2019) experienced SBS symptoms. Additionally, respondents believed that assessing SBS signs and symptoms should be conducted regularly, preferably every month. Nearly half of the respondents preferred an electronic instrument as a convenient tool to detect SBS, citing benefits such as flexible access, minimal data errors, reduced paper use, and ease of answering questions (Zhimin et al., 2019). Implementing this SBS detection instrument will help nurses identify SBS symptoms early and subsequently carry out appropriate treatments.
Strengths and Limitations
Understanding the knowledge and requirements of the SBS detection tool is crucial for ICU nurses and warrants research efforts to prevent and reduce the incidence of SBS in the ICU. This study focuses on describing the knowledge and necessity for SBS detection devices among ICU nurses. The findings highlight the need for such instruments, with respondents recognizing the importance of regular assessment of SBS signs and symptoms and preferring electronic tools for their convenience and accuracy. However, the limitation of this study is that it was conducted in a single area of Indonesia, which may not be representative of other regions with different environmental, cultural, and healthcare settings. The unique climatic conditions and building types in Indonesia might influence the prevalence and perception of SBS symptoms, making it essential to expand the research settings to include diverse geographic locations. Future studies should involve multiple regions and climates to provide a more comprehensive understanding of SBS among ICU nurses, ensuring that the findings and recommendations are broadly applicable.
Implications for Practice
ICU nurses are at a high risk of developing SBS. This study revealed that many nurses lacked understanding of the symptoms and causes of SBS. Nurses working extended shifts in the ICU should possess knowledge about SBS to implement prevention measures or seek appropriate treatment promptly if they experience symptoms. Consequently, targeted educational programs may need to be initiated for these nurses to enhance their understanding of SBS. The findings of a chosen instrument to detect SBS suggest that educational e-learning programs based on a learning management system and self-study might be more beneficial and reachable for ICU nurses, considering the hectic roster of the nurses that might prevent them from attending offline courses.
Future Research
This study underscores the necessity for future research to focus on developing an instrument specifically designed to detect SBS symptoms among ICU nurses. Following development, rigorous testing and validation of this instrument within ICU settings are crucial to assess its effectiveness and accuracy in detecting SBS symptoms early and reliably. Furthermore, future studies should expand beyond a single ICU or hospital to validate the instrument's consistency and applicability across different intensive care units and healthcare settings. This broader approach would enhance the generalizability of findings and provide insights into how variations in environmental conditions, healthcare practices, and patient demographics may impact SBS prevalence and detection methods. Such research efforts are essential for advancing the understanding and management of SBS among healthcare workers, ultimately contributing to improved occupational health and safety in healthcare settings globally.
Conclusions
The results of the study showed that most of the ICU nurses had insufficient knowledge regarding SBS. An SBS instrument, mainly electronic bases, needs to be developed to help the nurses conveniently detect SBS symptoms. Future Research should explore the possibility of extending the study to include different intensive care units or hospitals to validate the consistency of the results. Because of the nature of the type of chosen instrument (electronic-based), collaboration between health and technology experts to develop a more comprehensive and effective electronic SBS detection tool is necessary. The next step of study should conduct testing and validation of the proposed instrument through a pilot testing the developed instrument in an intensive care setting to evaluate its effectiveness and accuracy in detecting SBS symptoms. This study also suggests additional ongoing training programs for nurses, emphasizing early identification of SBS symptoms and proper use of the proposed new instrument, can be developed to prevent or treat SBS among ICU nurses. Ongoing implementation of the instrument and its regular evaluation are also paramount to ensure its effectiveness and relevance in the intensive care setting. In short, these findings show the relevance of SBS knowledge and its detection tool for nurses, mainly those who work in ICU.
Footnotes
Acknowledgment
The authors would like to express our sincere gratitude to all nurses who participated in the study, Critical Care Indonesia Nurses Association/Himpunan Perawat Critical Care (HIPERCCI) East Java branch, Indonesia East Java, Indonesia that facilitated the study and Faculty of Nursing, Universitas Airlangga that funded this research.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Consideration
The protocol of this study had passed an ethical review from the Institutional Review Boards located in Indonesia. All participants of the study were given information about the study and subsequently gave their consent to participate in the study.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by Faculty of Nursing Universitas Airlangga.
