Psychometric Properties of the Barriers to and Facilitators of Implementing the Sepsis Six Care Bundle (BLISS-1) Questionnaire

Introduction

Sepsis, a life-threatening organ failure induced by a dysregulated host response to infection, kills 11 million people globally, roughly 20% of the total fatalities.¹ In addition, sepsis leads to significant morbidity, extended hospital stays, and increased healthcare expenses. Respiratory tract infection like pneumonia is the most common site of infection.² The prolong stay in ICU, increase number of elderly people, greater use of invasive procedure, use of immunosuppression drugs, antibiotics resistance and nosocomial infection these risk factors can increase mortality rate related to sepsis.³ Also, delay recognition and initiate timely management of sepsis can lead to increase mortality rate related to sepsis.⁴ Clinical settings must, therefore, manage sepsis quickly and effectively to avoid these consequences, since every hour of delayed treatment raises the mortality risk by 7.6%.⁵ Daniels et al⁶ developed the Sepsis Six care bundle to simplify sepsis treatment. The bundle includes six critical interventions that must be started within an hour of sepsis diagnosis: high-flow oxygen, blood cultures, intravenous antibiotics, fluid resuscitation, serum lactate and hemoglobin measurements, and urine output monitoring.⁷ Studies suggest that the Sepsis Six bundle reduces mortality by 46.6% and hospital length of stay significantly.^6,8 However, despite the advantages of applying the Sepsis Six procedures, they are typically ignored due to a lack of sepsis knowledge, shortages in personnel and resources, and healthcare organizational issues.^9,10 Thus, sepsis treatment and patient outcomes must be optimized by targeting these barriers through education, appropriate resource allocation, and systemic changes. Adherence to the Sepsis Six bundle can save lives and reduce hospital stays and healthcare expenses.¹¹ Sepsis treatment requires a thorough awareness of these hurdles and the techniques needed to overcome them. Additionally, accurate and validated evaluation instruments like the BLISS-1 questionnaire are needed to examine nurses’ perspectives and identify sepsis treatment barriers. These instruments can reveal multiple barriers to nurses’ adherence to the Sepsis Six protocol, hence enabling the implementation of tailored interventions and policies to improve Sepsis Six performance and patient outcomes.⁶

The BLISS-1 Questionnaire

The BLISS-1 questionnaire was developed and validated in aim of analyzing the Sepsis Six care bundle implementation challenges and facilitators. Following semi-structured interviews with a purposive sample of healthcare workers, Roberts et al¹² created this tool using mixed methods. Content and framework analysis of the interviews yielded 64 belief statements across 14 theoretical areas. These assertions were then modified into a 51-item questionnaire and given to 261 stakeholders, yielding a 44.3% response rate. Many studies have used the questionnaire, identifying essential barriers such as inadequate audit and feedback systems, poor cooperation and communication, and limitations in resources like personnel and equipment.¹² The questionnaire’s comprehensive approach to identifying and classifying barriers and facilitators makes it a powerful tool for assessing the application of sepsis care procedures in varied clinical settings.

The reliability and factorial structure of the BLISS-1 questionnaire must be assessed to ensure research credibility. Reliability is often assessed using Cronbach’s alpha, with values over 0.70 indicating reliability.¹³ Meanwhile, principal component analysis (PCA) and parallel analysis (PA) are often used to assess factorial structure and ensure that the questionnaire assesses the appropriate components.¹⁴ According to McCaffery et al¹⁵ and Burke et al,¹⁶ the Sepsis Six bundle’s efficacy depends on accurate compliance and barrier assessment. Extensive reviews of the BLISS-1 questionnaire’s reliability and validity are therefore necessary for obtaining trustworthy study results that may inspire focused actions to enhance sepsis care. Hence, this study aimed to assess the psychometric properties of the BLISS-1 questionnaire.

Material and Methods

Study Design

The study employed a cross-sectional, descriptive design to assess clinical nurses’ perceived barriers to and facilitators of Sepsis Six performance. This design was chosen as it allows for data collection at a single point, offering a comprehensive snapshot of current perceptions and practices, suitable for identifying prevalent issues and informing interventions.

Setting

The study was conducted at King Abdullah University Hospital, specifically in critical care units such as the coronary care unit (CCU), emergency room (ER), intensive care units (ICUs), and other specialized units like the dialysis and burn units. Nurses were selected from these different units to provide a more comprehensive understanding of their perceptions related to Sepsis Six performance across different critical care contexts.

Population and Sample

The study targeted University Hospital critical care clinical nurses. Convenience sampling was used to recruit the participants, with the accessible population including CCU, ER, ICU, and other specialist unit nurses. The inclusion criteria were being a nurse with at least one year of unit experience, whereas the exclusion criteria were being an administrative nurse or not being available for the complete duration of the study. The sample size of 180 participants was deemed sufficient for conducting Exploratory Principal Components Analysis (PCA), including Parallel Analysis (PA) and tests of closeness to unidimensionality (ie, UniCo, Mean of Item Residual Absolute Loadings [MI-Real], and Explained Common Variance [ECV]). Moreover, Parallel Analysis is robust to sample sizes in this range,¹⁷ and FACTOR software’s implementation of UniCo, MI-Real, and ECV has been validated in samples under 200.¹⁸ Therefore, the current sample of 180 is considered adequate for the planned exploratory analyses. In this study, the sample size, N = 180 and the number of questionnaire items k = 54, resulting in a participant-to-item ratio of approximately 3.33. This ratio is supported by the moderate-to-high communalities (C ≥ 0.5). According to Guadagnoli and Velicer,¹⁹ when communalities meet this threshold, a minimum sample size of 150 is acceptable for reliable factor extraction.

Instruments and Measures

The BLISS-1 questionnaire, which comprises two primary sections, examines clinical nurses’ opinions of the Sepsis Six performance importance and barriers. The first section includes 54 questions aimed at evaluating the potential barriers to Sepsis Six performance, including resource restrictions, knowledge gaps, and organizational issues. The second section includes 50 items which measure nurses’ opinions of Sepsis Six performance and their trust in its effectiveness. A Likert-type scale is used to respond to the questionnaire items, allowing nurses to express their level of agreement or disagreement with each item.

Data Collection Procedures

Data were collected step-by-step to guarantee reliability and precision, and ethical approval (IRB # 2024/2023/3/17) was obtained from the institutional review board at Al-Balqa Applied University. The participants were asked to sign an informed consent form detailing the study’s goal, methods, risks, and benefits. The data collection staff received intensive training on the study’s objectives, BLISS-1 questionnaire delivery, and ethics. They were also trained on how to describe the study’s goals and acquire informed permission, stressing the voluntary nature of participation. Data were stored securely, and the participants’ responses were kept anonymous. Distribution of the BLISS-1 questionnaire to the eligible nurses in different departments was carried out at a convenient time to prevent clinical interruptions, and all completed surveys were securely retained for analysis. The participants’ privacy and rights were protected throughout the procedure, following ethical research guidelines and preserving data integrity.

Statistical Analysis

Statistical analysis was conducted using SPSS IBM. Means and standard deviations for the continuous data and frequencies and percentages for the categorical variables were calculated. The Cronbach’s alpha test of internal consistency was used to assess the reliability of the Sepsis Six Care Bundle (BliSS-1) Questionnaire and the Exploratory Principal Components Analysis (PCA) with Parallel Analysis (PA) test and the tests of Closeness-to-unidimensionality (UniCo, MI-Real, and ECV) were used to assess the factorial structure of the (BliSS-1) questionnaire, Scree-Cassilith’s plot and eigen value criteria were also employed in identifying possible underlying subscales of the BLiSS questionnaire. The Bivariate Pearson’s test of correlation was used to assess the correlations between metric measured variables.

Results

The study included 180 clinical nurses who completed and submitted the questionnaire. Table 1 shows the nurses’ sociodemographic and professional characteristics. The sample included 52.8% male participants and 23.9% participants who had never married. As for their experience, 46.7% of the participants had 5–10 years of nursing experience. Further, 35.6% of the nurses worked in the ICUs. Finally, 24.4% had a master’s or PhD degree.

Table 1 Descriptive Analysis of the Nurses’ Sociodemographic and Professional Characteristics

Table 2 shows the BLISS-1 questionnaire’s reliability analysis results, which indicated strong internal consistency with Cronbach’s alpha values of 0.978 for Sepsis Six performance barriers obstacles and 0.976 for performance significance. Based on content validity, the researchers removed four questions to strengthen the questionnaire.

Table 2 Reliability Analysis of the BLISS-1 Questionnaire

Table 3 shows the Sepsis Six performance barrier indicators’ Promax rotational factor analysis pattern matrix. The analysis yielded Barriers 1 and 2. Misconceptions like “Performing the Sepsis Six does NOT improve patient outcomes” (0.924), “Early and regular reassessment of patients requiring the Sepsis Six has NO effect on outcomes” (0.893), and “The RISKS of performing the Sepsis Six outweigh the benefits in CERTAIN patient groups” (0.890) loaded on personal Barrier. Meanwhile, Institutional Barrier contained logistical issues, including “There is the INSUFFICIENT provision of training required to perform the Sepsis Six” (0.925) and “There are INSUFFICIENT tools in use to guide & track Sepsis Six performance in individual patients” (0.913). Items 15 (“There is INSUFFICIENT leadership for improving Sepsis Six performance”) and 48 (“SOME steps in the Sepsis Six are more or less important than others”) again showed substantial obstacles, loading on the first component with values of 0.393 and 0.385. These findings show that conceptual misunderstandings and practical obstacles hinder sepsis care.

Table 3 Promax Rotated Factor Analysis Pattern Matrix for the Indicators of Sepsis Six Performance Barriers

Table 4 summarizes the first evaluation of the factorial structure assessment. The findings showed UniCo (unidimensional congruence) of 0.979, ECV of 0.888, and MIREAL of 0.205. High UniCo and ECV values and a low MIREAL value indicate a strong and coherent factorial structure, suggesting that the data is primarily unidimensional.

Table 4 Summary of the Overall Assessment of Factorial Structure - First Evaluation

The PCA pattern matrix for Sepsis Six performance significance is shown in Table 5. The largest loadings include prioritizing Sepsis Six above other activities (0.803) and enhancing performance via leadership (0.790). The nurses reported being confident in the Sepsis Six (0.766) and the quality of sepsis care (0.763), and the presence of a local sepsis champion was seen to be advantageous (0.751). The nurses also reported being likely to complete the Sepsis Six (0.740) and considered the Sepsis Six beneficial for all patient categories (0.734). The recognition of excellent performance with formal awards (0.728), clinical staff involvement in performance improvement (0.724), and ease of remembering daily practice steps (0.724) were seen as important. Further, sufficient equipment (0.712), cooperation (0.704), Sepsis Six evidence awareness (0.699), bed availability (0.694), frequent audits (0.694), and quick staff turnover (0.684) were viewed to be crucial for Sepsis Six performance. The Sepsis Six had overall advantages (0.679) and an influence on patient outcomes (0.677), and the nurses felt they had enough time (0.683) and abilities (0.680) to conduct it. Performance improvement plans (0.677), role identification (0.670), training (0.669), strong communication (0.667), and feeling responsible for achieving the Sepsis Six (0.664) were reported as necessary. Leadership support (0.660), optimism about future performance improvement (0.661), equal relevance of all phases (0.661), and colleagues’ views on the protocol’s advantages (0.657) were also stressed. Practical performance monitoring tools (0.657) and knowledge improvement intentions (0.655) were observed. The nurses reported that they took their peers’ perspectives into consideration (0.654) and favored the Sepsis Six when unsure of diagnosis (0.651). Proper septic patient treatment (0.627), Sepsis Six knowledge (0.616), capacity to escalate issues (0.615), supportive departmental culture (0.614), ease of remembering procedures via repeated usage (0.608), and regular performance discussions (0.586) were also reported as being important. Finally, the nurses reported receiving enough feedback (0.581) and seldom missing a sepsis diagnosis (0.515).

Table 5 Principal Components Analysis Pattern Matrix for the Indicators of Sepsis Six Performance Importance

Table 6 summarizes the second evaluation of the factorial structure, which yielded a UniCo of 0.625, ECV of 0.529, and MIREAL of 0.434. These metrics indicate considerable unidimensionality and explain the shared variance, suggesting the need for additional refining to improve the factorial structure.

Table 6 Summary of Overall Assessment of Factorial Structure - Second Evaluation

Discussion

Analyzing and interpreting clinical nurses’ sepsis management strategies reveals strengths and limitations of applying sepsis six guidelines. In terms of reliability, the BLISS-1 questionnaire was found to have strong internal consistency, with Cronbach’s alpha values of 0.978 for perceived Sepsis Six performance obstacles and 0.976 for perceived significance. These results significantly surpass the 0.70 criterion,¹³ demonstrating the tool’s construct measurement reliability. As a tool for measuring sepsis treatment obstacles and facilitators, the BLISS-1 questionnaire is therefore highly reliable and consistent with other validated instruments used to evaluate clinical performance and perceptions.¹²

The Promax rotation EFA found unique Sepsis Six performance constraints. The Sepsis Six protocol’s efficacy and hazards were questioned, and practical issues such as inadequate training, manpower, and funding were recognized as significant obstacles. The following items had high factor loadings in the pattern matrix: “Performing the steps in the Sepsis Six does NOT improve patient outcomes” (loading = 0.924), and “There is INSUFFICIENT staffing to perform the Sepsis Six” (loading = 0.904). The factorial structure’s initial evaluation showed high unidimensionality, with UniCo (0.979), ECV (0.888), and MIREAL (0.205) values indicating a cohesive and focused measure of the target components.²⁰ However, the second evaluation yielded lower unidimensionality scores (UniCo = 0.625, ECV = 0.529, MIREAL = 0.434), which may compromise the questionnaire’s ability to accurately measure components across samples or situations. The questionnaire may therefore need to be refined in varied therapeutic settings to achieve unidimensionality.²¹

The Promax rotated factor analysis for perceived relevance showed that the nurses rated the Sepsis Six regimen highly. Items like “I DO prioritize performing the Sepsis Six on a septic patient over other tasks” (0.803) and “It IS part of my role to improve Sepsis Six performance through leadership & support” (0.790) had high factor loadings, indicating protocol commitment. This supports previous research which has shown that healthcare workers have higher compliance and achieve better patient outcomes when they view protocols as valuable and essential.⁶ Other sepsis care research has emphasized the importance of nurses’ views and systemic support in protocol adherence.^12,22 Appropriate resource allocation and legislative assistance are therefore required to address operational burdens to the provision of sepsis care, while focused educational interventions are required to address attitudinal barriers. Sepsis protocols benefit from continual professional growth and supporting organizational structures.^10,16

The current study emphasizes the complexity of sepsis treatment burdens and the importance of using of trustworthy evaluation tools like the BLISS-1 questionnaire. Healthcare systems may enhance Sepsis Six procedure adherence by addressing individual and systemic issues, thus improving patient outcomes and lowering sepsis-related death. Often blamed for nurses’ non-compliance with the sepsis protocol are insufficient resources and poor staffing.²³ Although these are well-documented obstacles, it is also crucial to take into account whether in high-stress clinical settings such explanations have become almost automatic reactions or default rationalizations. Previous studies have underlined how nurses’ interaction with evidence-based protocols may be shaped by their workplace culture, perceived role limitations, and learnt responses to systematic constraints.^24,25 This possibility calls for more study that not only looks at structural issues but also looks at underlying attitudes and behavioral patterns possibly affecting adherence. Knowing both cultural and practical elements will help direct the creation of focused treatments meant to raise protocol compliance.²⁶ Further research is needed to improve sepsis care evaluation tools and identify comprehensive solutions to the burdens faced by nurses who provide sepsis care.

Implications and Recommendations

The findings of this study have highlighted the importance of addressing individual and organizational barriers to Sepsis Six protocol adherence. The BLISS-1 questionnaire was found to have high reliability and clear factor loadings, making it a reliable tool for detecting the barriers to Sepsis Six performance. The results suggest that hospital managers should prioritize the provision of training initiatives targeted at addressing clinical nurses’ knowledge gaps and misunderstandings of sepsis management. Further, more efficient allocation of resources such as personnel and equipment is required, and organizational policies should promote respect for the Sepsis Six protocol through leadership and audits. Future studies should refine the BLISS-1 questionnaire for use in varied therapeutic settings and create comprehensive intervention methods that include educational and systemic changes. By following these guidelines, healthcare systems may reduce sepsis-related morbidity and mortality.

Limitations

The use of a convenience sampling strategy may restrict the generalizability of the study findings. Further, cross-sectional surveys may overlook changes in views over time, and self-reported data may have response biases. Future research should use longitudinal designs and different sampling approaches to improve generalizability and robustness.

Conclusion

This study concludes that clinical nurses face significant barriers and facilitators while delivering the Sepsis Six protocol. Despite the Sepsis Six bundle’s proven advantages in lowering sepsis-related mortality and improving patient outcomes, numerous difficulties make adherence variable. The BLISS-1 questionnaire has been found to accurately assess these impediments and Sepsis Six performance relevance. Inadequate staffing, lack of training, and protocol skepticism were identified as being major organizational and individual barriers. Effective training initiatives, appropriate resource allocation, and supporting organizational policies are needed to improve Sepsis Six protocol adherence and patient care. This study emphasizes the need to enhance assessment methods and establish comprehensive strategies to help clinical nurses in sepsis treatment, hence improving patient outcomes and lowering healthcare costs.