Factors Militating Against The Practice Of Aseptic Technique At The Ward Level A Case Study Of Yobe State Specialist Hospital Potiskum
ABSTRACT
Background: Nurses are at greater risk of acquiring and transmitting Health Care Acquired Infections (HCAI) in the course of delivering nursing care; measures to prevent the transmissions are therefore a significant core nursing care. Factors militating against the practice of aseptic technique among nurses in infection control during management of burns plays a vital role in reducing their morbidity and mortality and hence cost of burn wound management at individual and ward level. Therefore, HCAI is the most serious complication of burns with sepsis being the main cause of death. Adherence to the standard operating procedures on burns management put in place by YSH on aseptic techniques assist in preventing infection spread. The aim of this study was to assess factors militating against the practice of aseptic technique among nurses in management of burns patients at YSH.
Methods: A cross sectional descriptive study design was employed to obtain sample size 59 nurses working in the burns wards, YSH. A self administered questionnaire and structured observational checklist was used to collect data. Data was coded and analyzed using SPSS version 21, descriptive statistics such as median, mean and frequency distribution were applied and categorical data was analyzed using chi-square. Measurements of association between the independent variables with key dependent variable were ascertained through logistical regression modeling.
Results: 42.9% of the participants did not wash their hands properly before, during and after the dressing procedure while 88.1% had good knowledge on aseptic technique; however 14.6% of the participants maintained the aseptic technique practice throughout the procedure while 85.4% did not. Statistical significance was found between barriers to aseptic technique and adequate water supply in the taps and soap at P=0.038(OR=4.5). 70.7% of the rooms lacked standard operating procedures on infection prevention. Presences of segregation posters were present at 31.6 % of the rooms. Barriers to aseptic technique implementation were noted by 54.8% of the nurse’s in hindering application of knowledge to practice.
Conclusion: Nurses working in the burns specialized units have adequate knowledge on aseptic technique and a major key role to play in the prevention of sepsis during burns patient management, but exhibit fair adherence in practice.
Recommendations: This results suggest that nurses in the specialized wards need to be re-trained on aseptic technique procedures by the institution and institutional policies be availed to the respective ward departments, in addition to adequate logistics on supplies and equipments Aseptic technique surveillance needs to be improved from the managerial to the ward level to maintain the Standard Operating Procedures.
CHAPTER ONE
INTRODUCTION
1.1 Background information
Patients with severe burns may die due to complications such as septicemia, Burns wound infection (BWI) is the most frequent nosocomial infection in burn units. Healthcare –associated infection is the most serious complication of burns with sepsis being the main cause of death (Church et al, 2006). Other consequences of burn wounds include pain, discomfort, inconvenience and disability (Odabas A.B, et al. 2009). Wounds management may also lead to financial drain. Non-adherence to aseptic techniques would prolong morbidity and mortality (McRobert & Stiles, 2014) and hence cost of burn wound management at individual and national level.
As social scientists agree, there is no national culture and so there is no national burn management culture and or guideline. Each burn unit has its own burn management culture influenced by many factors hence the need for unit-based studies since in social studies, transferability and generalization of findings is not recommended from trend analysis.
The number of patients burned annually is alarming (Andrews E.A. 2015). Globally it has been reported that fire related injuries account for 265 000 deaths per year, the vast majority being in low and middle income countries (World Health Organization, Fact sheet number 365 of 2014). The highest number of reported deaths were in South East Asia (57 %), followed by Africa (12, 2%) and low and middle regions in the Eastern Mediterranean (11%) according to the World Health Organization (WHO, 2002).
The WHO (2008), reported that the incidence of fire related injuries, which required medical attention per year was 10,9 million globally, with the most affected regions being South East Asia (5.9 million), followed by Africa (1,7 million) and the Eastern Mediterranean (1,5 million). Observably, the burden of burns is experienced mostly in developing countries where access to health care and resources are limited (Andrews E.A. 2015).
This study was done in Nigeria which is a developing country and in Yobe the capital city of Nigeria. Like all other developing countries, Yobe is characterized by urban migration, poverty and development of slum areas. These urban characteristics contributes and relates significantly to overcrowding and the risk of burns (Rode & Rogers 2011) Advances in research over the years has significantly improved the outcomes of burns as seen with the use of antiseptics in the 1960’s, increased use of occlusive dressings and early surgery in the 1970’s and topical antimicrobial agents in the 1990’s (Demling & DeSanti, 2001). Yet, despite these advances, some hospitals still use outdated methods and techniques such as the use of Silver Sulphadiazine (SSD) cream as the standard of care. Newer literature proves that the disadvantages of SSD outweighs the benefits (Opasanon, Muangman & Mamiviriyachote, 2010; Muangman, Pundee, Opasanon, et al., 2010; Caruso, Foster, Blome-Eberwein, et al., 2006; Varas, O’Keeffe, Namias, et al., 2005).
Most research in the management of burn wounds focuses on the surgical management of the burn with no study focusing on the management of burn wounds by nurses. Burns are currently being managed by nurses; however their clinical practices differ extensively. There are no standards or guidelines in place to inform nursing practice and consequently not all patients benefit from evidence informed burn wound management techniques’.
A lot of studies have been conducted in relation to surgical burn wound management. Emphases have been given to operation in Burn Unit which usually requires operations. The focus of this study was to assess aseptic techniques among nurse in management of burns. Nurses, are expected to be competent in wound management, which is a skill taught as part of the undergraduate general nursing curriculum (Bruce, Klopper & Mellish, 2011: 176).
In addition, knowledge provides the basis for informed decision-making and the framework to develop and maintain competence (Benbow, 1992). Nurses therefore have a responsibility to be competent on the principles of burn wound management. Severe and poorly managed burn infections can lead to paralytic ileus, shock, compartment syndrome and acute renal failure among others (Brunner and Suddarth’s 2010).
Chronic infections can cause septicemia or bone infection which can lead to death. Sepsis associated encephalopathy increases morbidity and mortality especially in patients (Maramattom, 2007). Burns care is complicated by numerous factors such as financial constrains, lack of resources, guidelines, healthcare personnel and patients factors, in the continent of Africa (Albertyn R, Numanoglu A. & Rode H., 2014). The role of aseptic technique measures in relation to other factors need to be identified and reinforced.
Nigeria has reported significant improvement in the practice of medicine (Elamenya et al 2015). Notable attempts have been observed in efforts to provide aseptic conditions in surgical wards. However, incidences of would infection is increasing. Management of wound infection remains a challenge in the surgical areas with burns patients being at high risk for infection (Coban Y.K 2012), leading cause of burns death are sepsis and multiorgan failure (William F.N 2009). Therefore, prevention and management is primary concern in burns care.
Some studies have been done in YSH on antibiotic sensitivity patterns (Kinyua, 2013) and pain management (Kiplangat, 2013). Aseptic Technique is depended on many factors including attitudes which are not constant. The factors found to determine the duration of stay of burns patients were age, causes of burns and presences of co-morbid conditions (Lelei L.K, et al, 2011) Aseptic technique in wound management studies need to be done periodically in many hospitals and even in the same wards to generate more knowledge.
1.2 Problem Statement
Burn wound infections if poorly assessed and managed can lead to long-term disabilities, increased morbidity and mortality. The role of aseptic techniques as infection control measures in relation to other factors need to be identified and reinforced and this will enhance patients care To minimize the injuries after a severe accident, intensive care performed by specialized professionals is required. This is hard to accomplish in a developing country, where very few specialized burns centre’s and trained burns professionals exist (Chalya et al, 2011). Rate of burns wound infection in YSH was 18.7% in total of 347 patients, with risk factors predisposing to the infection being varied from age, extent of burns surface area, different modes of management and its effectiveness (Wanjeri, 2013) Infections cause the patient more suffering and extend the stay at the hospitals. In order to prevent infection the environment around the wound should be clean (Almas et al, 2011). Therefore the need for this research was to assess aseptic technique during burns wound management among nurses.
1.3 Research Questions
- What is the available clinical evidence of aseptic technique practice in relation to burns wound management among nurses in YSH?
- What are the factors militating against the practice of factors militating against the practice of aseptic technique among nurses at ward level in YSH?
1.4 Objectives
To assess factors militating against the practice of factors militating against the practice of aseptic technique among nurses in management of burns patients at the ward level in Yobe state specialist hospital
Specific Objective
- To assess the practice of proper hand washing technique before, during and after procedure among nurses in management of burns patients at the ward level in Yobe state specialist hospital
- To assess adherence to standard wound dressing technique among nurses in management of burns patients at the ward level in Yobe state specialist hospital
- To assess practice of proper waste segregation among nurses during management of burns patients at the ward level in Yobe state specialist hospital
- To identify the factors that influences the practice of factors militating against the practice of aseptic technique among nurses at ward level in Yobe state specialist hospital.
1.5 Study Significance
Burn wound infection was the most frequent infection in burn units. Such injuries could be severe, requiring critical care and/or surgical intervention.
Burns often result to wounds. A wound may result from disruption of skin either intentional or accidental (Giacometti et al, 2000). Good management of wounds is key in prevention of Healthcare –associated infection. Many of these cases lead to premature deaths. The infection rate of burns wound at YNH was 23.6% (22/93 cases) the overall study revealed strong relationship between burn wound infection and mortality in YSH (Ngugi, 2013). Adherence of aseptic technique practice reduces on hospital acquired infection on the burns patients (WHO 2012). This study was to assess aseptic technique practice in relation to occurrence of burns wound infection in YSH and this will reduce prevalence of burns wound infections and support designs of preventive intervention.
1.6 Scope
Majority of wounds in YSH (59.3%) are Burn wounds while 22.7% are accidents related wounds. Majority of wound cases were found in the burns wards (56%) and rest were in burns unit (24.7%) wards. In YSH, in patients with wounds are found in the general burns ward, burns unit. This study did not limit itself to any specific ward but drew samples from all wards with burn patients.
1.7 Limitations
Sample size: the number of the population under study provided a small sample size-(59), as statistical tests require a larger sample size to ensure a representation of the population and to be considered representative of the group of people to whom results will be generalized.
Lack of previously done research studies on this topic in YSH, limited the literature review search to study’s done within and outside the hospital on the related topics.
Participants bias may result when they note they are being observed therefore distorting the data to be collected. Observational bias will be counteracted by each participant being observed three times by the researcher on different patients but carrying out the same procedure, on different days.
Time constraints of the semester on the duration expected for the development of the proposal to the publication of the results is limited.
1.8 Operational Definition
Aseptic technique: is a method designed to prevent contamination from microorganisms. It involves applying the strictest rules and utilizing what is known about infection prevention to minimize the risks that one will experience an infection (Kristeen Cherney and Rachel Nall 2015)
Burn – A burn is an injury to the skin or other organic tissue primarily caused by thermal or other acute trauma. It occurs when some or all of the cells in the skin or other tissue is destroyed by hot liquids (scalds), hot solids (contact burns), flames (flame burns), radiation, radioactivity, electricity, friction or chemicals, cold or frost bite (American Burn Association, 2009).
Burn wound management – Burn wound management is the treating of burn wounds. Management starts with an assessment of a burn wound in terms of size, depth and location. Post assessment, the wound is cleaned and dressings applied depending on the depth of the burn wound (Demling & DeSanti, 2004).
Burns unit – A burns unit is an organized medical system for the total care of the burned patient (British Burn Association, 2002).
Competence– is knowledge, skill (behavior), attitude (interpersonal) and values; a deliberate exercise of judgment based on knowledge and understanding (Bruce, Klopper & Mellish, 2011: 176).
Evidence- based wound management – The integration of best research evidence, with clinical expertise and patient values (Sackett, Straus, Richardson, et al., 2000).
Healthcare –associated infection (nasocomial infection): infection associated with healthcare in any setting .The infections are not present at the time of entry into the healthcare process but may acquires it while receiving treatment for other conditions.
(National Infection Prevention and Control Guidelines for Health Care Services in Nigeria, 2010)
Health: is a state of complete physical, mental and social well-being and merely the absence of disease or infirmity. (WHO, 2003)
Management – The specific treatment of a disease or a condition (Oxford English Dictionary, 2014).
Methodological assumptions – Methodological assumptions inform the nature of the research process, including the most suitable method to be used (Mouton, 1996: 124). In this study the methodological assumptions include: evidence-based research, the scientific method and ethical research.
Morbidity refers to the disease state of an individual, or the incidence of illness in a population.
Mortality refers to the state of being mortal, or the incidence of death (number of deaths) in a population.
Nurse – A nurse is a person registered with the NCN to practice nursing or midwifery (SANC, 1984: Nursing Act, 2005), and who practices her/his profession for gain (Searle, et al., 2009:50). Nursing – Nursing is a caring profession practiced by a person registered with the South Africa Nursing Council, which supports, cares for and treats a health care user to achieve or maintain health where possible; cares for a health care user so that he or she lives in comfort and with dignity until death (SANC, 1984).
The nursing process – A systematic, problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness (Chabeli, 2007).
Wound healing: the restoration of injured tissues by replacement of death tissue with viable tissue Closed wound dressing: wound that does not communicate directly with the atmosphere
Wound: a bodily injury caused by physical means with disruption of the normal continuity of the skin structure.
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