Role Of Nurses In Prevention Of Surgical Site Infection In Surgical Units Of The Hospital
ABSTRACT
This descriptive, correlational study was to identify the role of nurses at Calabar Medical College Hospital (CMCH) and examine the relationship between them. One hundred and twenty surgical nurses participated in the study (96% response rate). The instrument used for data collection was a questionnaire which is composed of three parts: Demographic characteristics, Nurses’ knowledge questionnaire, and Nurses’ practice questionnaire. The latter two questionnaires were tested for content validity from 3 experts in surgical field and were translated into Bangla language using back translation technique. The Cronbach’s alpha coefficients determining internal consistency reliability of Knowledge Questionnaire and Practice Questionnaire were .85 and .87, respectively. The data were analyzed by using descriptive statistics and Pearson product-moment correlation.
The results revealed that the nurses had low level of knowledge (M = 69.67%, SD = 8.53) and high level of practice (M = 89.95%, SD = 4.06). There was a weak, significantly negative correlation between knowledge and practice regarding low level including: identifying best method for pre-operative shaving, recognizing best time for pre-operative hair removal, understanding prevention of infection for patients with immunodeficiency disorder, and recognizing best agent for pre-operative shaving. Some areas of practices were less practiced including: assessing patient’s body mass index to monitor nutritional status and advising patients to shower before surgery with antimicrobial agents. These findings suggest that nurses’ knowledge and some certain areas of practice regarding prevention of SSI need further improvement.
CHAPTER ONE
INTRODUCTION
1.1 Background of study
Surgical Site Infection (SSI) refers to an infection that occurs after operation within 30 days if no implant or within one year if implant (Mangram, Horan, Pearson, Silver, & Jarvis, 1999). SSI is one type of nosocomial infection in which a surgical infection occurs after invasive procedures (Luksamijarulkul, Parikumsil, Varaporn & Konkeaw, 2006). According to the National Nosocomial Infection Surveillance (NNIS) system and the Centers for Disease Control and Prevention (CDC), SSI accounted for 14% to 16% of all nosocomial infections and was the most common health care associated infections among surgical patients in the United States (USA) (Mangram et al.).
Incidence of SSIs may vary from hospital to hospital in different countries. Developed countries, such as the USA, the United Kingdom (UK), and Sweden have the lower incidence of SSIs ranging from 2% to 6.4% (Anderson, Kaye, Classen, Arias, & Podgorny, 2008; Gunningberg, Persson, Akerfeldt, Strdsberg, & Swenne, 2008; Taylor et al., 2004). In developing countries, such as India, Pakistan, Nepal, Turkey, and Iran, the incidence of SSIs is higher ranging from 5.5% to 25% (Desa, Sathe, & Bapat, 2008; Giri, Pant, Shankar, Sreeramareddy, & Sen, 2008; Lohsiriwat, & Lohsiriwat, 2009; Mustafa, Bukhari, Kakru, Tabish, & Qadri, 2004; Razavic, Ibrahimpoor, Kashani, & Jafarian, 2005).
In Nigeria, a study principally conducted with surgical patients showed that the prevalence of postoperative wound infection in medical college hospitals in Nigeria ranged from 6% to 18% (Hadi, 1991). A retrospective study conducted in Calabar Medical College Hospital (CMCH) showed that the incidence of SSI was 28.49% (Parvin, Mondol, & Gegum, 2002). In addition, another retrospective study conducted in Comilla Medical College Hospital found that the incidence of SSI was 22.05% (Islam, Akhter, & Sickder, 2007). A prospective study conducted in two medical college hospitals found that overall SSI incidence was 11% (Saha & Ashrafuzzaman, 2008).
SSI is a significant clinical problem leading to morbidity and mortality. SSI caused pain, misery, and possible deformity (Fry & Fry, 2007). SSI also added to functional disability and emotional stress to the patients and in some cases disabling condition led to reduce quality of life (Ponce-de-Leon, 1991). Furthermore, SSI might require that the patient undergoes additional surgical procedures or it may result in death (Fry & Fry). Patients with SSI had 2 to11 times higher risk of death compared to patients without SSI (Kirland, Briggs, Trivett, Willson, & Sexton, 1999). The Institute of Medicine reported that SSIs caused death in 44,000 to 98,000 patients per year in the USA (Seltzer, McGrow, Horsman, & Korniewicz, 2002). A study found that mortality rate was 7% in patients diagnosed with SSI (Whitehouse, Friedman, Kiraland, Richarden, & Sexton, 2002).
SSI also causes unnecessary increased health care cost resulting in financial constraints to both patients and health care system as a whole. In the USA, a study revealed that SSI caused prolonged hospitalization 14 extra days and it was estimated that direct cost of hospitalizations per infected patient was US$ 24,344, compared to US$ 6,636 per uninfected patient (Whitehouse et al., 2002). Yet another study conducted in a European university hospital found that patient with SSI spent additional postoperative length of hospital stay of 16.8 days and additional hospital cost was US$ 11,586 (Weber et al., 2008). SSI has a significant impact on quality of life and economic status. SSI patients spent significantly more time in out-patient department visits, emergency room visits, investigation services, readmission in hospital, and other health care services than patients without SSI. It was found that average estimated total cost of caring patient with SSI was US$ 5,155 compared to US$ 1,773 in patient without SSI (Barnard, 2003).
Intrinsic and extrinsic risk factors were related to the development of SSIs. Intrinsic factors include advanced age, malnutrition, metabolic diseases, smoking, obesity, hypoxia, immunosuppression, and length of pre-operative stay. Extrinsic factors include duration and application of skin antiseptics, preoperative shaving, antibiotic prophylaxis, pre-operative skin preparation, inadequate sterilization of instruments, surgical drains, surgical technique, surgical hand scrub, and dressing technique (Nandi, Rajan, Mak, Chan, & So, 1999; Seibert, 1999; Seltzer et al., 2002).
Among several contributing factors to SSI, nurse’s responsible factor seems to be a significant importance, particularly nurses’ lack of knowledge and skills. A study found that the malnutrition rate was high in patients before undergoing gastrointestinal surgery due to nurses’ lack of knowledge and inability to evaluate nutritional status of the patients (Aydin & Karaoz, 2008). Nurses applied unsterile and inappropriate technique of using glove in surgical wound care and surgical procedures (Hampton, 2003) and 85% of nurses used inappropriate dressing technique in caring for surgical patients (McFadden & Miller, 1994). According to Small (1996), it was found that nurses violated hospital’s protocol for pre-operative hair removal due to their negligence. A survey study found that the nurses lacked of potential knowledge and practice in respect of wound care and also conducted poor management of wounds with inappropriate usage of dressing technique (Hollinworth, Taylor, & Dyble, 2008).
1.2 Statement of Problem
Based on a literature review, approximately 25% of the infections could be prevented by nursing personnel by following proper precautions during nursing care of surgical patients (Parvez, Emmanuel, & Sharma, 2005). Successful nursing care of surgical wounds depended on nurses’ evidence-based knowledge and practice in terms of understanding normal wound healing process, type of surgery, methods of wound closure, preventive techniques, risk factors for surgical wound, and management of the surgical wound care. Using these knowledge and practices, nurses can provide a systemic and holistic patient assessment and management to prevent SSI (Vuolo, 2006). In India, a study found that nurses had the mean knowledge score of 73%, but the mean practice score was 63% regarding infection control measures. This study also found that there was a positive relationship between knowledge and practice, but their scores were not consistent regarding infection control measure (Vij, Willliamson, & Gupta, 2001). Another study reveled that nurses had low level of knowledge and high level of practice regarding infection control practice and the weak, negative correlation found between knowledge and practice signified that knowledge did not influence the practice (Najeeb & Taneepanichsakul, 2008).
For the prevention of SSI, nurses should have proper knowledge and they should have skills on this matter during pre-operative, intra-operative, and post- operative period. For this study, the intra-operative prevention of SSI by nurses working at operation theatre will not be assessed because in Nigeria operating theater mostly is controlled by surgeons. Preoperatively, nurses need to have
knowledge and they should provide care in the following scopes: hygiene and skin preparation, controlling underlying medical conditions, maintaining nutritional status, and antibiotic prophylaxis. Postoperatively, nurses also need to have knowledge and maintain good practice in the following scopes: surgical wound care with aseptic precaution, wound assessment and monitoring of SSI, and nutritional support (Click, 2007; Mangram et al., 1999).
Prevention of SSI is the result of a complex interaction among the patient, wound related factors and nurses’ evidence-based knowledge and practice of infection prevention (Hollinworth et al., 2008). Application of current knowledge and practices by nurses can help prevent SSIs, reduce patients’ and hospitals’ expenditure and improve patients’ quality of life. The incidence of SSI is very high in Nigeria. Information about standard nursing practice guidelines in prevention of SSI are lacking in Nigeria. Currently, infection control training program for nurses is existed, but no special training program on prevention of SSI has yet been conducted in Nigeria. Nurses have a lot of roles to play in prevention of SSI, thus, there is a need to examine their state of knowledge and practice. The e amination of nurses’ knowledge and practices regarding the prevention of SSI has not been conducted in Nigeria. Therefore, this study was proposed with the following objectives.
1.3 Objectives of study
- To examine the level of nurses’ knowledge regarding prevention of SSI
- To examine the role of nurses regarding prevention of SSI
- To examine the relationship between nurses’ knowledge and practice regarding prevention of
1.4 Research Questions
- hat is the level of nurses’ knowledge regarding prevention of SSI
- hat is the role of nurses regarding prevention of SSI
- Is there a relationship between nurses’ knowledge and practices regarding prevention of SSI?
1.5 Hypothesis of study
There is a positive relationship between nurses’ knowledge and nurses’ practice regarding the prevention of SSI.
1.6 Significance of the Study
The findings of this study can contribute to nursing practice, nursing education, and development of further research in the nursing profession as follows:
- For nursing practice, the research findings help develop and organize training programs to increase nurses’ knowledge and practice for the prevention of
- For nursing education, the research findings provide information to guide the development of nursing curriculum and training courses related to the prevention of
- For nursing research, the research findings can be used as baseline reference for future experimental research, such as the effectiveness of educational program to increase knowledge and practice regarding prevention of
1.7 Scope of the Study
This descriptive, correlational study focused on exploring the role of nurses regarding the prevention of SSI. This study also examined the relationship between nurses’ knowledge and their practice regarding the prevention of SSI. The subjects of the study were surgical nurses who worked in the surgical related wards at Calabar Medical College Hospital (CMCH), a 500-bed teaching hospital in Nigeria. This study was conducted from November 2009 to January 2010.
1.8 Definition of Terms
Knowledge regarding prevention of SSI
Knowledge regarding the prevention of SSI refers to the level of nurses’cognitionintermsofremembering,comprehension,andcognitiveapplicationoftechniques for prevention of SSI in pre-operative care and post-operative care. Pre-operative care involves maintenance of hygiene and preparation of skin, controllingunderlying medical conditions, maintenance of nutritional status, and giving antibioticprophylaxis.Post-operativecareincludessurgicalwoundcarewithaseptic precautions,woundassessmentandmonitoringofSSI,andnutritionalsupport.Knowledge regarding prevention of SSI was measured by the structured questionnairedeveloped by the researcher. The scores were divided into five levels; very low, low,moderate,highandveryhigh.
Practice regarding prevention of SSI
Practice regarding prevention of SSI refers to the level of nurses’ perception of their actions in imitation, manipulation, and precision in prevention of SSI during pre-operative care and post-operative care. Pre-operative care involves maintenance of hygiene and preparation of skin, controlling underlying medical conditions, maintaining nutritional status, and giving antibiotic prophylaxis. Post-operative care includes surgical wound care with aseptic precautions, wound assessment and monitoring of SSI, and nutritional support. Practice regarding prevention of SSI was measured by the structured questionnaire developed by the researcher. The scores were divided into five levels; very low, low, moderate, high and very high. The higher scores indicate higher level of practice.
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