The Impact of Nursing in the Prevention of Surgical Site Infection in Surgical Units of Hospital Among Nnamdi Azikiwe University Teaching Hospital, Nnewi
Chapter One
Objectives of study
- To examine the level of nurses’ knowledge regarding the prevention of SSI
- To examine the Impact of nurses regarding the prevention of SSI
- To examine the relationship between nurses’ knowledge and practice regarding the prevention of SSI
CHAPTER TWO
LITERATURE REVIEW
Conceptual Review
Surgical Site Infection
Intact skin is the patient’s first line of defense against bacterial invasion. A surgical incision is un-intentional breech of this defense mechanism, after which the surgical wound can be contaminated by bacteria from multiple sources (Fry & Fry, 2007). Surgical site infection (SSI) refers to an infection that occurs within 30 days of the operation, if no implant is left in place or within one year of operation, if an implant is left in place and the infection appears to be related to the operation. SSIs are divided into three types, depending on the depth of infection penetrating into the surgical wound: superficial incisional infection, deep incision infection, and organ/space infection (Florman & Nichols, 2007; Gray & Hawn, 2007; Mangram et al., 1999; Pear, 2007).
SSIs are the most common type of nosocomial infection among surgical patients and are commonly caused by the patients’ own flora and by health care providers (Florman & Nichols, 2007). According to the National Nasocomial Infection Surveillance (NNIS) system of the Centre for Disease Control and Prevention (CDC), SSI accounted for 14% to 16% of all nosocomial infections and was the most common nosocomial infections among surgical patients, and accounted for 38% of such infection (Mangram et al., 1999).
Incidence of SSI
SSI is a world wide clinical problem. In developed countries, approximately 5,000,000 patients developed an SSI during the 44 million inpatients surgical procedures performed annually and rate of SSI was 2% to 5% in the USA (Anderson et al., 2008; Nichols, 2004). In the UK, a study was conducted with caesarean section patients found the incidence of SSI was 2.9% (Ward, Charlett, Fagan, & Crawshaw, 2003). In Sweden, a study reported that the overall SSI rate was 6.4% in orthopedic and thoracic surgical patients (Gunningberg et al., 2008). In 2002, a one-month prospective national multi-cancer surveillance study was conducted in general and gynecology units of 48 Italian hospitals. This study revealed that an incidence of SSI was 5.2% (Petrosillo et al., 2008). Medeiros et al. (2005) conducted a survey study in a tertiary teaching hospital in north-east Brazil. The survey included 5,742 patients of thoracic, urologic, vascular and general surgery. Data analysis revealed that the overall incidence of SSI was 8.8% in 1994 and 3.3% in 2003. In Greece, a prospective study was conducted in 8 surgical wards in patients underwent the surgery during a 9- month period. This study found that the overall incidence of SSI was 5.2% (Roumbelaki, Kritsotakis, Tsioutis, Tzilepi, & Gikas, 2008).
The incidence of SSI is higher in developing countries. In African country (Tanzania), a study showed that SSI incidence was 19.4% (Eriksen, Chugulu, Kondo, & Lingas, 2003). In Peru, a study revealed that incidence of SSI was 26.7% (Hernandez, Romes, Henostroza, & Gotuzzo, 2005). In India, a study showed that overall SSI incidence in a variety of surgical procedures was 18.92% (Desa, Sathe, & Bapat, 2008). In Thailand, a retrospective study of 492 hepato-biliary-pancrease and colon surgical patients was conducted (Kahachindawat et al., 2007). They found that overall incidence of SSI was 7.7% in which most of SSIs were detected within 20 days after operation. Another study that conducted in Thailand with 330 patients undergoing colorectal cancer surgeries found that overall incidence of SSI was 14.5% (Lohsiriwat & Lohsiriwat, 2023). A study carried out at Manipal Teaching Hospital in Nepal reported that an incidence of SSI was 7.3% (Giri et al., 2008).
In developing countries, SSI rate was high compared to developed countries. The magnitude of the problem should be determined and many countries remain largely ignored of SSI. Developing countries including Nigeria need to establish surveillance system to prevent and control of SSI.
Impact of SSI
SSI could have devastated impact on the patient’s course of treatment and is associated with increased treatment intensity, prolonged hospital stay, and increased the hospital charges by 10% to 20% (Lissovoy et al., 2023; Nandi et at., 1999). In the USA, a study revealed the impact of SSI on the length and costs of hospitalization. SSI prolonged the length of hospitalization by 14 extra days and it was estimated that additional cost per infected hospitalized patient was US$ 24,344, compared to uninfected patient (Whitehouse et al., 2002). Another prospective study conducted by Weber et al. (2008) found that among 6,283 surgical patients, 187 were diagnosed positive for SSI. They also found that additional length of hospital stay was 16.8 days and additional hospital charge was US$ 11,586. Lissovoy et al. (2023) conducted a survey among 723,490 varieties of surgical patients, out of which 6,891 of SSI patients were identified and they found that in SSI patients, the extended length of hospital stay was 9.7 days and increasing cost of US$ 20,842 per admission. A study revealed that each SSI prolonged length of hospital stay by 7 to 9 days and resulted in an added hospital cost of greater than US$ 3,000 per SSI patient (Barnard, 2003).
CHAPTER THREE
RESEARCH METHODOLOGY
Research Design
The descriptive correlational study was conducted to obtain information on knowledge and practices of nurses regarding prevention of SSI at Nnamdi Azikiwe University Teaching Hospital (NAUTH) in Anambra and also to examine the relationship between these variables.
Population and Setting
One of the largest government acute care centre and teaching hospital in Anambra, Nigeria was conveniently selected to be a target setting for the study. Anambra is located in the south geographical zone of Nigeria. The NAUTH is located in the town of Anambra. There are more than one thousand patients getting admitted per day in this hospital. The total number of nurses is 300 nurses, out of which 138 nurses are working in the surgical wards. There were 13 surgical wards covering general surgery, orthopedics, ENT (ear, nose, and throat), eye, gynecology, and labour (postpartum and caesarian section). Nurses who were working in these wards were recruited, if they held a minimum of diploma degree in nursing and had at least six months of experience in surgical related wards.
CHAPTER FOUR
RESULTS AND DISCUSSION
Subjects’ Demographic Characteristics
The demographic data of the subjects are presented in Table 1. The majority of the subjects were female (90.8%). The average age was 40.86 years old (SD = 6.47), ranging from 28 to 55 years old. The majority of the subjects (95.8%) were married. More than one-fourth (27.5%) worked in the male (17.5%) and female (10%) surgical wards. The average years of working experiences in the surgical wards was 3.77 years (SD =1.29), ranging from 1 to 16 years. Most of them (93.3%) completed diploma in nursing. More than half of the subjects (54.2%) were trained in the infectious control program.
CHAPTER FIVE
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
Discussion
The study was aimed to examine the nurses’ knowledge and their practice regarding prevention of SSI in NAUTH, Anambra, Nigeria. This section discusses the results in relation to the research questions and the hypothesis.
Nurses’ Knowledge Regarding Prevention of SSI
In this study, the average scores of knowledge regarding prevention of SSI of the subjects were at a low level (marginal to moderate level), with pre-operative knowledge was at a low level and post-operative knowledge was at a moderate level. Many factors might contribute to the low level of knowledge regarding prevention of SSI among nurses in this study. Firstly, most of the subjects (93.3%) completed diploma in nursing and only eight subjects (6.7%) completed bachelor degree in nursing. For nursing education in Nigeria, curriculum in both diploma and bachelor degree in nursing included general principal of infection control. The focus on evidence-based practice and knowledge regarding prevention of SSI has not been implemented. Therefore, no specific contents of prevention of SSI included in the nursing program would be one factor for lower level of knowledge in this area.
Recommendations
Based on the results of this study, it is indicated that problem of lacked knowledge regarding prevention of SSI among nurses is alarming. To improve the quality of care and the quality of life of patients suffering from surgical infection, the following implications and recommendations are offered.
Nursing practice
The results of the study display information of nurses’ knowledge and practice regarding prevention of SSI in the NAUTH. This information should be transferred to stakeholders, such as Secretary of Nigeria Ministry of Health and Family Welfare, the Director of nursing services, and hospital administrators. Education and training program using current evidence-based knowledge and practice would help improving the quality of nursing care. Hospital administrator should provide effective prevention of SSI policy as an institutional goal by developing standard guidelines for prevention of SSI for staffs in surgical units.
Nursing education
The results of the study indicated that nurses lacked knowledge regarding prevention of SSI. Inadequate education in the previous Nigeria nursing curriculum and previous, outdated in-service training program may be the cause. Thus, it is recommended that the syllabus in Nigeria Nursing Curriculum should be reviewed and added comprehensive program regarding prevention of SSI, so that nursing students would be well-prepared before graduation. More up-to-date in- service training program should be organized to enhance nurses’ competency regarding prevention of SSI and eliminate knowledge deficit.
Nursing research
The findings from this study will provide a reference criterion for further studies in the field of SSI in Nigeria. This study can be improved by increasing the sample size and medical hospitals to enhance the generalizability. A replication of this study using observation method is recommended to examine the Impact of nurses regarding prevention of SSI. Predictive study of factors related to nurses’ practice for prevention of SSI is recommended for future study.
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