Factors Militating Against the Practice of Aseptic Technique at the Ward Level; A Case Study of Yobe State Specialist Hospital, Potiskum
Chapter One
Objectives of the Study
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.
CHAPTER TWO
LITERATURE REVIEW
Classification and principles of Treatment of Burn Injury
Burn wound results from tissue necrosis caused by application of or exposure to heat (thermal), cold, caustic chemicals or frictional force on the skin. In the case of thermal burns, extent of injury is proportional to the temperature applied, duration of contact and thickness of the skin.
Causes of burns include hot liquids (scald burns), flames, explosions involving flammable gases or liquids (flash burns), electricity, radiation and hot surfaces/objects (Brunicardi FC 2004; Juan PB, Burret-Nerin, David NH, et.al 2007; Wanjeri JK. 1995).
The extent of burn injuries is calculated according to the Lund and Browder chart whereby the Total body (skin) surface area (TBSA) is 100%. Inhalational burn injuries account for a further additional 10% (Brunicardi FC, Andersen D.K, Billiar T.R, et.al 2004). Treatment of burn wounds are depended on size and depth of wound as described in tables 2 and 3 below. Hence wounds need to be classified well for proper treatment to be administered.
2.1 Pathophysiologic Response to Burn Injury
Burn injuries provoke an inflammatory response which results in increased cellular, endothelial and epithelial permeability, hypermetabolism and extensive microthrombosis. Most manifestations of this response disappear in 72 hours except for hypermetabolism which remains until wound coverage is achieved (Bloemsa GC, Dokter J, Boxma H, et al.2008; Alberto M. 2010).Associated clinical states include fluid and electrolyte imbalance leading to burn shock, nutritional deficiencies with muscle catabolism, immunologic and neuroendocrine response (Elevated growth hormone levels, low levels of total T3 and T4). There is hypercortisolemia and elevated levels of glucagon (Alan DM 2000). Further, treatment of burn wounds is dependent on equipment, part of the body affected, how well the burn facilities are kept and maintained.
2.2 Factors influencing aseptic technique Measures
The outcome of burn wound management is depended on the type of first Aid given to the injured patient. Burns assessment and management are critical in elimination of infections. The initial care starts right from the point of burn and the type of first aid given. Intense early inflammation associated with untreated burns can cause progression of depth over 48 hours and so prompt first aid can limit the extent of the primary burn injury (Tobelem et al. 2013). If cooling is commenced within 3 hours of injury, it can significantly reduce pain and edema, decrease cell damage by slowing cell metabolism in hypoxic tissue, decrease inflammatory response, stabilize vasculature and ultimately improve wound healing and reduce scaring (Cuttle L et al (2009). Cooling should be done with cool running water is preferred more than cold compress as this can cause vasoconstriction. Prolonged cooling of extensive burn wounds ((>20% total body surface area [TBSA] in adults ;> 10%TBSA in children) can cause hypothermia and thus cooling should be suspended if hypothermia is suspected (Cuttle L, & Kimble R 2010).
The type of intervention to be given to a burn patient would depend on whether or not the injured is an adult or a child. Patients’ demographic is also another concern in clinical management of burn wounds according to Burns management guidelines as per (McRobert J & Stiles K 2014).
For instance different approaches are recommended for: Adults: >3% TBSA partial thickness burn :All deep dermal and full thickness burns , associated with either electrical shock, chemical burn, non-accidental injury inhalation injury , burns to the face, hands , perineum , limbs or truck and burns not healed within two weeks. Children: >1% TBSA partial thickness burn, all deep dermal and full thickness, circumferential burns and burns involving the face, hands, soles of feet, perineum, all burns associated with smoke inhalation, electrical shock or trauma, Severe metabolic disturbance, burn wound infection, all children “unwell with a burn”, unhealed burns after 2 weeks, neonatal burns of any size and all children with burns and child protection concerns
Management of burn wound is depended on the cause of the burn. The cause of burn is also another variable to wound management and thus infection rate. For instance, electrical burns or electrocution injury can cause deep cutaneous burns, cardiac arrhythmias, limb loss, and serious systemic effects (Hettiaratchy S & Dziewulski P 2004). This will depend on whether or not injury is caused by domestic (low) versus industrial (high) voltage injury. The Low voltage electrical injuries will cause localized, deep burns and may initiate arrhythmias while high voltage injury will cause severe tissue damage, penetrating through fat, muscle, and bone.
CHAPTER THREE
RESEARCH METHODS
Research Design
The study was a cross sectional descriptive survey which was aimed at assessing factors militating against the practice of aseptic technique among nurses in management of burns patients in Yobe state specialist hospital.
Study Population
The nurses working in burns wards that were allocated on dressing procedure at the time of data collection within the period of May and June 2016. The population was chosen because most of the burns patients that were admitted with burns were nursed in the burns wards.
CHAPTER FOUR
RESULTS
Introduction
This was a cross sectional study involving 42 nurse participants working in burns ward at Yobe state specialist hospital. The aim of the study was to assess the factors militating against the practice of aseptic technique among nurses during burns management. The quantitative collected data was coded and analyzed by using of SPSS version 21.0. Analysis was done through calculating descriptive statistics in frequency and proportions for categorical data and measures of dispersion for continuous data. Qualitative data from observations was tabulated thematically into themes. Inferential statistics such as chi-square test was used to show relationship between selected independent and dependent variables. Correlation between quantitative variables was done.P-value was set at 0.05.
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATION
Discussion
Although the study did not show any statistical significance for age and level of education the findings on highest education/professional level (21.5%) attest to the fact that the numbers of higher education degree holders working in the wards are still limited compared to 69% diploma nurses with the mean age of 40.7. This can be explained by the fact that the older nurses acquire knowledge from their years of experience, exposure to continuous professional education than the younger nurse or most of the older nurses may have been deployed to work in other ward departments with light duties.
From the study the years of experience in the burns department show that the (50%) had less than five years experience, which affirms the rotations of nurses across other wards allowed inadequate time to acquire specific knowledge and skills in areas of specialty.
Half of the respondents (50%) acknowledged that they had knowledge on aseptic technique during burns management and that there are barriers to implementation of the technique, major cause being inadequate supplies (33.3%), insufficient knowledge on aseptic technique (19%) and staff shortage (4.8%). This affirms the study findings from Mutisya et al (2015) on assessment of research utilization by nurses and the influencing factors, inadequate facilities for implementation of research accounted for 66.4% which is line with this study that lack of facilities could be a barrier to implementation of aseptic technique.
The study further revealed that majority of the nurses (88.1%) have knowledge of aseptic technique, possibly due to the fact that they were trained on aseptic technique measures during their training in school of nursing before qualifying and the training provided by the hospital infection control department with at least once training(38.1%), twice( 28.6%).
Majority of the causes of burns was dry fire (90.2%) and electrical burns (75.6%) resulting in sustained majority being upper limb trunk and head injuries as they try to stop the fire. These findings however differed from a study by Wanjeri (2015) in that similar causes of fire included majority hot fluids (46.3%), dry fire (40.3%) and least by electricity (6.5).
Nurses have the knowledge on aseptic technique but do not practice either because they lack facilities to implement with 24(57.1%)did not properly wash their hands before, during and after the procedure, this correspond to studies where the nurses were observed not to follow recommended methods of managing wound in YSH (Ndirangu, 2008) and In orthopedic wards at YSH, the nurses also were observed not to follow recommended methods of managing wounds by not using aseptic technique during the procedure (Karimi,2008).
Although the study findings found application of knowledge through wearing of face mask at (100%) before procedure, there lacked emphases on application of aseptic technique during wound dressing at 47.5% surface disinfection . Application of ethical principles in practice by a professional nurse is mandatory, in this study nurses-patient relationship communication created by the nurses only 7(17.1%) introduced themselves to the patients while less than half got consent to carrying out the procedure on them. This can be as result of a few staff trying to dress many patients in a shift or assumption of the fact that the patients have been in the ward so there will be no need of the consent. This findings are consisted with Amalberti.at.al( 2006) who found out that workarounds “adaptation of procedures by workers to deal with the demands of the work” these procedures are often adapted to bypass or avoid a problematic feature of the system like adherence to aseptic technique.
From the study on waste segregation, the availability of black bins with peddles (81%) in the procedure room only while the yellow and red paper bags served as receiver for infectious waste during the procedure. This highlight a risk to the staff if accidental poured down as they try to put the waste into the bags therefore contaminating their hands in the process. The same sentiments were shared in a study that recognized that hands can potentially become contaminated when opening or closing waste baskets and hence the need of waste bins with peddles (Backman et.al. 2012).
It was observed that Availability of decontamination solutions in the procedure rooms in some wards had no dilution date, ratio of the disinfectant used and the duration of time the instruments had been decontaminated owing to the prolonged use without replacement, study findings shared showed decontamination was being carried out with less than three buckets steps required (Gichuhi,2015). These findings clearly indicate other factors such as supervision, provisions of correct and adequate materials and supplies’ can actually improve the quality of aseptic technique adherence among nurse
In this study availability of sterile basic dressing packs and gowns were available, but the participants who opened the packs aseptically were 9(21.4%) and 12(29.3%) remembered to check the expiry date of the pack. This could be attributed to the fact that they carry out the procedures as one staff due to shortage and use of the available other professionals like physiotherapists and occupational therapist during the procedure occasionally and assumption that they are not expired once brought by the staff from the sterilizing department.
On Application of aseptic technique knowledge into practice the study showed procedure was maintained by only 6(14.6%) while 22(51.2%) did not attempt to maintain the aseptic technique, while logical sequence of implementing the procedure was observed by 7(17%) , 27(65.9%) did not do it properly. Findings of observation of the nursing outcome, only 3(7.1%) of the documentation reflected the nursing process with regard to wound management, 59.5% did not document properly while 33.3% did not at all, documented procedure gives evidence of the procedure done by who, where, when and what the condition of the dressing was before, during and after the dressing. similar study findings were shared by Ohlen. A et al. (2013), showed documentation was often fragmented and information sometimes hard to find, often describing caring needs but lacked interventions and evaluations and Andrew E.A (2015) showed that a standardized format was not followed and description of the procedure were uncommunicative e.g. dressing done, no complaints which were also observed during this study
Although the hospital has an infection control department that implements improvement of the aseptic technique and injection safety practices, wards still were noted to lack standard operating procedure on waste segregation 13(68.4%), accidental exposure to blood and body fluid 29(70.7%), hand washing process and material and equipment decontamination. Reasons raised to justify this was, burns unit had relocated to a different place , shortage of staff , work load due to high number of patients, lack of supplies, lack of continues monitoring, education and ignorance. It was observed Waste products were discarded outside the rooms during procedure. According to International Council of Nurses (2011), nurses in clinical care are producers of health care waste and yet are active participants in waste disposal procedures and nurses in management positions develop policies that deal with the procurement of supplies as well as the production and elimination of health care waste.
Results of this study indicate that barriers that affect the practice include inadequate water supply and soap in the taps13( 31%), burns ward had fairly more supply of water than Ward 4D this could be attributed to its location of the pumping system , inadequate supply of alcohol based hand rub, supplies for dressing burns wound s and the availability of less than one to ten sink bed ratio. These findings suggest similarity consistent to Otiende (2013) where they found that the hospital had inadequate working facilities and equipments and the respondents were dissatisfied with the health and safety regulations offered by the institution. The findings are strongly associated with Okechuku et al (2012) study that the majority of the healthcare workers complained of inadequate resources to practice standard precautions, in addition to a survey done by Warley et al( 2009) on standard precaution training among nurses indicated that above 56.3% of them reported having received adequate training despite 76% of them reporting complete knowledge on standard precautions, some of the factors that led to poor compliance were workload, insufficient training and lack of protective gear .
Finding from the study showed an association between barriers to aseptic technique and practice of proper hand washing technique(X2= 18.9, P<0.001) and adherence to standard wound dressing technique(X2= 31.5, P<0.000). Lack of proper hand washing and wound dressing technique contribute to aseptic technique barriers. Lack of waste segregation bins has no association with barriers to adherence to aseptic techniques according to this study at(X2= 0.66, P=0.72)
There is a strong significance between the inadequacy of water and soap with barriers to aseptic technique with P=O.O38. Presence of water and soap contribute to adherence of aseptic technique through hand washing and therefore the odds of not adhering to aseptic technique is four times higher in the absence of adequate supply of water and soap.
Conclusion
Nurses working in the burns specialized wards have a major key role in the prevention of sepsis during burns patient management and as such need to be competent in factors millitating against the practice of aseptic technique. Most nurses have adequate knowledge on aseptic technique but exhibit fair adherence in burns wound management practice in YSH, therefore adequate supplies and proper practice on aseptic technique will reduce mortality and morbidity rate among the patients at YSH.
Recommendations
Adherence of aseptic technique during burns management is paramount and cannot be under estimated; therefore, from the results of this study, the following recommendations were made:
- Continuous Medical Education programme and Availability of reference policydocuments on aseptic technique to enhance adherence on factors militating against the practice of aseptic technique among nurses in burns wards.
- Adequate supply of equipments and materials example color coded bins to supporteffective waste segregation by nurses at the burns wards.
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