Role of Nurses in Prevention of Surgical Site Infection in Surgical Units of the Hospital
Chapter One
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 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, 2009). 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., 2009; 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. (2009) 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).
SSI created economical and social burden, and increased secondary treatment cost ranging from US$ 7,500 to US$ 10,000 per infection (Seltzer et al, 2002). A study found that the cost of SSI varied depending on the type of operation and the type of infecting pathogen. Estimated cost ranged from US$ 3,000 to US$ 29,000, SSI was accounted for upto US$ 10 billion annually in healthcare expenditures (Kirkland et al., 1999). Patients with SSI spent not only prolonged hospital stay but also increased direct cost due to loss of their work, increased use of drugs, and the use of additional laboratory (WHO, 2002). Patients who acquired SSI required significantly more outpatient visit, re-admission, longer time hospital stay, additional nursing care, excessive laboratory test, more dressing supplies, and in some cases patients needed re-surgery (Perencevich et al., 2003; Urban, 2006). The indirect costs were more difficult to be calculated and included the loss of productivity and job by the patient and family members (Urban, 2006).
CHAPTER THREE
RESEARCH METHODOLOGY
Research Design
The descriptiveม correlational study was conducted to obtain information on knowledge and practices of nurses regarding prevention of SSI at Calabar Medical Hospital (CMCH) in Cross River and also to examine the relationship between these variables.
Population and Setting
One of the largest government acute care centre and teaching hospital in Cross River, Nigeria was conveniently selected to be a target setting for the study. Cross River is located in the south geographical zone of Nigeria. The CMCH is located in the town of Cross River. 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 CMCH, Cross River, 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.
Secondly, it has been proposed that education and training prepare nurses to gain better/more knowledge (Najeeb & Taneepanichsakul, 2008; Pancorbo-Hidalgo et al., 2007; Suchitra & Devi, 2007). However, this claim could not be applied in this study. An additional analysis showed that there was no significant difference in nurses’ knowledge between nurses who were trained in infection control program and those who were not, this might be because of the fact that the infection control training program offered to nurses in Nigeria might not particularly focused on the prevention of SSI. This is necessary for further improvement of this training course. In addition, a study revealed that Nigeriai nurses have been trained to perform task-oriented nursing care rather than problem oriented nursing care (Hadley & Roques, 2007). This factor may limit nurses’ willingness and ability to search new knowledge.
Thirdly, less years of working experience in surgical ward might affect the low level of knowledge among nurses. In this study, an average year of working experience was approximately 4 years. A study found that nurses who had more years of working experience showed their knowledge level of infection control at a higher level than those with less years of experience (Vij et al., 2001). Another study revealed that nurses who had more working experience had better pain management performance compared to those who had less year of experience (Lui, So, & Fong, 2008).
Finally, nurses might have a confusion of roles in their providing care regarding prevention of SSI. Usually, most preventive activities for prevention of SSI are responsible by surgeons. Therefore, nurses might be confused at how to integrate the prevention of SSI into their daily practice. This factor might relate to their low level of knowledge.
Consideration was given to each item of nurses’ knowledge regarding prevention of SSI. The data showed that nurses had high level of knowledge regarding prevention of SSI in the areas of recognizing signs of SSI, performing hand washing for reducing the risk of SSI, comprehending swab culture for investigation to assess SSI, concerning high risk of SSI in immunodeficiency patients, and understanding important maintenance of normal nutritional status in surgical patients. These data indicate that nurses had knowledge of SSI prevention in areas of general infection control. Nurses gained this general knowledge from their SSI prevention information from diploma or bachelor nursing program and/or service experiences.
However, this group of subjects still lacked knowledge in some areas of SSI prevention. These areas were related to the best time for pre-operative hair removal, and the method of using clipping shaving method for pre-operative shaving. These data indicated that nurses could not access to evidence-based nursing practice of SSI prevention. The limitation of this SSI evidence-based of practice of SSI has not been included in Diploma and bachelor program in nursing. The lack of nurses’ knowledge in this study indicated the urgent need to evaluate and revise the education and training program in prevention of SSI because the knowledge acquired through basic and continuing education and in-service training could enhance nursing practice (Even & Donnelly, 2006).
Nurses’ Practice Regarding Prevention of SSI
It was revealed that the average practicing scores of the nurses were at a high level. The present study also revealed that pre-operative practice was identified at a high level and post-operative practice was identified at a very high level. This finding indicates that nurses had provided good nursing practices for prevention of SSI. There are several individual and organizational factors that influence high level of practice. The first factor is sufficient supplies of water, gloves, disposal boxes, antiseptic solutions, and surgical instruments. These supplies can help nurses to perform good practice. A study had found that surgical infection control was related to sufficient resources of caring for surgical patients (Nguyen, Nguyen, & Jones, 2008). The second factor, hospital administrator in CMCH increased tight supervision and monitoring system from supervisors to staff nurses. These tight supervision and monitoring system could increase the hours that nurses in government hospital spend their working time in direct contact with their patients compared to previous study that nurses spent only 5.3% of their working time in direct patient care (Hadley & Roques, 2007).
The third factor is related to the policy of implementing code of conduct of nurses for patient care endorsed by Nigeria Nursing Council. This policy may lead the nurses to increase their awareness to perform practice regarding prevention of SSI. The forth factor may be due to the low sensitivity of the questionnaire of prevention of SSI practice in this study. Considering each item of the practice questionnaire, most of the items were related to the information of general practice of infection control rather than the prevention of SSI. Hence, revision of the practice questionnaire is needed for further study.
The fifth factor may be due to the social desirability that the subjects responded to the self-report practice questionnaire. They might tend to respond in order to get higher scores even though they might not have performed those activities (Adams et al., 2005). Finally, the Nigeriai nurses have been trained to perform task oriented nursing care rather than problem-solving oriented nursing care. This reflects that nurses may perform nursing care without knowing the reason why they need to do that task.
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 CMCH. 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 role 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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