Nurses' Knowledge and Practice Regarding Prevention of Surgical Site Infection in Bahir Dar,Northwest Ethiopia

Abstract

Background:

Surgical site infections (SSIs), a type of nosocomial infection, are a leading cause of morbidity and death and increase the overall cost of care. The processes and procedures involved in the operations can endanger the life of the patient significantly. Knowledge of, and nurse practice focused on, the prevention of SSIs have not been studied well in Ethiopia, especially in our area. Therefore, we decided to establish the extent of knowledge and actual practice of SSI prevention among nurses empirically in the Bahir Dar city administration region.

Methods:

An institution-based cross-sectional study was conducted in Bahir Dar city hospitals from January 5–15, 2017. The systematic random sampling technique was used to collect data from nurses using a self-administered structured questionnaire. The extent of knowledge and practice concerning SSI was determined using multiple-choice questionnaires covering the nurse's knowledge and practices. Logistic regression was applied to assess the association between dependent and explanatory variables. The association was interpreted using the adjusted odds ratio (AOR) and 95% confidence interval (CI).

Result:

The scores for the nurses' knowledge and practice in regard to the prevention of SSI were 74.5% and 45.1%, respectively. Learning institution (AOR 6; 95% CI 2.52–14.22), service year (AOR 8.9; 95% CI 3.21–21.4) and history of training on infection prevention (AOR 5.3; 95% CI 2.11–13.7) were associated significantly with the nurses' knowledge about prevention of SSI. History of training in infection prevention (AOR 4.75; 95% CI 1.9–12.05), type of learning institution (AOR 21.35; 95% CI 8.01–56.22) and years of service (AOR 29.3; 95% CI 6.89–124.9) also were associated significantly with the nurse's practice in preventing SSI.

Conclusion:

Nursing practice related to prevention of SSIs is not satisfactory. Therefore, efforts to transform nurses' knowledge into practice is an urgent need for educational and awareness programs to improve knowledge and practice changes in regard to prevention of SSI are urgently needed.

Surgical site infection (SSI) is commonly identified 30–90 days after an operation or as much as one year later when there is an implant. It is an adverse sequela of surgery and often results in at least one of the following: Purulent drainage from the deep incision, incision dehiscence, localized pain or tenderness, abscess, or other evidence of infection involving the incision seen on direct or by radiologic examination [1,2]. An SSI is a common healthcare-associated infection that can cause patients extreme pain and result in a long hospitalization and additional cost [3]. A prospective cohort study in Cameroon public hospitals demonstrated a prevalence rate of SSI of 9.16% [4]; and in a Ugandan referral hospital, the incidence rate of SSIs was 16.4% for superficial infections and 47.1% for deep and organ space infections [5].

In Ethiopia, the reported prevalence rate of SSI is 14.8% [6] to 19.1% [7]. In the literature, SSIs are associated with both intrinsic and extrinsic factors. Intrinsic factors include extremes of age (older adults and newborn infants), malnutrition, metabolic diseases, smoking, obesity, hypoxia, immunosuppression, and length of pre-operative stay. Extrinsic factors include the improper application of skin antiseptics, pre-operative shaving, inadequate antibiotic prophylaxis, pre-operative skin preparation, contaminated or dirty surgical procedure, poor surgical instrument sterilization, dirty surgical drains, inadequate hand scrubs, excessive staff traffic in the operating theatre, and improper dressing techniques [1,2,8,9].

To address these problems, the World Health Organization recommends routine use of prophylactic antibiotic within 60 minutes prior to skin incision, close adherence to sterile technique, appropriate pre-surgical skin disinfection, and implementation of the surgical safety checklist [1]. Nurses play a major role throughout the continuum of care in preventing SSI. Therefore, they can modify SSI risk factors with attention to their daily routine to include such practices as proper hand hygiene, routine administration of prophylactic antibiotics in the recommended time frame, adequate skin preparation, and correct post-operative wound management [8,9]. A study in Pakistan showed that the majority of nurses demonstrated poor knowledge but provided good clinical practice to support the prevention of SSI [10].

By contrast, studies in other countries indicated that most nurses lacked the required knowledge about prevention of SSIs according to evidence-based guidelines and recommendations [10 –14]. Scholars identified different factors associated with knowledge and practice of nurses in this regard. These include, but are not limited to, service and educational status [14 –16], work load [17,18], extent of nursing education [15,18], and training on infection prevention mechanisms and non-adherence to infection prevention practices and SSI prevention guidelines [11,14,19,20].

Subjects and Methods

This institution-based cross-sectional study was conducted from January 5–15, 2017, in the hospitals of Bahir Dar, the administrative city of northwest Ethiopia. Bahir Dar is the capital city of the Amhara region and is located 550 km from Addis Ababa, the capital city of the country. There are four hospitals: Felege Hiwot Referral Hospital, Adisalem District Hospital, Gamby General Hospital, and Adinas General Hospital. These hospitals provide preventive, curative, and promotive services for more than nine million people. At all hospitals at the time of our study, there were more than 843 members of health professional staffs, 358 of whom were nurses. Wide ranges of elective and emergency procedures are performed in each hospital. All hospitals had an Infection Control Committee that is charged with prevention and control of infection, but they were not properly facilitated and did not provide training tailored for newly hired nurses. The data were collected from intensive care units, emergency departments, medical and surgical wards, pediatric departments, neonatal nurseries, recovery units, and obstetrics and gynecology departments of the four hospitals [15].

The sample size was determined using a single population proportion formula with the following assumptions: 95% confidence interval (CI), 40% proportion [16], and 5% marginal error. By considering adjustment for the expected non-response rate (10%) and correction formula, the final sample was 208. Because the study hospitals followed a yearly rotation policy (interdepartmental rotation) [15], all nurses at the four hospitals were included in the study regardless of their work area. The calculated sample size was proportionally distributed to each hospital according to their nursing staff size. The sampling frame was obtained from each hospital from the human resource management office. The study participants were selected using systematic random sampling. The first participant was selected from the frame using the lottery method. The Nurse's Knowledge Questionnaire and the Nurses' Practice Questionnaires were then distributed to the sample of 208 nurses.

The outcome measures of this study were knowledge (good/poor) and practice (favorable/unfavorable) of nurses regarding prevention of SSI. The independent variables were socio-demographic characteristics (age, sex, religion, marital status, income, and extent of education) and institutional factors (training in infection prevention and availability of antiseptic solution, antibiotic prophylaxis, and personal protective equipment).

An English-language version of the structured and tested self-administered questionnaire was used to collect the data (English is the medium of instruction in all Ethiopian nursing schools). To assure data quality, two weeks prior to the actual data collection, the questionnaire was tested on a 5% sample of nurses who were not included in the main study (Gondar University Referral Hospital).

Nurses' knowledge regarding the prevention of SSIs was assessed by multiple-choice questionnaires designed to measure three cognitive elements: Remembering, comprehension, and cognitive application. The contents included knowledge needed for prevention of SSI during both the pre-operative and the post-operative period. For the pre-operative period, the contents covered hygiene and skin preparation, controlling underlying medical conditions, maintaining nutritional status, and antibiotic prophylaxis. For the post-operative period, the test included surgical incision care with aseptic precautions, site assessment and monitoring for SSI, and nutritional support.

There were 25 questions, with each question followed by three response alternatives: one answer was correct, and two answers were distracters. The correct response for each question was recorded as “1” and the incorrect as “0”. The minimum score was zero, whereas the maximum score was 25. A higher score indicated a greater degree of knowledge. The participants who scored 14 and above were categorized as “knowledgeable” and those who scored less than 14 were categorized as “not knowledgeable” in the prevention of SSI.

Nurses' practice in the prevention of SSIs was assessed by 25 statements using a 5-point Likert scale (never practice = 1, rarely practice = 2, sometimes practice = 3, often practice = 4, always practice = 5). The test was designed to measure three levels of practice: imitation, manipulation, and precision. The contents include practices needed for the prevention of SSI during the pre-operative and post-operative period. For the pre-operative period, the contents were hygiene and skin preparation, controlling underlying medical conditions, maintaining nutritional status, and antibiotic prophylaxis. For the post-operative period, the contents included surgical incision care with aseptic precautions, site assessment and monitoring for SSI, and nutritional support. The Likert scale scores were dichotomized into two. Those participants who reported preventive practices as “always” and “often” were recoded as “1”, and those who either did not ever practice, rarely, or sometimes practiced were recoded as “0”. The minimum score was zero, whereas the maximum score was 25. The higher scores indicated better practice. For interpretation, the researcher divided the dichotomized scores into “favorable practice” and “non-favorable practice.” The participants who scored ≥14 were categorized as using favorable practice, and those who scored <14 were categorized as non-favorable practice. The questions addressed the most important recommendations by the National Infection Prevention and Patient Safety Guideline [8].

Four nursing diploma holders who served as data collectors (one for each hospital) and four nursing BSc holders who served as supervisors (one for each hospital) were recruited during the data collection period (the data collectors and the supervisors were not from the same hospitals). At each hospital, the aim of the study was clearly explained to the study participants before they filled out the questionnaire. The data collectors and supervisors were trained in one day on how to facilitate the data collection process and prevent errors. The research team utilized effective methods for controlling bias by standardization of the outcome measure, removal of nursing staff from the outcomes collection process, use of written reports only, and fair diligence in informing the participants about the study purpose and objectives. Questionnaires were reviewed and checked for completeness, accuracy, and consistency by supervisors and the research team every day during the data collection period. The data were coded, entered, and edited in EpiData version 3.1 statistical packages and exported to SPSS version 20 software for data analysis.

At the beginning of the analysis, summation of the practice scale was made. The variables were recoded and dichotomized. Descriptive statistics were used to illustrate the means, standard deviations, medians, and frequencies of the study variables. Bivariable analysis was computed, and those variables whose p values were ≤0.2 were fit into the backward stepwise multivariable logistic regression model. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to determine the strength of any association between dependent and independent variables. P values ≤0.05 were considered statistically significant.

Results

Socio-demographic characteristics of study participants

A total of 204 nurses from the four hospitals returned the completed questionnaires, giving a response rate of 98%. The mean age of the study participants was 29 years. Almost one third of participants, 150 (73.5%), were BSc degree holders, and more than half, 107 (52.5%), were graduates of governmental educational institutions. One hundred sixty-five (81.1%) of the participants had more than five years of work experience, and less than half, 98 (48%), had received training in SSI prevention (Table 1).

Table 1.

Socio-Demographic Characteristics of 204 Study Participants, Bahir Dar City Administration Hospitals, Ethiopia, 2018

Variable	Frequency	Percentage
Current age (y)
20–29	145	71
≥30	59	29
Sex
Male	71	35
Female	133	65
Marital status
Single	45	22
Married	159	78
Education
Diploma	54	26.5
BSc	150	73.5
Educational institution
Government university/college	107	52.5
Private university/college	97	47.5
Work experience (y)
<5	39	19
≥5	165	81
Ever took infection prevention training
Yes	98	48
No	106	52

Nurses' knowledge about prevention of SSI

The mean score on the knowledge questions was 54.8 (standard deviation [SD] 7.85). In this study, 152 (74.5%; 95% CI 32–68) of the respondents proved knowledgeable about prevention of SSI. In the bivariable logistic analysis; participants' age, sex, education, learning institution, years of service, and training in infection prevention were the most significant predictors of nurses' knowledge about prevention of SSI. However, after controlling for the potential confounders, learning institution, service years, and having taken training in infection prevention were significantly associated with a nurse's knowledge of SSI prevention. Those nurses who had graduated from governmental institutions were about six times more likely to be knowledgeable about SSI prevention than those who graduated from private institutions (adjusted odds ration [AOR] 6; 95% CI 2.52–14.22) (Table 2).

Table 2.

Multi-Variable Logistic Regression of Factors Associated with Knowledge of Surgical Site Infection Prevention among Nurses Working in Bahir Dar City Administration Hospitals, 2018

Variable	Knowledge		COR	AOR
Variable	No	Yes	COR	AOR
Age group
<30	46	99	1	1
≥30	6	53	4.1 (1.65–10.24)	1.62 (0.56–4.71)
Sex
Female	41	92	1	1
Male	11	60	2.43 (1.16–5.1)	1.17 (0.4–3.5)
Education
Diploma	26	28	1	1
BSC	26	124	4.43 (2.24–8.8)	2.25 (0.98–5.152)
Learning institution
Private	40	57	1	1
Government	12	95	5.6 (2.7–11.5)	6 (2.52–14.22)
Service (y)
<5	23	16	1	1
≥5	29	136	6.74 (3.2–14.32)	8.9 (3.21–21.4)
Training
No	41	65	1	1
Yes	11	87	5 (2.4–10.45)	5.3 (2.11–13.7)

AOR = adjusted odds ratio; COR = crude odds ratio.

Participants who had worked in nursing for more than five years were about 8.9 times more likely to be knowledgeable about prevention of SSI than with five or fewer years of service (AOR 8.9; 95% CI 3.21–21.4). Those nurses who had training in infection prevention methods were about 5.3 times more likely to be knowledgeable about prevention of SSI than those who had not (AOR 5.3; 95% CI 2.11–13.7) (Table 2).

Practice of nurses on prevention of SSI

In this study, the number and proportion of nurses who practiced good SSI prevention strategies was 92 (45.1%). In the bivariable analysis, sex, education, type of program they had graduated from, years of service, and having taken training in infection prevention methods were the factors significantly associated with good practice in the prevention of SSI.

After controlling for confounders, sex, learning institution, years of service, and having taken training in infection prevention were significantly associated with the nurses' practice in the multivariable analysis. Those nurses who graduated from governmental institutions were about 21.35 times more likely to practice SSI prevention than those who had graduated from private institutions (AOR 21.35; 95% CI 8.01–56.22).

Nurses' working for more than five years were about 29.3 times more likely to practice good SSI prevention strategies than those who had less than five years of service (AOR 29.3; 95% CI 6.89–124.9). Those nurses who had ever taken training in infection prevention were 4.75 times more likely to practice SSI prevention than those who had not (AOR 4.75; 95% CI 1.9–12.05) (Table 3).

Table 3.

Multi-Variable Logistic Regression of Factors Associated with Practice of Surgical Site Infection Prevention among Nurses Working in Bahir Dar City Administration Hospitals, 2018 (n = 204).

Variable	Practice		COR (95%)	AOR (95%)
Variable	No	Yes	COR (95%)	AOR (95%)
Sex
Female	97	36	1	1
Male	15	56	10 (5.06–20)	10.5 (3.44–31.9)
Educational level
Diploma	40	14	1	1
BSc	72	78	3.1 (1.6–6.15)	1.85 (0.6–6)
Learning institution
Private	87	10	1	1
Government	25	82	28.5 (12.9–63.61)	21.35 (8.01–56.22)
Service years
<5	34	5	1	1
≥5	78	87	7.6 (2.83–20.36)	29.33 (6.89–124.9)
Training
No	72	34	1	1
Yes	40	58	3.07 (1.73–5.45)	4.75 (1.9–12.05)

AOR = adjusted odd ratio; COR = crude odds ratio.

Discussion

Surgical site infection is one of the most common types of hospital-acquired infection. Prevention is one of the most important challenges in delivering optimal nursing care. Feedback regarding SSI rates to staff has been associated with improvement in the quality of care [22]. Although all health professionals involved in patient care are responsible for ensuring patient safety, nurses play a major role, as they usually are involved in each step around the clock [23]. Therefore, nurses must have adequate knowledge and good practice regarding the prevention of SSI. This study aimed to establish empirically the degree of knowledge and actual practices of SSI prevention among nurses in Bahir Dar city hospitals.

This study showed that 74.5% of nurses, with a mean survey score of 54.8, had good knowledge of SSI prevention. This study finding was better than that of other similar and related studies of scholars in different countries [10,13,15,16,24]. The discrepancy might be attributable to the characteristics of the study participants, learning institutions, provision and availability and or inadequate supply of consumable materials to prevent infection, and accessibility of information regarding SSI prevention. This finding was in line with the results of a study conducted in Nigeria [12,20,25].

In Nigeria, the score on nurses' knowledge tests regarding SSI prevention ranged from 63.6% to 68.1%. The implication of the Nigerian finding was that needs-based knowledge of SSI prevention, apart from general information on infection control, might be acquired during college study. Therefore, because the knowledge-based questions were designed based on higher quality of care, the possible reason for the similarity of the findings in the current study might be similar professional and nursing educational curricula across the nation, with similar training being provided during college study.

This study revealed that years of service was significantly associated with knowledge about the prevention of SSI. Those study participants who had served for at least five years were about 8.9 times more likely to be knowledgeable about prevention of SSI than those whose service was shorter. This finding was in line with a study at Gondar University and Debre Marcos Referral Hospital–Ethiopia and a teaching hospital in Nigeria in which years of experience was associated with knowledge regarding infection prevention [15, 25].

The association found in this study probably is attributable to the fact that as the number of years of practice rises, knowledge increases. This knowledge often is gained through using technology, communicating with a colleague, or speaking repeatedly with the patient, family, or other significant social support person [26]. In our study, knowledge about prevention of SSI was significantly associated with ever taking training on infection prevention methods.

Those nurses who have had training on infection prevention methods were about 4.75 times more likely to be knowledgeable about prevention of SSI than those who had not; this was consistent with what was seen in studies done in Gondar University and Debre Marcos Referral Hospital-Ethiopia [15] and two tertiary hospitals in Port-Harcourt, Nigeria [12].

This could mean that updating the knowledge of health workers about prevention of infection changed their previous understanding and resulted in a good score on knowledge questions. In addition, the importance of lifelong learning is understood within the context of maintaining knowledge about holistic patient care throughout one's career [27].

This study also tried to assess the practice of the nurses in prevention of SSI. The findings showed that the total practice score regarding the prevention of SSI was 45.1% with a mean score of 50.8. This score was lower than that of related findings from Bangladesh [13] and of Palestinians [16], which revealed that 89.95% and 91.1% of those nurses, respectively, had good practice for SSI prevention.

The discrepancy we noted may be related to a shortage or inadequate supply of consumables, the workload of nurses, and a disorganized hospital policy on infection control, as determined in our study. In addition, in previous studies, the nurses' practice area was a dynamic environment. Openly sharing and evaluating best practices and gaining practice with interdisciplinary teams, coordinating care based on the practitioner experience, and assessment of patient help to ensure evidence-based care leads to a continuous path of discovery and innovation [26].

In this study, practice strategies focused on prevention of SSI were significantly associated with having training on infection prevention methods. Those nurses who had had such training were 4.75 times more likely to practice SSI prevention strategies than those who had not. This finding was similar to that in a review of the literature, where training of nurses on safe practices was associated with action for SSI prevention [12,20,28].

This study revealed that years of service was a significant factor associated with practice in preventing SSI. Those study participants who had served for at least five years were about 29.3 times more likely to employ strategies to prevent SSI than were whose service was less than five years. This finding was in line with studies in various countries by different scholars [14,15]. This could be mean that as the number of years of practice increases, nurses are more likely to be exposed repeatedly to surgical environments and become more experienced through working with senior medical staff. As the number of years of practice increases, the importance of lifelong learning is understood within the context of maintaining competency, providing high-quality patient care, and enhancing future career opportunities [27].

Conclusion and Recommendations

Almost 75% of the respondents had a good knowledge of SSI prevention, and the extent of knowledge is statistically significant when one considers years of service and having had training in infection prevention. It is important to note, however, that transfer of knowledge to practice was poor. Updating the knowledge and the practice of nurses through continuing training on the prevention of SSI, emphasizing the importance of following the latest evidence-based practices of infection control in continuing education/training programs, and providing training programs for new nurses and those with fewer years of service in infection control are all important. We highly recommend regular replication of this study using an observation checklist to assess the knowledge and practice of nurses.

Strengths and Limitations of the Study

The strengths of the study were the use of a contextually adopted standardized questionnaire to measure the domain of nurses' practices and knowledge regarding SSI prevention, and the high response rate. Because there has been no similar study conducted in our area, this project created baseline information for future studies. As the data were collected by health professionals, there may be a social desirability bias. The domains of a nurse's practice were self-reported and may be limited by recall bias.

Footnotes

Acknowledgments

Our heartful thanks go to Bahir Dar University for covering all the expenses of the research work and the data collectors and to all the study participants who voluntarily participated in this study.

Author Disclosure Statement

This study was conducted after approval of the proposal by the Bahir Dar University (BDU) institutional review board committee, and ethical approval and clearance was obtained from this board. Permission and a supportive letter were obtained from the health bureau and hospital medical director's office before data collection. Participation was voluntary, and information was collected anonymously after obtaining written consent from each respondent by assuring confidentiality throughout the data collection period. Participants also were told the objective of the study and had the right to refuse to participate or to stop or withdraw at any time during data collection.

Consent for publication is not applicable.

The authors declare that we have no competing financial interests.

Additional information about the dataset and analysis is available from the corresponding author on reasonable request.

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