Effectiveness of a Self-instructional Module on Knowledge and Observed Practices of Nurses with Regard to Prevention of Central Line–Associated Blood Stream Infection:A Before

Abstract

Background:

Healthcare-associated infections, a significant burden to patients and public health, are a major cause of increased mortality in critically ill patients. They not only cause increased functional disability and emotional stress but also cause a huge burden financially. Many healthcare professionals have found that education programmes and use of prevention bundles have resulted in decreased incidence of these infections. The present study was a quality improvement initiative by the investigator to improve the knowledge and practices of nurses related to prevention of central line–associated bloodstream infection.

Methods:

A before–after research design was used. Nurses (n = 51) working in critical care areas of a 1,200-bedded tertiary care hospital were recruited by purposive sampling. The intervention comprised of a structured self-instructional module which included general information on central line catheters as well as specific information on infection prevention in central line catheters. The Centres for Disease Control and Prevention guideline on prevention of 2011 update formed the basis of the module development. A 28-item knowledge questionnaire and an observational checklist were the tools utilised in the study.

Results:

The post-test mean knowledge and practice scores were significantly higher than the pretest scores (P < 0.05). There was a 36% increase in knowledge, and the competencies had enhanced by 41% post-intervention. Hand hygiene compliance, which was 47.1% pre-intervention, had increased to 78.4% post-intervention.

Conclusion:

Frequent ongoing education programmes on infection control are essential for improving the knowledge as well as practices of nurses working in critical care areas.

Keywords

Central line–associated blood stream infections (CLABSI)nurses knowledge practice self-instructional module

Introduction

Central line catheters are routinely used in intensive care units (ICUs) to monitor central venous pressure, administer fluids and blood products and provide total parental nutrition and medications. Large vessels such as internal jugular, subclavian or femoral vein are the common sites used for central venous access. These catheters pose high risk for blood stream infection in critical ill clients due to multiple factors such as age, severity of illness and underlying disease conditions contributing to increased morbidity among hospitalised clients. The Hindu news (2017) reported that the incidence rate of central line–associated bloodstream infections is 7.92 per 1,000 central line-days. National Healthcare Safety Network survey conducted from 2006 to 2008 also reported the incidence of central line–associated blood stream infections (CLABSI) rates as follows: Medical-surgical ICUs 1.5 to 2.1 per 1,000 catheter-days, medical-surgical wards 1.2 per 1,000 catheter-days, haemodialysis units as 1 to 4 per 1,000 catheter-days (Deepti et al., 2014).

Though the above statistics is alarming, these central line–associated bloodstream infections are preventable if standard care guidelines or protocols are followed by health personnels. Reviews have revealed that the CLABSI prevention bundles are available and are comprised of five components such as barrier precautions, use of chlorhexidine for skin cleansing prior to insertion of central line, avoidance of femoral site for central line, use of recommended insertion-site dressing practices and removal of the central line when no longer needed.

Several reviews have also elicited the positive impact of education programmes and use of CLABSI prevention bundles in decreased incidence of CLABSI. A study conducted in the Menoufia University, Egypt, to assess the effect of instructional module related to central venous catheters, on nurses’ knowledge and practices related to prevention of CLABSI, revealed an increase in the knowledge from 31.7% to 91.7% and practices from 45% to 93.3% (P < 0.05). The study reported fewer patient complications among the study group compared to the control group (Atia, 2017). Similarly, a quasi-experimental study conducted in the Department of Medical- Surgical Nursing, Faculty of Applied Medical Sciences, Al-Baha University, Saudi Arabia, on 44 ICU nurses revealed a significant statistical difference in the mean knowledge and practice scores regarding prevention of central line–associated bloodstream infection before and after the implementation of the educational module (El-Sol & Badawy, 2017). Another interventional study conducted in surgical and emergency ICUs at Zagazig University revealed the effectiveness of an education programme on knowledge, and improved practice of healthcare providers. Incidence of CRBSI decreased from 6.01/1,000 catheter-days to 3.9/1,000 catheter-days after the educational intervention (El Nemr et al., (2013). Taking into consideration the above facts the current study too intended to explore the impact of a well-designed self-instructional module on knowledge and the existing practices of nurses working in critical care areas with a view to reinforce better practices with regard to the prevention of central line–associated infection.

Methods

Aims

The aim of the study was to:

To determine the knowledge of critical care nurses regarding the CLABSI prevention guidelines as per the 2011 CDC guideline for prevention of intravascular catheter-associated bloodstream infections.

To observe the existing practices of critical care nurses caring patients with central line catheters.

To evaluate the impact of a well-structured self-instructional module on the knowledge and practices of nurses regarding CLABSI prevention.

Design

The study design was a pre–post-intervention study.

Setting

The study was conducted in a tertiary care multi-speciality 1,200-bedded hospital in Mangalore from April 2018 to March 2019. Registered diploma and graduate nurses working in critical care areas units were included in the study.

Participants and Procedure

Nurses caring for patients with central venous line on day shift were the samples of the study. Purposive samples of all eligible registered nurses were recruited for the study. Informed consent was obtained from all participants willing to be a part of the study, and they were assured about the confidentiality of the study. Ethical clearance was obtained from the Institutional Ethics committee Ref No: NUINS/CON/NU/IEC/2017-18 dated 14 September 2017. A pre-intervention knowledge questionnaire was administered to all the subjects on the same day. On the same day, the researcher observed the existing practices of three nurses with the observational checklist and the same was followed in subsequent weeks. Each nurse was observed for duration of 10–15 minutes. After each observed practice, the investigator handed over the self-instructional module on the prevention of CLABSI to the nurses, and they were directed to read the information in the module at their own pace. Post-intervention knowledge and practice of the nurses were evaluated on the seventh day.

Intervention

The self-instructional module was developed by the investigator by identifying the gap between the knowledge and practice on the prevention of CLABSI through review of literature on knowledge and practice of nurses regarding prevention of CLABSI. The investigator also reviewed standard guidelines/protocols on the prevention of CLABSI. It refers to a booklet prepared on CLABSI and its prevention. The module contained information on types of central line catheters, its advantages and disadvantages, selection of catheter insertion sites and device selection, infection prevention in central line catheters and cutaneous antisepsis, catheter obstruction and dressing guidelines, replacement of central line administration sets, hub care and aseptic technique. The module was validated by 11 experts, of which nine experts had responded. Three experts were from the field of medical surgical nursing, three intensivists, one clinical instructor and the other two experts were from the infection control department. The content validity index (CVI) of the module was 0.90.

Data Collection

A 28-item knowledge questionnaire with a blue print was developed based on the contents of the self-instructional module by the investigator. The questionnaire composed of multiple choice and fill in the blanks questions with one correct response. The questionnaire was administered to 51 nurses at a time. It took each respondent to complete the questionnaire in 20–30 minutes. The tool was validated by nine experts and the CVI was found to be 0.89. The reliability of the knowledge questionnaire was assessed using split half method by administering the tool to 10 subjects. The reliability coefficient was 0.83, which indicated that the tool was reliable.

On the same day, the practices of nurses in their respective clinical settings were observed while caring patients with central venous line. Nurses who responded to the knowledge questionnaire were observed with the help of a structured observational checklist (Table 1) pre- and post-intervention. The blueprint of items for the observational checklist was prepared as per the objectives, guidelines of Centres for Disease Control and Prevention (2011), and checklist used in National Accreditation Board for Hospitals and Healthcare for prevention of CLABSI. The final checklist consisted of 13 major steps. Each step had two options: yes or no. Step 3 included hand hygiene compliance, which was subdivided into eight steps. Subjects were observed using the checklist for the correct step performance. The samples were given score of one for the correct step performed and zero for the incorrect. Out of the 13 major steps, step 3 (hand hygiene) and step 4 (adheres to aseptic technique during procedure) were to be performed by all the samples without fail. They were considered as ‘must to do’ steps and any subjects who failed to perform the steps 3 and 4 were scored zero for the entire tool. The CVI of observational checklist was 0.95, and its reliability was assessed by the test–retest method, and the obtained value of Karl Pearson correlation coefficient was 0.90.

Table 1

Observational Checklist for Caring Patients with Central Venous Line.

Sl. No.	Steps to Be Performed
Assessment
1	Inspect inserted site for the following (bleeding, redness, catheter position and clot)
2	Assess the patient for fever: >38°C 8th hourly
Procedure
3	Perform hand hygiene
3.1	Apply a palmful of the product in a cupped hand, covering all surfaces
3.2	Rub hand palm to palm
3.3	Right palm over left dorsum with interlaced fingers and vice versa
3.4	Palm to palm with fingers interlaced
3.5	Backs of fingers to opposing palms with fingers interlocked
3.6	Rotational rubbing of left thumb clasped in right palm and vice versa
3.7	Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa
3.8	Dries hands
4	Adheres to aseptic technique during procedure
5	Uses maximal sterile barrier precautions (i.e. mask, cap, gown and sterile gloves)
6	Changes dressing as per hospital policy Transparent dressing: 7 days Gauze dressing: 2 days Immediate dressing change if soiled
7	Performs hub care with 2% chlorhexidine
8	Flushes the catheter before and after use with heparin solution
9	Flushes catheter every 8th hourly
10	Changes set for continuous infusions (every 4 days)or at least every 7 days

Source: Authors’ derivation based on CDC 2011 guidelines.

Demographic details such as age, gender, nursing qualifications, clinical experience, working unit, prior exposure to training programmes on the prevention of CLABSI and patient information data such as site of insertion of central line catheter, duration of catheter in place and types of central line catheters used were also collected for the study.

Data Analysis

Descriptive and inferential statistics were utilised to analyse the data suing SPSS (Version 16). Effectiveness of the intervention was analysed using paired ‘t’ test and Karl Pearson’s correlation coefficient was used to find the relationship between knowledge and practices of nurses. The P < 0.05 was considered as significant.

Results

Sample Characteristics

Among the 51 nurses, majority (n = 33, 65%) belonged to the age group of 21–25 years, and 86% were registered diploma nurses. With regard to their clinical experience majority (n = 18, 35%), had a work experience of 1–5 years and it was found that (n = 26, 51%) had undergone prior training on the prevention of CLABSI (Table 2).

Table 2

Distribution of Sample Characteristics (n = 51).

Characteristics	N	%
Age
21–25	33	65
26–30	6	12
>30	12	23
Gender
Male	5	10
Female	46	90
Qualification
GNM	44	86
BSc (N)	6	12
PBBSc (N)	1	2
Work experience
<1 year	18	35
1–5 years	18	35
6–10 years	8	16
>10 years	7	14
Prior training on CLABSI prevention
Yes	26	51
No	25	49

Source: Authors’ own findings.

Majority of the patients (57%) had jugular central venous access and 45% had the catheter in place for duration of 6–10 days (Table 3).

Table 3

Distribution of Patient Characteristics (n = 51).

Characteristics	N	%
Site of insertion of central line catheter
Jugular vein	29	57
Subclavian vein	22	43
Duration of catheter in place
1–5 days	10	20
6–10 days	23	45
>10 days	18	35
Type of central line catheter used
Peripheral	23	45
Tunnelled	28	55

Source: Authors’ own findings.

Knowledge of Nurses Regarding Prevention of CLABSI

In the pre-intervention, a majority of the nurses (73%) knew the measures of maintaining patency of central line. Very few nurses (12%) were aware of the frequency of flushing the implanted port with heparinised saline, while post-intervention this knowledge had enhanced to (65%). The number of respondents with correct responses was higher in the post-test than those in the pretest for all the items (Table 4).

Table 4

Frequency and Percentage Distribution of the Pre- and Post-test Knowledge Items (n = 51).

Knowledge Items	Pretest		Post-test
Knowledge Items	n	%	n	%
1. Which among the following is not a vascular accessing device?	33	65	48	94
2. What are the complications?	21	41	38	75
3. After insertion of central line in the jugular or subclavian vein which measure is used to confirm the placement of tip of the central line?	14	28	43	84
4. The most common clinical manifestation of central line–associated bloodstream infection is…	25	49	46	90
5. Which solution is the most preferred to clean the site of central venous catheter?	19	37	41	80
6. Which of the following nursing measure is carried out to maintain patency of central line?	37	73	41	80
7. The maximum duration of placement of central line is….	28	55	38	75
8. After insertion of central line when does the fibrin (clot) formation begins?	16	31	34	67
9. What is the main cause of blood occlusion in the central line catheter?	26	51	37	73
10. To flush the tunnelled catheter which thrombolytic agent is used?	13	26	37	73
11. How much amount of thrombolytic agent is used for tunnelled catheter?	13	26	43	84
12. What is the dilution of heparin (ml) in 0.9% normal saline for central line catheter flush?	18	35	35	69
13. How much ml of blood can be taken from central line catheter for blood sampling?	15	29	36	71
14. What is Hub? Hub refers to ……………	14	28	40	78
15. Hub should be changed after every ………… days.	24	47	42	82
16. Which fluids can enhance microbial growth within the central line set?	14	28	38	75
17. How frequently the central line set should be changed after use?	9	18	32	63
18. How frequently the central line set should be changed during administration of blood products?	13	26	35	69
19. How frequently the central line set should be changed during administration of total parenteral nutrition?	19	37	37	73
20. After how many days the stitch of the tunnelled catheter is removed?	16	31	35	69
21. Which of the following is not to be performed in the routine care of insertion site?	18	35	37	73
22. After every ……… weeks the implanted port should be flushed with heparinised saline.	6	12	33	65
23. The following is an example of mechanical blockage of central line catheter except………?	16	31	35	69
24. Which type of dressing is more appropriate for central venous catheter site?	26	51	47	92
25. Which one of the following sites is not used for central line insertion?	21	41	39	77
26. Following options are the complication of tunnelled catheter except …………	21	41	38	75
27. Which of following is the appropriate reason for removing tunnelled catheter?	27	53	42	82
28. Inappropriate removal technique of tunnelled catheter results in.	11	22	44	86

Source: Authors’ own findings.

Knowledge scores were arbitrarily categorised into three groups: poor (1–13), average (14–20) and good (21–28). Among 51 nurses, (41%) had good knowledge before the intervention which improved to (77%) after the intervention.

Practices of Nurses Regarding Prevention of CLABSI

In the pre-intervention, accurate documentation of the date of insertion of central line was followed by (96%) nurses. Hand hygiene compliance was observed in (47%) and adherence to aseptic technique was followed by (41%) nurses. The least performed task related to prevention of CLABSI in the pre-intervention was assessing the patient for fever (35%) and flushing the catheter before and after use with heparin and flushing it 8th hourly. In the post-intervention all the nurses (100%) documented correctly the date of insertion of central line and the hand hygiene compliance improved to (92%) and adherence to asepsis to (71%). The frequency of respondents demonstrating correct practices related to prevention of CLABSI in the post-test was higher than the frequency of respondents in the pretest (Table 5).

Table 5

Frequency and Percentage Distribution of Subjects Based on their Pre- & Post-Intervention Practices (n = 51).

Procedure	Pretest		Post-test
Procedure	N	%	N	%
Assessment
1. Inspection of inserted site for the following (bleeding, redness, catheter position and clot)	20	39	44	86
2. Assess the patient for fever: >38°C 8th hourly	18	35	37	73
3. Procedure
4. Performs hand hygiene	24	47	40	78
a. Applies a palmful of the product in a cupped hand, covering all surfaces	24	47	42	82
b. Rubs hand palm to palm	24	47	45	88
c. Right palm over left dorsum with interlaced fingers and vice versa	24	47	47	92
d. Palm to palm with fingers interlaced	24	47	50	98
e. Backs of fingers to opposing palms with fingers interlocked	24	47	47	92
f. Rotational rubbing of left thumb clasped in right palm and vice versa	24	47	46	90
g. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa	24	47	47	92
h. Dries hands	23	45	47	92
5. Adheres to aseptic technique during procedure	21	41	36	71
6. Uses maximal sterile barrier precautions (i.e. mask, cap, gown and sterile gloves)	24	47	40	78
7. Changes dressing as per hospital policy 7.1 Transparent dressing seven days 7.2 Gauze dressing two days 7.3 Immediate dressing change if soiled	23	45	37	73
8. Performs hub care with 2% chlorhexidine	24	47	45	88
9. Flushes the catheter before and after use with heparin solution	18	35	38	75
10. Flushes catheter every 8th hourly	18	35	36	71
11. Changes set for continuous infusions (every four days) or at least every seven days	19	37	39	77
12. Changes administration set for blood products every 24 hours	21	41	44	86
13. Documentation
13.1 Documents the date of insertion of central line	49	96	51	100
13.2 Records procedure correctly on nurses chart	20	39	43	84

Source: Authors’ own findings.

The practice of nurses was arbitrarily categorised into three categories as 0–11 (incompetent), 12–14 (competent) and 15–21 (proficient). Among 51 nurses, 61% were incompetent before the intervention and it reduced to14% after the intervention. Only 4% of the nurses were found to be competent prior to the intervention and the numbers increased 45% after the intervention while the number of proficient nurses increased to 41% after the intervention.

Effectiveness of Self-instructional Module on Knowledge and Practice of Nurses Regarding Prevention of CLABSI

The mean knowledge score (10.45) of the subjects before the intervention had significantly enhanced to 21.59 (P < 0.001). This indicates that the self-instructional training module was effective in enhancing the knowledge of nurses regarding the prevention of CLABSI (Table 6). Similarly, a significant difference in the practices was observed before and after the intervention (t = 6.82, P < 0.001) (Table 7).

Table 6

Difference in the Knowledge Before and After the Intervention (n = 51).

Knowledge	Mean	SD	Paired t Test	P Value
Pre-intervention	10.45	4.57	16.01	<0.001
Post-intervention	21.59	2.155	16.01	<0.001

Source: Authors’ own findings.

Table 7

Difference in the Practices Before and After the Intervention (n = 51).

Practices	Mean	SD	t ⁺	P Value
Before intervention	9.61	9.42	6.82	<0.001
After intervention	17.67	3.85	6.82	<0.001

Source: Authors’ own findings.

⁺See Results

Discussion

Unlike several reviews that have studied the effectiveness of training programmes on knowledge and practices of nurses regarding CLABSI prevention, the present study utilised a self-instructional module to enhance the knowledge and practices of nurses within their available time space. The current study findings identified that though 51% had undergone prior training on CLABSI management, the knowledge and practice of nurses regarding CLABSI prevention were significantly low prior to the intervention. This indicates the need for frequent ongoing updates on infection control practices to be delivered to the nurses as a quality improvement policy. Similar to the present study, several studies have also revealed the positive impact of education on knowledge and improved infection control practices of nurses handling patients with central venous access (Deshmukh & Shinde, 2014; Hemavathy et al.,2016; Jacob et al., 2014; Pushpakala & Ravinath, 2014).

Contrary to the present study findings, a descriptive study conducted among ICU nurses on infection control practices revealed that 80% followed correct practices related to CLABSI prevention (Deshmukh & Shinde, 2014). This study had a similar number of study participants, but the majority were graduate nurses with BSc(N) qualification, unlike the current study where the majority (86%) were with GNM qualification. Hence, higher qualification plays a significant role in controlling mortality and morbidity associated with CLABSIs.

The current study identified that hand hygiene, though considered an essential practice for infection control, was observed only in 47% of the nurses before the intervention, while it improved to 78% after the intervention. This could be attributed to the increased workload, staff shortage and failure of strict polices related to adherence of CLABSI prevention protocols. Nevertheless, these practices need to be reinforced and strictly monitored by quality control team of the hospital for better patient outcomes.

Due to the paucity of time in the clinical areas, nurses fail to review topics of patient concern and safety. The present study recommends that e-learning modules on quality patient care be made accessible to nurses during their off-duty timings so as to improve their knowledge and practices in their concerned area of clinical practice.

Education is a continuous process, and updating oneself with newer evidence-based practices in the care area is primarily one’s own responsibility. Thus, hospitals must look for creative ways of updating nurses to promote efficient nursing practices and thereby the global visibility of the hospital. From the literature and findings of the present study, it is clear that formal training provided to nurses during the clinical service is a cost-effective and simple measure to improve the delivery of quality care and control of several nosocomial infections in the hospital setting. Hospital policies should also strictly emphasise on aseptic practices for quality patient care.

CLABSI prevention is a quality indicator for accreditations with quality improvement agencies that make its importance in clinical practice area. This further provides recognition to the hospital, promotes patient satisfaction and generates better income to such organisations.

Though several studies had revealed a significant relationship between knowledge and practices regarding prevention of CLABSI (Bayoumi & Mahmoud, 2017; El-Sol & Badawy, 2017), the current study found a negligible positive correlation between knowledge and practice, but it was statistically not significant (r = 0.115, P > 0.05). This may also be attributed to the small sample size, professional qualification and years of clinical experiences of the samples who have participated in the current study.

Strengths and Limitations

The strength of this study was that it was a participant observational study conducted in a real clinical setting. It involved the development of a module which could also be used as a ready reckoner for nurses in the hospital to prevent CLABSIs. Though the hospital was a 1,200-bedded hospital with 350 nurses, the sample size was restricted to only 51 due to the non-availability of patients with central line catheters. Data collection was carried out for 12 weeks, and it was a single observation of a particular nurse with regard to their practices. Post-test of knowledge and practices was conducted after a week. Hence, long-term retention of the knowledge could not be assessed nor could the sustainability of their practice be reported.

Conclusion

Nurses are the forerunners of any healthcare organisation and play a significant role in disease prevention and health promotion. Hence, every healthcare industry needs to play a proactive role in motivating nurses to stay updated with current trends in promoting safe and efficient healthcare practices.

Footnotes

Acknowledgements

The investigators acknowledge and thank NITTE (deemed to be) University, the medical and nursing superintendent of the hospital as well as the study participants for permitting us to conduct the study in the real setting.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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Effectiveness of a Self-instructional Module on Knowledge and Observed Practices of Nurses with Regard to Prevention of Central Line–Associated Blood Stream Infection:A Before–After Intervention Study

Abstract

Background:

Methods:

Results:

Conclusion:

Keywords

Introduction

Methods

Aims

Design

Setting

Participants and Procedure

Intervention

Data Collection

Observational Checklist for Caring Patients with Central Venous Line.

Data Analysis

Results

Sample Characteristics

Distribution of Sample Characteristics (n = 51).

Distribution of Patient Characteristics (n = 51).

Knowledge of Nurses Regarding Prevention of CLABSI

Frequency and Percentage Distribution of the Pre- and Post-test Knowledge Items (n = 51).

Practices of Nurses Regarding Prevention of CLABSI

Frequency and Percentage Distribution of Subjects Based on their Pre- & Post-Intervention Practices (n = 51).

Effectiveness of Self-instructional Module on Knowledge and Practice of Nurses Regarding Prevention of CLABSI

Difference in the Knowledge Before and After the Intervention (n = 51).

Difference in the Practices Before and After the Intervention (n = 51).

Discussion

Strengths and Limitations

Conclusion

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

References