الفهرس 
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Abstract
Summary
Surgical site infections (SSI) are frequent and serious complications of surgical procedures. They are associated with a prolonged duration of hospitalization, readmissions, re-interventions and the patient may suffer from permanent disability or even death. Bundle of care is known as evidence-based measures and commonsense measures that were thought to pose the patients to minimal risk of infection and hold potential for benefit. The elements of SSI bundle of care are perioperative antibiotic prophylaxis, hair removal before surgery, perioperative normothermia and discipline in the operating room.
The Aim of the Study
This study aimed to assess nurse’s performance regarding bundle of care for prevention of wound site infection, through the following:
1. Assessing nurse’s knowledge regarding bundle of care for prevention of wound site infection.
2. Assessing nurse’s practice regarding bundle of care for prevention of wound site infection.
3. Assessing patient’s signs and symptoms of wound site infection.
Research Questions:
1. What is nurse’s performance regarding bundle of care for prevention of wound site infection?
2. Are there signs and symptoms of wound site infection of their patients?
Operational definitions:
Surgical Site Infection Bundle of care: is a simple set of evidence-based practices that, when implemented collectively, improve the reliability of delivery and improve patient outcomes, prevent SSI, decrease length of hospital stay including the following steps.
• Pre-operative phase.
• Intra-operative phase.
• Post – operative phase.
Nurses Performance: nurses’ performance referred to nurses’ knowledge and practice.
The study was portrayed under the four main designs as follows:
- Technical design.
- Operational design.
- Administrative design.
- Statistical design.
I- Technical Design:
The technical design included setting, subjects and tools of data collection.
Research Design:
A descriptive exploratory design was utilized in carrying out this study.
This design helps the investigator to describe and document aspects of a situation as it naturally occurs. As well, this design helps to establish database for future research (Sileyew, 2019).
Setting:
This study was conducted at the general surgical units (two units, male general surgical unit (15nurses) and female general surgical unit (15nurses) and the operating rooms (10 nurses) at Bahtim Hospital affiliated to Ministry of Health. The Male general surgical unit was located in the second floor, consists of three rooms containing ten beds, female general surgical unit was located in the third floor, consists of 15 beds and Operating department was located at the second floor, consists of (recovery room, endoscopy room, minor operations room, intermediate operations room, major operations room, sterilization room, sterilized equipment room and store).
Subject
1. A convenient sample of all available nurses (40) in general surgical units (male and female) at Bahtim Hospital.
2. A purposive sample of all available patients during data collection period who met the inclusion criteria.
• Inclusion criteria:
1. Patient undergoing general surgeries.
2. Able to communicate and agree to participate in study.
• Exclusion criteria:
1. Patient with comorbid diseases (diabetic & cardiac disease).
2. Patient performed pervious general surgery
Tools of Data Collection:
The data was collected through the following tools:
I-Self-Administered Nurse’s Questionnaire: it was developed by the investigator in an Arabic language after reviewing the recent and relevant literature
It was divided into two parts:
Part one: Nurses’ personal characteristics include (age, gender, level of education, years of employment, experience in surgical ward and attending related training sessions).
Part two: Nurses’ knowledge regarding bundle of care for prevention of surgical site infection, it was adapted from (Tanner et al., 2016; WHO, 2016; Waltz & Zuckerbraun, 2017; Sadaf et al., 2018; Woldegioris et al., 2019) and modified by investigator according to aim of the study to assess nurse’s level of knowledge regarding bundle of care for prevention of wound site infection. It included 62 questions as following, surgical site infection (7 questions), recommendations to reduce surgical site infection (5 questions), SSI bundle of care at preoperative phase (13 questions), SSI bundle of care at Intra-operative (14 questions) and SSI bundle of care at post-operative phase (23 questions).
Scoring system:
Answers were either Yes or No with total score (62 mark), one score was given when the response was correct and zero when it was incorrect.
According to Sickder, (2010), who recommended that the total scoring system to be calculated as following:
o 85% or more was considered satisfactory level of knowledge (≥53 marks).
o Less than 85% was considered unsatisfactory level of knowledge (<53 marks).
II-Nurse’s Practice Observational Checklist: it was developed by the investigator in English language after reviewing the recent and relevant literature to assess nurses’ practices related to bundle of care for prevention of infection (Sadia et al., 2017; Mohsen et al., 2020, Sun et al., 2020 & Tomisic et al., 2020) it included 58 steps. Consistuting the following procedures:
• Preoperative SSI bundle of care observational checklist (19 steps).
• Intraoperative SSI bundle of care observational checklist (16 steps).
• Post-operative SSI bundle of care checklist (23 steps).
Scoring system:
One grade was given to the step which was done correctly and zero was given to step which was done incorrectly or not done and the step that done incorrectly was considered not done. So, total score of 58 questions were 58 degrees.
According to Sadia et al., (2017), who recommended that the total score to be classified as following:
• 90% and more was considered satisfactory level of practice (≥ 64 marks).
• Less than 90% was considered unsatisfactory level of practice (<64 marks).
III-Patients’ clinical data; it was developed by the investigator; to assess signs and symptoms of infection for patient undergoing general surgery and included the following:
1. The studied patients’ personal characteristic included (Age, gender, Marital status, educational level and place of residence).
2. Patients’ characteristic form included (Smoking, healthy diet, ICU admission, number of days, postoperative complications, length of stay in hospital, presence of drains and number of drains).
3. Patients’ Physiological parameters, it included (temperature, heart rate, respiration, capillary refill, body mass index and laboratory tests).
4. Signs & symptoms of wound appear include (pain at surgical site, Oozing blood at surgical site, redness around surgical site, discharge from surgical site, swelling at wound site, tenderness at surgical area, hot or warm to touch, fever and increased WBCs count).
II- Operational design:
The Operational design included preparatory phase, content validity and reliability, pilot study and fieldwork.
Preparatory phase:
It included reviewing of related literature, and theoretical knowledge of various aspects of the study using periodicals, magazines, articles, books and internet.
Validity and reliability of the study tools: It was ascertained and tested through jury of seven experts (5 professors, one assistant professor and one lecturer in the field of medical surgical nursing, faculty of nursing, Ain Shams University who reviewed the content of the tools for comprehensiveness, accuracy, clarity and relevance and necessary modifications was done accordingly.
Face validity: refers to the extent to which a test appears to measure what it claims to measure based on face value (King et al., 2020).
Content validity: is the degree to which a test or assessment instrument evaluates all aspects of the topic, construct, or behavior that it is designed to measure (Hong et al., 2019).
Reliability: The tools were measured to ensure that an assessment tool produces stable with consistent result overtimes. The reliability coefficient for the study tools were calculated using the correlation coefficient Cronbach’s alpha test as:
Tool No of questions Cronbach’s Alpha
Knowledge 62 0.97
Practices 58 0.993
Pilot Study:
It was carried out on seven nurses (10% of the total number of nurses) and 5 patients (10% of total number of patients) after developing the tool and before starting the data collection to evaluate the clarity, applicability and to estimate the needed time to fill out of the study tools. No necessary modifications were done. Therefore, the pilot study samples were included in the total sample.
Field work:
• The sample of the study was recruited according to the inclusion and exclusion criteria.
• The researcher started data collection by introducing herself to the nurses and explaining the aim of the study and oral approval from nurses to participate in the study was obtained prior to any data collection.
• Assessing nurses’ practice firstly, then assessing the knowledge regarding SSI Bundle of care for prevention of surgical site infection by using questionnaire tool.
• The observational checklist was filled by the investigator based on observing nurses’ performance regarding application of SSI Bundle of care, it took from 20:30 minutes.
• Nurses distributed the questionnaire to the nurse in the morning and afternoon shifts, it took about 20-30 minutes for each nurse to complete the questionnaire.
• Data collection was done 4 days per week (Tuesday & Sunday&wensday and Thursday), it took about 4 hours from (9 am to 1 pm and some-times from 3 pm to 7 pm) it took six months starting from the first of November 2021 up to the end of April 2022, in the previously mentioned setting in morning and afternoon shifts.
• Also the researcher met with studied patients during data collection period, they were patients met the inclusion criteria in the previously mentioned setting, and introduced herself to them, explaining the aim of the study, the effect of this study on reducing SSI and oral approval from patients to participate in the study was obtained prior to any data collection.
• Assessing patients’ clinical data was done by assessing of patients’ Physiological parameters and monitoring patients’ signs&symptoms of wound appear, it was done by the investigator.
III- Administrative design:
An approval to carry out this study was obtained from director of Bahtim Hospital and director of surgical unit. An Issued litter from the Dean of Faculty of Nursing at Ain-Shams University and official permission was obtained from the director of the Bahtim hospital and the head of surgical department.
Ethical considerations:
The ethical research considerations in this study included the following:
The research approval was obtained from the Scientific Research Ethical Committee Ain shams university faculty of nursing before starting the study, oral consent was obtained from the nurses and patients under study after clarifying the aim of the study to them. The researcher assured maintaining anonymity and confidentiality of the study subject/data in addition, nurses and patients were informed that participation is voluntary.
IV- Statistical Design:
The data obtained was synthesized, analyzed, and presented in numbers, percentage, in the form of tables and figures. Recorded data were analyzed using the Statistical Package for Social Sciences (SPSS), version (20.0). Quantitative data were expressed as mean and standard deviation (SD). Chi-square (X2) test was used when comparing between related sample. P-value <0.05 was considered significant, P ≤0.001 was considered as highly significant and P value >0.05 was considered insignificant.
Results:
• Nearly half (45.0%) of the studied nurses their age between 30<40 years with, Mean age 34.0 ± 7.44 years, about three quarters (70.0%) of them were females and almost half (50.0%) of them had technical institute of nursing. Also, nearly half (47.5%) of the studied nurses their experience was from year to less than five years in general surgical unit and about three quarters (72.5%) didn’t receive any training courses regarding infection control.
• The mean age of the studied patients was 43.0 ±10.59 years, nearly two thirds (62.0%) of them were males. Concerning marital status and educational level two fifth (40.0%) of the studied patients were married and had intermediate education. Also, the majority (84.0%) of the studied patients were from urban area.
• Almost three fifth (60.0%) of the studied patients weren’t smoker and nearly two thirds (62.0%) of them didn’t eat healthy diet. Regarding ICU admission about one quarter (22.0%) of the studied patients admitted to ICU and 54.5% of them stayed for 5 days. Also, 78.0% and 40.0%, respectively of the studied patients had wound infection as a postoperative complication and stay more than 5-10 days at hospital. Regarding presence of drains and its numbers 92.0% and 82.6%, respectively of the studied patients had one drain.
• Concerning physical observations of studied patients, 60.0% of the studied patients had hyperthermia, also, 58.0% and 74.0%, respectively of them had tachycardia and normal respiration rate. Regarding capillary refill, BMT and laboratory tests, (76.0%, 74.0% & 100.0%) of the studied patients their capillary refill were equal or more than three seconds, overweight and all performed CBC and CRP.
• Regarding signs of infection, most (92.0%) of the studied patients had oozing blood at surgical site and the majority (86.0%) of them had pain at surgical site and fever as a sign of infection.
• Concerning total nurses’ knowledge parts, 65.0%, 60.0%, 60.0%, 50.0 % and 62.5% of the studied nurses had un satisfactory level of knowledge regarding all aspects of knowledge (surgical site infection, following recommendations to reduce surgical site infection, SSI bundle of care at preoperative phase, SSI bundle of care at Intra-operative and SSI bundle of care at post-operative phase) respectively.
• In relation to total nurses’ knowledge about total SSI bundle of care, 67.5.0% of the studied nurses had unsatisfactory level of total knowledge while, 32.5% of them had satisfactory level of total knowledge.
• Regarding nurses total practices regarding SSI bundle of care, 77.5%, 80.0 % and 82.5% of the studied nurses had unsatisfactory level of practices regarding preoperative observational checklist, intraoperative observational checklist, post-operative observational checklist and respectively.
• Concerning total nurses’ practices about SSI bund of care, 77.5% of the studied nurses had unsatisfactory level of total practices, while 22.5% of them had satisfactory level of total practices.
• The current study revealed that, there was a statistically significant relation between the studied nurses’ total level of knowledge and their age (p ≤ 0.05*). While, there was a highly statistically significant relation between the studied nurses’ total level of knowledge and their gender, educational level, experience and training courses (p ≤ 0.000**).
• There was a statistically significant relation between the studied nurses’ total level of practices and their sex &educational level (p ≤ 0.05). While, there was a highly statistically significant relation between the studied nurses’ total level of practices and their age, experience and training courses (p ≤ 0.000**).
• In relation to the correlation between total level of knowledge and total level of practices among studied nurses, there was a statistically significant correlation between the studied nurses’ total level of knowledge and their total level of practices (p ≤ 0.05*).
Conclusion:
More than two thirds of the studied nurses had unsatisfactory total level of knowledge regarding bundle of care for prevention of wound site infection. Concerning nurses’ practice, the results of the current study revealed that more than three quarters of the studied nurses had unsatisfactory level of total practices. Also, there was a statistically significant correlation between the studied nurses’ total level of knowledge and their total level of practices about bundle of care for prevention of wound site infection.
Recommendation:
In the light of the result of the present study, the following recommendations are suggested:
• Replication of the current study on a larger sample and another setting.
• Routinely updating knowledge and practice of nurses through in-service continuing education programs associated with clinical training on the latest evidence-based practices of infection prevention especially SSI.
• Develop a system for continuous, strict follow up for nurses during work, with a periodical evaluation of their attitudes and their adherence to evidence-based preventive measures for SSI.
• Illustrated simplified guidlines booklet about bundle of prevention of SSI should be available at all surgical units.