Compliance and Barriers Facing Nurses with Surgical Site Infection Prevention Guidelines

Background: Surgical Site Infection (SSI) is defined as infection that occur-ring within 30 days after surgical procedure or within a year of implantation of prosthesis. Surgical Site Infection can happen in up to 30% of surgical procedures and records for up to 14% of Hospital Acquired Infection (HAIs). Aim of the Study: The aim of this study was to assess levels of nurse’s Compliance; knowledge and practice regarding prevention of surgical site infection Guidelines and identify the barriers facing nurses’ compliance with surgical site infection prevention Guidelines. Design: Cross sectional descriptive study design self-reported survey. Settings: Data was collected from surgical departments from selected Menoufia Governorate Hospitals, Egypt. Sample: A large convenience sample of 450 nurses was selected. Initially 600 questionnaires were distributed, of which only 400 returned completed, a response rate of 66.6%. Tools: was comprised of the: 1) Pre-designed structured questionnaire to assess nurses’ socio-demographic characteristics’ and Nurses’ knowledge, 2) Likert-scale: to assess nurses’ compliance, nurses’ practice and nurses’ barriers facing nurses with surgical site infection prevention guidelines. Study period: The study was conducted from July to November 2019 in the selected hospitals. Results: nurses’ compliance mean scores were in low level with a mean of 13.01, it is clear that most of the nurses have poor knowledge, most of the nurses have poor practice about surgical site infection, concerning the most barriers of compliance facing nurses with surgical site infection and some measures for the prevention of surgical site infection are not nurses’ responsibilities. Recommendations: Evaluation of nurses’ and hospitals’ application of the guidelines is important to improve the quality of care. Education and training program should be conducted to improve nurses’ knowledge and practice in some areas using evidence-based practice.


Introduction
Surgical site infections (SSIs) are the most preventable hospital acquired infection (HAI) related with any surgery [1] [2]. SSI is defined as infection that occurs within 30 days after a surgical procedure or within a year of implantation of a prosthesis. SSI can happen in up to 30% of surgical procedures and records for up to 14% of HAIs [3]. It was reported a huge weight in terms of patient morbidity and mortality and costs to healthcare around the world due to Surgical site infections (SSIs) [4]. The fundamental danger of contamination is microorganisms (viral or bacterial) entering surgical incisions. The development of SSIs depends upon on virulence, bacterial load, and the patient's ability to withstand infections [5]. Transmission of microorganisms can be minimized through following evidence based guidelines for prevention of transmission of them, including the aseptic technique. Hand washing techniques in pre-operative aseptic strategies consist of a number of factors such as preliminary hand washing, method of rubbing, drying of hands, wearing an operating gown, and wearing sterile gloves. One of the factors that affect the success of hand washing is the degree of compliance with the recommended standard procedures [6] [7].
Prevalence study found that wound contaminations after surgery represent SSIs happen in 2% -5% of patients experiencing surgical procedure extending from 160,000 to 300,000 cases for each year in the US, [8] [9]. SSIs are related with delayed term of hospitalization, readmissions, re-intercessions, changeless incapacity or even passing [10].
Throughout the literature, SSIs were associated with factors including advanced age, malnutrition, metabolic diseases, smoking, obesity, hypoxia, and immune-suppression. Moreover, factors like application of skin antiseptics, preoperative shaving, antibiotic prophylaxis, preoperative skin preparation, inadequate sterilization of instruments, surgical drains, surgical hand scrubs, and dressing techniques were among the most frequently reported risk factors [11] [12]. The most critical issue in preventing surgical site infections is the entire and absolute compliance of health professionals with the recommendations in the guidelines [13] [14].
Although the occurrence of surgical site infections (SSIs) is a great deal higher in low-and middle-income nations in contrast to high-income countries, SSIs  [15]. Clearly, better SSIs prevention is needed. Preventing SSI requires a multifactorial strategy as the increasing improvement of antibiotic resistance makes it essential that the operating room (OR) is free from infection as possible [16].
Wound contamination can be prevented by implementing certain guidelines from the nurses and other health care workers that minimize the risk of SSIs.
Actions such as all staff complying with Preventing SSI guidelines including hygienic practices and correct cleaning of the OR between operations are examples of measures that can reduce SSI load in all health care facilities [17].
There is a general agreement that up to 60% of SSI would be reduced by applying sufficient counteractive action and checking nurses compliance with SSI [15] [17], since sets of measures (or "packages") have exhibited a decrease in SSI rates [18] [19].
As most SSIs are avoidable [20], all details preoperative, intraoperative and post-operative care should be investigated and evaluated to make certain highquality practices are evidence-based. Prevention of SSI is a balance between harm, cost, and patient value [15]. Surgical patients, who meet many fitness care specialists on their perioperative period, rely on OR nurse to provide advantageous care as properly as to make sure the prevention of SSIs. That is, OR nurses are accountable for enforcing hygiene and aseptic principles in the OR to stop and limit the spread of infections. In addition, OR nurses are responsible for perioperative care together with different professionals in the crew [21].
Nurses play a major comprehensive role and span of continuum care in preventing surgical site infections. Therefore, they can modify SSI risk factors in their daily practice such as improper hand hygiene and skin preparation, in order to prevent SSI. [7] [8]. Many sets of guidelines in this area have been proposed in the past decade by the organizations working in the area of SSI prevention, such as the Center for Disease Control and Prevention (CDC) [22], WHO, [23], and the National Institute for Health and Clinical Excellence (NICE). [24]. However, adherence to the recommended best practices according to the guidelines for SSI prevention remains low among nurses [22] [24]. Multiple studies have reported that proper practices for the prevention of infection among nurses have been affected by some barriers, such as Lack of knowledge, resources and SSI preventive guidelines, lack of direct leadership involvement, lack of dedicated time for implementation of the improvement activities, lack of dedicated time for training and education, poor access to supplies in support of identified and agreed action, poor communication, lack of awareness of the need to address the problem, lack of data to support and track improvement efforts, non-attendance or non-compliance with educational activities, absence of local standard operating protocols (SOPs) or an implementation manual for SSI prevention [9] [24].
ity of health care outcomes globally, particularly in developing countries. This infection can have serious impacts including: prolonged hospital stay, reduced quality of life, increased mortality, additional cost for patients and their family, and rising health care cost. In Egypt, a little nursing research has been done to assess the level of nurses' compliance, knowledge and practice regarding surgical site infection prevention guidelines and investigating the correlation among them, as well as, identifying the barriers facing the nurses to comply with guidelines of SSI. All over the world, the use of SSI prevention guidelines is supported by scientific research. However, In Menoufia Governorate in Egypt, the extent to which nurses implement these guidelines in surgical departments is still unclear.
Therefore, there is a standing need to provide all Menoufia hospitals with written guidelines for nurses, patients and other health care employees to gain knowledge and practice regarding surgical site infection prevention (SSIs).
Moreover, it might generate attention and motivation for further researches into this area.

Aim of the Study
The aim of this study was to assess levels of Nurse's Compliance, knowledge and practice regarding prevention of surgical site infection Guidelines and to identify the Barriers facing nurses' compliance with surgical site infection prevention Guidelines.

Design
A cross-sectional descriptive study, design self-reported survey was conducted.

Setting
Data was collected from surgical departments from selected Menoufia Governo-

Sample Size Estimation
In this study, it is used the Raosoft sample size calculator [25]. in which, margin of error was 5% is a common choice, confidence level was 95%, the population size, 20,000, the response distribution was 50%, the recommended sample size was 377 which calculated electronically based on the Raosoft  Nurses who will voluntarily participate and give consent.

Exclusion Criteria
Head nurses; Student nurses; Nurses who will refuse to participate in the study.

Study Period
The study was conducted between July to November 2019 in the selected hospitals.

Approval to Conduct the Study
An official letter was issued to the directors of Menoufia Governorates Hospitals, Egypt.

Protection of Human Rights
Each subject was informed about the purpose and the nature of the study. The subjects were informed that their participation is totally voluntary and the confidentiality and anonymity were assured.

Pilot Study
The tools were administered to 50 nurses in a pilot study, the panel of experts approved all the sections of the tools, as well as the scoring systems to evaluate its applicability. Minor rewording for some items was made to improve readability and understandability for practice section, as it was adopted.
The questionnaire was distributed to the nurses working in the surgical department in the previously mentioned hospitals for filling it.
The questionnaires were completed by nurses in their surgical departments

Statistical Analysis
Data were analyzed using SPSS [28]   Hospital (20). Respondents were different genders, age, and years of experience. Table 1 shows that about two thirds of the studied sample were females (65.8%), more than one third (39.0%) of the sample were in the age group of 20 -30 years and more than half (56.0%) were having bachelor degree in nursing. Regarding Work experience in surgical ward, it is indicated that, (44.8%) were having 1 -5 years experience in surgical ward. As well as, it indicates that (81.5%) of nurses did not attend surgical site infection prevention guidelines training programme previously. Table 2 describes frequency of nurse's responses concerning compliance of surgical site infection prevention guidelines. It is evident that, among 400 nurses, limited compliance with the surgical site infection prevention guidelines was obvious in several topics. Three quarters (75.0%) of the nurses reported that they never ensure patients bathe or shower and (77.3%) never limit the number of people and doors being opened, and (69.0%) never check wounds for infection and use standard dressings on primary wounds. Table 3 indicated that, nurses' compliance mean scores were in low level with a mean of 13.01 (SD = ±3.00), and majority (84.75%) of the nurses were classified in low compliance, (13.25%) in moderate compliance, and (2%) in high compliance.    Table 5, it is clear that most of the nurses have poor knowledge about surgical site infection, as about two thirds of nurses (65.5%) were in the low level of knowledge with mean knowledge score of (6.00 ± 5.97).

Results
It is obvious that minority of nurses always practiced the ten items of surgical site infection prevention guidelines in Table 6. As only (5.8%) of nurses always practiced washing hands before and after changing wound dressing touching the surgical site, (6.0%) of them always practiced advising their patients to take preoperative showering bathing with anti-microbial agent, (8.3%) always use an aseptic technique during surgical wound dressing, and (9.0%) always use sterilized dressing material for cleaning surgical wound dressing. Table 7 shows the levels and the mean total score of Nurses practice with surgical site infection prevention guidelines. It is clear from this table that, most of the nurses have poor practice about surgical site infection, as about three quarters of nurses (74.5%) were in the low level of practice with mean practice score of (14.71 ± 4.65).
In Table 8, concerning Barriers of Compliance with surgical site infection prevention guidelines, about two thirds (59.0%) of nurses agree that, lack of a professional model, nurses do not have enough time (64.0%), and some measures for the prevention of surgical site infection are not nurses' responsibilities (60.0%), are the most barriers facing them with surgical site infection prevention guidelines. Table 9 illustrates the correlation among Age, experience, compliance, Knowledge, and practice. It is shown from this table that there was a strong statistical significant correlation among Age, experience, compliance, Knowledge, and practice for nurses in relation to surgical site infection prevention guidelines. Table 10 revealed that, there was no statistical difference among nurses who attended surgical site infection prevention guidelines training programme previously and who did not.

Discussion
Effective surgical site infection prevention requires redesigning systems to reduce barriers and to optimize prevention strategies and guidelines based on evidence-based processes of care; all nurses should comply with the surgical site infection prevention guidelines which are essential for lowering surgical site infection rate [29]. The current study explores the nurse's compliance, Knowledge, and practices of surgical site infection prevention guidelines at Menoufia Governorate. The current study findings revealed that, among 400 nurses, limited compliance with the surgical site infection prevention guidelines was obvious in several topics. Three quarters (75.0%) of the nurses reported that they never ensure patients bathe or shower, and (77.3%) never limit the number of people and doors being Open Journal of Nursing opened, and (69.0%) never check wounds for infection and use standard dressings on primary wounds, moreover, nurses' compliance mean scores were in low level with a mean of 13.01 (SD = 3.00), and majority (84.75%) of the nurses were classified in low compliance, (13.25%) in moderate compliance, and (2%) in high compliance. These findings are similar to other studies such as Aloush., et al., [30], Jahansefat et al., [31], and Narendranath et al., [32], who reported poor compliance among nurses. As well, Alhirish et al., [33] in Egypt, and Rizwan et al., [34] who reported a significant increase in nosocomial infection in Pakistan as a result of poor compliance with infection prevention guidelines.
On the other hand, our findings contradict those of several other studies.
El-Saed et al., [35] reported a high compliance rate for nurses. Aysha et al., [36] found satisfactory compliance after implementation of a nursing care program, and Sherpa et al., [37] revealed higher compliance of nurses for the guidelines, including hand washing, and using sterile gloves.
In addition, the current study findings describe frequency of incorrect and knowledge with mean knowledge score of (6.00 + 5.97). These results were in accordance with Sadaf., Shafqat, Hussain, 2018, [38] who concluded that, nurses had poor knowledge concerning surgical infection and this study revealed that the nurses' information was poor regarding interference of surgical site infection. Responses of the nurses to knowing the simplest technique for pre-operative shaving indicated that the majority (50) were response to affirmative that show that they understand it and thirty four nurses were response to NO that was a negative response.
Other study conducted by Zucco, Lavano, Nobile, Papadopoli, Bianco (2019) [39], they reported that, only 53.8% knew that preoperative hair removal, if necessary, should take place shortly before surgery, and 28.9% of the sample did not know the right definition of "bundle". Over three quarters of participants stated that they always perform hand antisepsis before and after biological sample collection while 9.7% considered that wearing gloves during this practice is sufficient to prevent SSI. Furthermore, 91% of nurses reported that they always performed hand antisepsis before and after invasive procedures. Their study findings highlight the areas that were most lacking in nurses' training and for which targeted activities are needed. These data could support healthcare managers to implement interventions focused at enabling adherence to effective pre-Open Journal of Nursing vention practices to reduce risk to all patients.
Moreover, other study reported that when assessing knowledge on strategies for SSI prevention, more than two thirds (73%) of the participants knew that the appropriate time for shower or bath with an antiseptic agent is the day before surgery, but only 53.8% knew that preoperative hair removal, if necessary, should take place shortly before surgery. Moreover, 28.9% of the sample did not know the right definition of "bundle". When nurses were asked to rate the effectiveness of some interventions for SSI prevention, dressing change if it is visibly soiled received the highest score (8.9) [39].
In addition, it is obvious that minority of nurses always practiced the ten items of surgical site infection prevention guidelines. As only ( These results were in accordance with Sadaf, Shafqat, Hussain, 2018 [38] who explained that, the link between Knowledge and practice is positive and association is critical. As well, Knowledge could be necessary that affects the performance. The study shows that nurses have poor Knowledge and practices concerning surgical infection this study reveals that the nurses' knowledge was poor regarding interference of surgical site infection. In a study that was in accordance with our study, previous education with VAP, more years of experience, and was important factors seeming to increase nurses' compliance. These findings highlighted the significance of education and training in the improvement of nurses' compliance and quality of care, and support the reports from previous studies [31] [42].

Strengths and Limitations
• A major strength is that the current study evaluated nurses' knowledge, practice, compliance and barriers of the guidelines of SSI. • On the other hand, one limitation is the use of self-reported measures to evaluate nurses' knowledge, practice, and compliance.

Conclusions
• Nurses working in the surgical related wards reported a low level of knowledge, practice and compliance regarding the prevention of surgical site infection guidelines. Open Journal of Nursing • The most barriers of compliance with surgical site infection prevention guidelines that reported by nurses were: lack of a professional model, nurses do not have enough time, and some measures for the prevention of surgical site infection are not nurses' responsibilities.
• The current study indicated that there was strong statistical significant correlation among age, experience, compliance, knowledge, and practice for nurses in relation to surgical site infection prevention guidelines.

Recommendations
• Evaluation of nurses' and hospitals' application of the guidelines is important to improve the quality of care.
• Education and training program should be conducted to improve nurses' knowledge and practice in some areas using evidence-based practice.
• Improve compliance with the surgical site infection prevention guidelines through comprehensively modified and updated nursing curriculum to include the prevention of surgical site infection.
• Future studies are recommended to conduct observational measurement to enhance the reliability of the findings.
• The hospital administrators need to conduct education and training programs to enhance knowledge of SSI prevention to improve the quality of nursing care in this area.