Methicillin-Resistant Staphylococcus Aureus (MRSA) is a bacterium that lives in the skin or the nose of around 25-30% of people and is prevalent in many healthcare settings to-day leading to increased morbidity and mortality. Staff nurse play a key role in preventing MRSA, yet there is a lack of research on how education can enhance knowledge regarding MRSA its prevention, control and treatment. This study proposes to measure the knowledge of the registered nurses, who work in surgical units in Saudi Arabia regarding the prevention, control, and treatment of MRSA. An experimental design will be utilised using a pre and post text questionnaire. An educational intervention will be drawn up from the literature focusing on the factors that are crucial in the prevention, control, and treatment of MRSA. This information will also be used to form the questionnaire. 136
The research aim is to determine if an educational intervention could enhance the knowledge base of nurses regarding the prevention, control, and treatment of MRSA in a surgical unit, in Saudi Arabia.
Objectives of the Study
The research has the following objectives:
• To undertake a review of the literature on the role of knowledge, amongst registered
nurses in the prevention, control, and treatment of MRSA
• To identify the knowledge of registered nurses in a surgical unit, in Saudi Arabia
regarding MRSA its prevention, control and treatment
• To determine if an educational intervention could enhance the knowledge base of registered nurses regarding the preventative measures that could be employed to control the spread of MRSA.
• To make recommendations regarding educational programmes, which focus on the
Prevention, control and treatment of MRSA
The research question is: what is the level of knowledge of registered nurses regarding MRSA, its prevention, control and treatment within surgical units in Saudi Arabia and how could an educational intervention enhance this knowledge base?
There is no difference between the knowledge of nurses regarding the prevention, control and treatment of MRSA following an educational intervention.
Methicillin-Resistant Staphylococcus Aureus (MRSA) and infection control have been an endemic problem since the 1960s and have become a global issue (Rayner 2003; David & Daum 2010; Azeez-Akaned 2010; Azeez-Akaned 2010). The mortality rates involving MRSA have increased 20-fold during 1993-2002 in England and Wales (Office for National Statistics 2005). MRSA is a bacterium that lives in the skin or inside the nose of around 25-30% of people presenting challenges to nurses and other healthcare professionals regarding its prevention, treatment and control (Jimmy & Snyder 2010). The altitudes, behaviours, knowledge on MRSA and their perceptions regarding MRSA are decisive factors in affecting the outcomes on parties (Storr, Topley & Privett 2005). One of the recommended assessment strategies by Makoni (2002) is establishing a greater understanding of the microorganism sources, the nature of transmission, and the predisposing risk factors. Similarly, May (2000) recommends the adoption of standard infection control precautions. It is acknowledged that staff nurse play a key role in preventing the spread of MRSA, and they should be aware of the practises that will minimise the infection. The literature does demonstrate a lack of research on techniques to control the spread of MSRA. Indeed it has been shown that hand-washing, one of the most fundamental practises to minimise the spread of MSRA is often overlooked by nurses and health care practitioners (Makoni 2002; Topley & Privet 2005). Alongside these McDonald et al, 2003 argue that there is no information on the knowledge of registered nurses regarding MRSA and infection control. This proposal aims to explore if an educational intervention can enhance the knowledge of registered nurses, regarding the prevention, control, and treatment of MRSA.
The research for the literature was conducted from different databases: Medline, CINAHL, PUBmed, Ovid and ProQuest. The articles were collected in the period from 2000 to 2012, restricted to English only publications. The key terms used for this literature research initially where MRSA and infection control, which yielded in excess of 500 articles. Further use of exclusion criteria such as a registered nurse, knowledge, experience, and surgical unit were applied, which substantially reduced the number of relevant articles. Out of the articles sourced and for the aim of this paper the 6/7 most clear studies will be reviewed.
The literature demonstrates that mortality and morbidity from Healthcare associated infections, including MRSA is increasing (Gastmeier et al. 2006). According to the European Centre for Disease and Control (2009, pp. 16-36), almost 25,000 patients lose their lives across the EU from infections linked with a number of multidrug resistant bacteria. Not only does this bring the traumatic consequences for individuals and their families, it also brings significant financial challenge in a global context (Gemmell et al. 2006; Johnson, Pearson & Duckworth 2005; Tiemersma et al. 2004), consequently, it becomes significant preventative issue that urgently needs to be addressed.
In the UK study Easton et al. (2007), assessed the perceived practice and knowledge of nurses and doctors regarding MRSA in a hospital set up. Data collection was done using a survey method, whereby questionnaires were utilised through group administration as part of the study day. In addition, in order to gain an appropriate sample size, face-to-face interviews were also carried out with personnel from surgical and medical wards over a three-month period using the same questionnaire.
The study yielded 174 interview responses from 87 nurses in medical and surgical units and 87 doctors, and 47 self-completed questionnaires. The questionnaires of which all but one questions were open-ended, sought to assess knowledge regarding the prevention, assessment, and treatment of MRSA. In addition, demographic data was also collected including the post held by the respondent and the time since qualifying. SPSS was used for the data analysis and correct answers were confirmed from the local guidelines and literature. Responses were calculated with 95% confidence levels and differences between the staff groups were compared using a Chi Squared test (P < 0.05). The results demonstrated a considerable variation in responses between doctors and nurses answering correctly. No significant differences were found in interviewers based on the age of the respondents or in the time since qualification. Additionally, there was no significant difference between the interview and the self-completed responses. Perhaps, not surprisingly, the doctors were more knowledgeable about antibiotic choice, whereas nurses demonstrated a higher awareness of infection control issues. The authors suggest that assumptions should not be made about the staff knowledge or awareness of MRSA (Easton et al. 2007).
There are no limitations in the study including the use of a convenience sample, it suggested that the utilisation of the same questionnaire for both professional groups, who have had quite different educational preparations may have influenced the results. Additionally, it could be argued that a lack of knowledge regarding prevention and control measures may be potentially more detrimental to patients, rather than limited knowledge of antibiotics, especially when not all personnel is engaged with prescribing. The situation, therefore, may be more serious than the authors suggest; in the interpretation process care must be taken as a result of interpretation.
Alongside the educational awareness of staff, the literature also suggests that the resources deployed in regard to infection control are paramount. Cunney, et. al. (2006), carried out an infection control survey in 2003, examining the resources used in preventing nosocomial infection such as isolation facilities from 68 acute hospitals in the Republic of Ireland. The study was conducted using a survey technique with questionnaires. An analysis of the data illustrated that there were significant problems in the execution of services, both in terms of the physical and human resource. The authors suggest that issues arise when organisational policies are advisory rather than mandatory; they also suggest the need for European consensus and direction regarding the minimum resources to prevent MRSA (Cunney et. al. 2006). This study demonstrates that while preventative measures have been shown to be successful and cost effective, deployment of resources from treatment to preventative approaches brings challenges.
Conversely Van Gemert-Pijnen et al. (2005), illustrated that protocols while having a crucial role in the prevention of MSRA are not easily utilised by different professional groups. Furthermore, they conclude that protocols should be developed that are attuned to the knowledge and skills of the healthcare worker. This seems to suggest no need for healthcare workers to acquire knowledge on activities being undertaken than following instructions. It's clear that without the knowledge the former may enhance compliance. In their study, they adopted a comprehensive approach in a range of staff groupings including doctors, nurses and cleaning staff. Given that preventative measures need to be embraced and implemented by the complete healthcare team, an acknowledgement of the difference in the knowledge base and associated behaviours is essential.
In recognition of the many factors that impact upon the spread of MRSA, Gill et al., (2006), conducted a study that identified awareness levels and the perceived MRSA contraction risk amongst visitors, patients, and workers of the UK National Health Service (NHS) employees. The authors concluded that there was a high awareness level among the public and healthcare workers alike, however, the link between this awareness, and any subsequent preventative behaviour is not easily demonstrated.
Bellamy (2008, pp. 6-10), conducted a study to evaluate the satisfaction of patients regarding the care and information provided by infection control nurses relating to MRSA. Given the importance of the skills, knowledge and attitude of staff in prevention and controlling of MSRA, it is necessary to explore if the staff specifically employed with infection control imperative evidence to be more effective in this area. Not surprisingly, the results revealed that patients did demonstrate an increased awareness; however, the study did not include a control group who were being cared for by non-infection control nurses. In addition, the link between the better-informed patients and the prevalence of MRSA was not explored.
The literature indicates a lack of research in this area, as well as widespread diversity of knowledge, experience, attitude, and behaviour. In response, this study aims to identify and measure the perceptions of registered nurses, their behaviours, attitudes, knowledge, and experiences, in an effort to enhance MRSA infection control and treatment.
The literature demonstrates that there are a number of preventative measures that can be put to covert the incidence and spread of MRSA. These include hand washing (Mayhall 2004; Kennamer 2002), using alcohol rub in place of soap, (Fairclough 2005). Environmental cleanliness (Weston 2008; Johnston et al. 2005), post operative antibiotics (Johnston et al. 2005; Platt 2001), and assessment of patients at risk (Fairclough 2005; Mayhall 2004; Storr et al. 2005).
According to Parahoo (2006), in order to meet the aims and objectives of the research, the researchers must select the most appropriate research design. Given the emphasis of knowledge in the prevention, control and treatment of MRSA an experimental design has been selected as the most appropriate mechanism to determine if an educational intervention could improve the knowledge base of practicing nurses and, thus, impact upon the patient care. A survey technique utilising a pre and post-test knowledge questionnaire will be employed to collect the data.
There is no difference between the knowledge of nurses regarding the prevention, control and treatment of MRSA following an educational intervention. The findings of this research will be used in improving nursing profession as follows;
- The findings of the research will help develop and structure training programs so as to increase knowledge and practices of the nurses in prevention and control of MRSA
- The findings will also help in providing information to guide in developing of the nursing curriculum for training courses regarding prevention and control of MRSA
- The research findings either can be used as a baseline for reference in future experimental researches so as to increase the knowledge and practices in control of MRSA.
Research design is a plan of how the research is to be conducted, focusing on the product and formulating a research problem as a point of departure, as well as the logic of the research. The research will explore and describe the knowledge of nurses in connection to infection control and principles connected to sterile techniques in an operating room, thus, the research will be conducted in an explorative, descriptive, and contextual research designs carried in a quantitative approach (Polit & Hungler 1997).
The knowledge regarding prevention and control of MRSA refers to the stage of nurse’s cognition of conditions concerning comprehension, remembering and cognitive application of methods in prevention and control of MRSA in pre-operative and post-operative care. Practice on prevention of MRSA refers to nurses’ perception level of their actions in manipulation, imitation and precision in prevention and control of MRSA during pre and post operative care. The pre and post operative data will be collected using a structured questionnaire developed by the researcher.
A questionnaire will be developed to establish knowledge of the nature and risk factors for MRSA and knowledge of information and advice on resources that are required to support measures for infection control in a surgical unit. The questionnaire will capture demographic data including post, age group, speciality and time since professional qualification. The questions were open ended and they invited selection of answers from a wide range of options. The questionnaire will have face and content validity as it will be developed through consultation with the experts. The expert will advise on the design of the questionnaire and also on infectious diseases. Contextual design in the research design refers to the study being done in a situation where an incident normally occurs. In this case, the incident of interest is explored in its instant environment or physical site. This study is to be conducted amongst registered nurses working in operating rooms of a surgical unit in Saudi Arabia.
A questionnaire will be used as a data collection instrument. Given below is a list of questions which are compiled by a researcher to obtain the information on a certain topic. Questionnaires have an array of advantages, which involve:
- They are cost effective in investigations involving large size of samples and enormous geographical regions as well when the number of questions is enormous;
- Many computer software packages can be used to analyse the questionnaires;
- Many people are familiar with them;
- They reduce occurrences of biases, since the questions are presented uniformly without central biases;
- In comparison, to telephone or face to face interviews they are less intrusive (Fox & Bayat 2007).
The data will be collected through questionnaires designed by the researcher with the experts assisting in the field. The questions will be close ended and multiple choices as they are popular and provide excellent uniformity as they are easily processed (Babbie 2001). The questionnaire will be self-administered. The respondents will be encouraged to identify what issues are influential in their understanding of their research topic and how they will express their concerns in their own language (Fox & Bayat 2007). Therefore, the participants will have the feeling of anonymity which will contribute to providing honest responses. The questionnaires will consist of three parts, which are:
• Section I: this section will contain the demographic data and the biographical profile of the respondents such as gender, experience of the registered nurse and the highest qualification of the nurse.
• Section II: in this section, the focus will be put on the knowledge of the nurse in relation to control principles of infection in the operating room. The questionnaire will be preceded based on the literature review.
• Section III: the focus will be on the knowledge of nurses regarding the application of sterile technique principles in the operating room. The questionnaires will be issued along with the consent forms. The consent forms will be issued so as to stress the importance of the study and that confidentiality will be maintained.
A random sample of 20 professional registered nurses who work in surgical units in the selected hospital in Saudi Arabia will be targeted to participate in the study, and a further 20 will be randomly selected for a control group. Sampling is necessary, as it is economically more efficient to work with a small group of participants. The researcher will adopt random sampling method to select the sample group. The experimental group involves 20 practitioners, which amount to approximately 25% of the nursing population in a variety of surgical settings within the chosen hospital in Saudi Arabia. A random sample of 20% of the total population has been deemed adequate in providing information pertinent to the whole group with about a 90% level of confidence (Yin 2009, pp. 45-66).
Methods of Data Collection
Data collection will be undertaken for a period of six months. In the assessment phase questionnaire will be administered to collect baseline data and the knowledge of the nurse regarding infection control. Later the nurses practice’s on infection control will be assessed through collection of data about nurse’s performance on infection control.
Once the participants have been randomly selected into the control and experimental groups, the questionnaires will be given out to the participants. For the experimental group, the questionnaires will be administered by the researcher at the commencement of the educational intervention. The questionnaires for the control group will also be administered in a group session for uniformity with the experimental group. It is anticipated that this personal approach will assist in ensuring an acceptable response rate.
Two tools will be utilised for data collection. The first tool is an infection control precautions questionnaire which will be used to asses the knowledge of nurses regarding infection control in a surgical unit. It will contain eight questions about MRSA infection and 23 questions on standard precaution measures in a surgical unit. The second tool will be observation sheets that are divided into two parts; the first part will have a checklist for infection control precaution observations and second part will have laboratory investigation records.
Qualitative data is analysed through statistical procedures (Polit & Hungler 1997). Descriptive design will be used in the research study. Inferential and descriptive statistics will be used to interpret the data collected. Inferential statistics will be used to estimate the universality of the findings of the through which analysis of a large sample population is done as represented by the sample (Bobbie & Mouton 2002). Descriptive statistics will assist in describing the registered nurses responses in questionnaires and summarise the distribution of their knowledge regarding the infection control and the principles of sterile techniques in the operating room. Descriptive statistics will be used to describe and synthesize the data. Averages and percentages will be used as means of the descriptive statistics. The data will be represented in the form of graphs and tables. SPSS computer statistical package will be used to analyze, store and report the data collected.
A pilot study is crucial as it helps to obtain the information for improving the project and to estimate the feasibility of the project. The pilot study will be conducted with six registered nurses from different private hospitals with surgical units in Saudi Arabia. Data from these nurses will be collected using the initial versions of the questionnaires. The pilot study data will not be included in the analysis of the research study. This is aimed at establishing the reliability of the questionnaire and whether it would achieve the objectives and hypothesis of the study. However, the data studied will not be included in the data analysis in the research study. The purpose of the pilot study is to find out whether the participants understood the questions from the questionnaire. Furthermore, it seeks to know whether the likelihood for any alterations in the way the research will be conducted is present (Polit & Hungler 1997).
Validity and Reliability
Validity is the degree to which an instrument measures the parameter which it is supposed to (De Vos, Strydom, Fouche & Delport 2005). It refers to whether the actual concept in question is measured by the instrument and whether the concept is accurately measured (Polit & Hungler 1997). Validity is either categorized as content or face validity. Content validity is defined as the degree to which the items in the instrument represent the research study contents. The content validity is established by the judgment basis and the experts’ opinion. The content validity of the instrument will be ensured through consulting experts in the operating room techniques. Face validity regards the outward appearance of the measurement procedure. The structure of the questionnaires should accurately measure the concept and appear relevant to measure the concepts. Experts will be engaged to evaluate whether the questions are arranged in a logical order (Polit & Hungler 1997).
Reliability of an instrument is evaluated with regard to consistency, stability, and repeatability of the results. The degree of consistency and reliability with which an instrument measures the attribute it is designed to is referred to as reliability. Again, the reliability of the questionnaire will be established by submitting it to the experts in the operating room to ensure that the questionnaires are consistent with the research. The pilot study assures the reliability of the questionnaires (Polit & Hungler 1997). The cronbach’s alpha coefficient will be used to determine internal consistency reliability of the knowledge and practice questionnaires.
The system of moral values concerned with the extent to which the research procedures adhere to legal, social, and professional obligations of the participants is referred to as ethics (Polit & Hungler 1997). In this section, the rights to privacy, confidentiality, anonymity, clear consent and harmful rights are considered.
The right to privacy of the respondents respect is imperative. The privacy is when what is intended to others to observe or analyse is maintained. The following rules in the rights of privacy to the participants should be observed:
- The participant has a right to fill or to refuse to fill the questionnaires;
- The participant has the right to answer or refuse telephonic or emailed questionnaires;
- The participant has the right to refuse to answer any questions (Bobbie & Mouton, 2002).
The research will assure participants that no identification is required and, therefore, their privacy is assured. In this research, only the researcher and the supervisors will have access to information gathered from the participants and, thus, their privacy is guaranteed (Polit & Hungler 1997).
Anonymity refers to the principle where the participants prefer to have their identity kept secret while, on the other hand, confidentiality refers to keeping secret the information gained during the research from the participants. Either in the state of confidentiality protection of the participant is in such ways that even the researcher cannot link the information to the participant. Moreover, the individual identities of the participants will not be connected to the information they provide and will not be publicly divulged. The participants in this study will be assured that information gathered from them will be confidentially kept. The principle of confidentiality will be explained to them at the time of distributing consent forms. Anonymity will be guaranteed by assigning a number to each questionnaire and ensuring that no identification information is recorded on it (Polit & Hungler 1997).
Adequate information on the goal of the study, procedures followed during the study, advantages and disadvantages of the study to the participants as well as credibility of the researchers will be communicated to potential participants. This allows them to give consent to participation in the study voluntarily (Holloway & Wheeler 1998). The participants in this study will sign a consent form. Consent to conduct the research will be obtained from the university, unit managers and nurses from two private hospitals in Saudi Arabia.
Dissemination strategies will include publication of the research studies in journals, postal distribution to the target group and other educational methods which include lecturers, seminars and meetings. In this research, private hospitals, which participated in the study, will receive recommendations on the changes to make to their existing guidelines on infection control in their surgical units.
The user was involved in the process of conducting this research. The research design was formulated in consultation with the user.
Anticipated Research Impact
The research will have an impact as it will make recommendations on whether to upgrade the existing guidelines concerned with infection control in surgical units. This may, in turn, assist nurses in becoming more knowledgeable in this field. Nurses should attend congresses where lecturers on any new developments on evidence-based practices are given. The training helps nurses who do not have additional training on the operations of surgical units to obtain theoretical knowledge.