Nurse’s knowledge and practice towards prevention of infection for burn patients in burn center at Sana’a City, Yemen

Abstract

Background

Infections are the most prevalent consequence following burn injuries, and they cause the patient greater pain and lengthen the hospital stay. Burn injuries are potentially fatal conditions, and burn patients require specialized care. This care should be provided by trained and skilled nurses who adhere to specified rules or protocols to limit the likelihood of infection and consequences.

The aim of the study

Assess the nurse's knowledge and practice regarding infection prevention for burn patients in the Burn Center at Sanaa City, Yemen.

Method

A descriptive-cross-sectional, which means that data were collected during October and November 2022. The self-administered questionnaire was used to collect information about the knowledge of nursing staff related to burn care. The observation checklist was used to assess the actual practices of nursing staff during patient care in the Burn Center in Sanaa City, Yemen. The sample size was 51 nursing staff members.

Results

More than one-third (41 %) of participants were in the age group ≤25 years old, and more than two-thirds (72 %) of participants had ≤5 experience years. More than three-quarters (88.2 %) of participants had an inadequate level of knowledge and most (90.2 %) of them had unsatisfactory practice regarding the prevention of infection in burn patients. There is a significant association between the level of nurses' knowledge regarding the prevention of infection in burn patients and experience years (0.047).

Conclusion

The findings of the current study revealed most of the participants had an inadequate level of knowledge and most of them had unsatisfactory practices regarding the prevention of infection in burn patients. Regular in-service training should be provided to update and refresh nursing practices related to caring for burn patients.

Introduction

Burn wound infections are a serious complication that can lead to severe health consequences if left untreated. Proper wound care and infection prevention measures are crucial in reducing the risk of infection and promoting healing. Nearly 180,000 deaths happen due to burning each year, as estimated by the World Health Organization in 2018.¹

Burn patients can acquire infections due to various factors. In the first seven days after injury, the affected burn areas are initially colonized by Gram-positive and Gram-negative bacteria from different sources, which plays a critical role in the development of further infections. The transition from colonization to infection primarily depends on three factors: the degree of bacterial colonization, the patient's immune response, and the pathogen's virulence.²

Overall, infection management is a critical aspect of caring for burn patients. By following proper protocols for wound care and taking steps to prevent exposure to infectious agents, healthcare workers can help ensure that burn patients receive the best possible care while minimizing their risk of complications. Nurses also play an important role in educating burn patients and their families about their condition and how to care for their wounds at home. This includes teaching them how to change dressings, administer medications, and monitor for signs of infection or other complications.³

The first step to effective infection control in any healthcare facility, especially burn units, is practicing good hand cleanliness. Masks, sterile gowns, and sterile gloves are examples of personal protective equipment that should be used when providing patient care. To reduce the growth of microorganisms on medical equipment, sterilization, and disinfection are essential; otherwise, germs are likely to spread.⁴

Nurses are essential in burn units because they coordinate all the patient's activities. As a result, nurses must be familiar with the multi-systems affected by burning, as well as aseptic practices and competent diagnostic and psychosocial skills.⁵ Burn patients require the highest level of care since burn injuries are potentially fatal. To lower the risk of infection and complications, this care should be provided by skilled and informed nurses who adhere to certain rules or procedures. Since hospital-acquired infections (HAIs) are considered an undesirable consequence and are a sign of the quality of patient care, there is evidence that the management and care of patients with burn injuries require a special set of knowledge and skills from responsible multidisciplinary team members, particularly the nurse. Additionally, specific infection control guidelines should be developed to prevent infections in general.³

According to a previous survey conducted in Yemen, just 26 % of nurses in private hospitals in the city of Sana'a had good procedures regarding infection control methods. Another survey conducted in Sana'a healthcare facilities found that just 7.2 % of nurses understood infection control protocols well⁶ Therefore, the aim of the study is to assess the nurse's knowledge and practice regarding infection prevention for burn patients in the burn center in Sanaa City, Yemen.

Methodology

Study design and setting

A cross-sectional study was conducted in the Burn Center at the Republican Teaching Hospital Authority in Sana’a City, Yemen. This center is the only one in the Republic of Yemen. The number of beds in the department reaches 21 beds, and the intensive care department accommodates eight beds. The population of the study was all nurses at a burn center in the Republican Teaching Hospital Authority.

Sampling method and technique

Total coverage of staff who work in the burn center. Samples were selected using a convenient sampling technique, and data was collected from these participants. The final sample size of nurse staff was (51).

Tools of data collection

Two tools were a collection from previous literature and books. A research-structured questionnaire and an observation checklist.^1,3,7 The tool I nurse knowledge of prevention of infection was divided into two parts: Part I: Demographic characteristics: It included the age, sex, qualification, experience, availability of infection prevention protocol, and training courses. Part II: Knowledge of nurses toward prevention of infection in burn patients included 26 questions. Using true and false questions. Items were constructed under five main domains including Knowledge of burn & its associated infections (Q1–Q6), Knowledge of Microorganisms of burn wounds (Q 7–Q 9), Knowledge of Burn wound culture (Q 10–Q 12), Knowledge of Infection Control in a burn unit (Q 13–Q 15), Knowledge of Infection Control during the care of the patient (Q 16–Q 26). Each correct response was scored one point, while incorrect or "I don't know" answers received 0 points. A higher score reflected a greater level of knowledge. The scores for each question were totaled to obtain a cumulative knowledge score for each participant. The total score was calculated out of 26 possible grades. The knowledge scores were classified as inadequate knowledge: <75 %, adequate knowledge: more than ≥75 %. Tool II: Practice of Nurse' (observation checklist). It included 27 practical steps. The practical steps number from (Q1 to Q27) observations were done by checklist (Done and Not done). Each correct done scored one point and not done or I don't know answer scored a 0. A higher score indicated a greater participant's practice. The score gained for each step was summed up to get a total practice score for each participant. The total score was computed out of 27 grades. Practice scores were categorized into two groups: unsatisfactory practice, which was defined as <75 %, and satisfactory practice, which was defined as ≥75 %.

Validity and reliability of the tool

To ensure accuracy and clarity, the questionnaire was developed based on previously validated and reliable studies.^3,7 Additionally, five specialists, including one medical professional and four academic nursing specialties, evaluated the questionnaire to ensure that all questions were worded appropriately and could not be misinterpreted. As a result, some questions were removed, some were added, and others were rewritten. Other questions submitted by the researcher with the support of the litter questions submitted by the researcher with the support of the literature supervisor and experts were adjusted to add or remove to address misinterpretation and doubtlessness from credence and completeness of study tools. Reliability by chrobch alpha = 0.82.

The pilot of the study

The pilot study was achieved before data collection was presented to point out the weakness of the questionnaire and achieved before data collection. A pilot study was carried out on five participants from a sample size of nurses on items in a questionnaire to assess the clearing, and feasibility of the study, and modification of the questionnaire was made. Those participants were included in the study because a small sample size was available.

Data collection technique

Data was collected through the two months from October to November 2022 and a good relationship was maintained throughout the whole period of data collection, nurses were told to sign the written consent form. The specific time for the interview was between 8 a.m. to 2 pm. The questionnaire was prepared in English language and translated from English into Arabic. The self-administration questionnaire was conducted in the Arabic language in a quiet environment in the public area of the selected department, away from noise and other distractions. Data for the study was obtained through a self-administered questionnaire completed by nursing staff; each nurse took an average of 25–30 min to complete the questionnaire. The second data collection tool, the observational checklist, was used to conduct direct observation of participant nurses. Every nurse was closely observed while providing care by the researcher. The researchers reviewed all collected data daily to ensure its completeness and accuracy. They also finalized the data before proceeding with further analysis.

Data processing and statistical analysis

Following data collection, acceptable statistical methods were employed to organize, tabulate, summarize, and analyze the data. For statistical analysis, the collected data was processed using the Statistical Package for Social Science (SPSS 25) research program. Descriptive statistics, including frequency and percentage, were calculated. To determine whether the data was normal, the Kolmogorov–Smirnov test and histogram analysis were utilized. To investigate the correlation between the level of nurse knowledge and their practice in preventing infection in burn patients using the Chi-square test, with a P-value set at 0.05.

Ethical consideration

Ethical approval was obtained from The Research Ethics Review Committee (RERC) of Al Razi University (ref. no.16/FMHS/2022). To collect data, permission was obtained from the administration of Al-Razi University to access the hospital, and the administration of the hospital approved it. The questionnaire's confidentiality was ensured by coding it, and anonymity was maintained to validate the data collected. Nurses provided written consent for participation in the paper-based questionnaire, with the freedom to withdraw from the study at any point.

Results

Table 1 notes that, the distribution of demographical characteristics of nurses, nearly two-thirds (63 %) of the nurses were male, while (37 %) of them were female. Less than half (41 %) of nurses were age group ≤25 years, followed by (33 %) in were age group between 26−30 years, while (26 %) of them were age group over 30 years, the majority (87 %) of nurses had diploma certification, while (13 %) have bachelor's, majority (87 %) of nurses had a protocol of infection control, more than half (57 %) of nurses have training courses, while less than half (43 %) of nurses did not have a training course, most of them (72 %) have <5 years' experience, while (28 %) of them have >5 years experience.

Table 1.

Distribution of demographic characteristics of nurses (n = 51).

	Items	Frequency	%
Sex	Male	32	62.7 %
	Female	19	37.3 %
Age group	≤25 years	21	41.2 %
	26–30 years	17	33.3 %
	>30 years	13	25.5 %
Mean & SD (28.00 ± 5.28)
Qualification	Diploma	75	87.2 %
	Bachelor's	11	12.8 %
Training course	Yes	29	56.9 %
	No	22	43.1 %
Protocol of infection	Yes	72	83.7 %
	No	14	16.3 %
Experience years	≤5 years	35	68.6 %
	>5 years	16	26.7 %
Mean & SD (4.69 ± 3.32)

Table 2 shows there is a significant association between the level of nurses' knowledge of prevention of infection in burn patients and the age group of nurses (0.048), there is a significant association between the level of nurse's knowledge regarding prevention of infection in burn patients and experience years (0.047), while there is not a significant association between the level of nurse's knowledge regarding prevention of infection in burn patients and qualifications of nurses was (0.104), there is not a significant association between the level of nurse's knowledge regarding prevention of infection in burn patients and raining course of nurses was (0.718).

Table 2.

Association between the level of nurse's knowledge regarding prevention of infection in burn patients and characteristics of nurses (n = 51).

Items	Knowledge level
	Inadequate		Adequate		Total		P. value
	F	%	F	%	F	%
Age group
≤25 years	20	95.2	1	4.8	21	100	.048
26–30 years	16	94.1	1	5.9	17	100
>30 years	9	69.2	4	30.8	13	100
Qualifications
Diploma	36	92.3	3	7.7	39	100	0.104
Bachelor's	9	75.0	3	25.0	12	100
Training course
Yes	26	89.7	3	10	29	100	.718
No	19	86.4	3	13.6	22	100
Experience years
≤5 years	33	94.3	2	5.7	35	100	.047
>5 years	12	75.0	4	25.0	16	100

Chi-square test P value < 0.05 level of significance.

Table 3 shows there is not a significant association between the level of nurse's practice regarding preventive measures of infection in burn patients and characteristics of nurses as the age group of nurses, qualification of nurses, training courses of nurses and experienced years were (0.658, 0.845, 0.881, 0.564), respectively.

Table 3.

Association between the level of nurse's practice regarding preventive measures of infection in burn patients and characteristics of nurses (n = 51).

Items	Practice level
	Unsatisfactory		Satisfactory		Total		P. value
	F	%	F	%	F	%
Age group
≤25 years	18	85.7	3	14.3	21	100	.658
26–30 years	16	94.1	1	5.9	17	100
>30 years	12	92.3	1	7.7	13	100
Qualifications
Diploma	35	89.7	4	10.3	39	100	.845
Bachelor's	11	91.7	1	8.3	12	100
Training course
Yes	26	89.7	3	10	29	100	.881
No	20	90.9	2	9.1	22	100
Experience years
≤5 years	31	88.6	4	11.4	35	100	.564
>5 years	15	93.8	1	6.3	16	100

Chi-square test P value < 0.05 level of significance.

Table 4 shows there is not a significant association between the level of nurses' Knowledge and practice regarding the prevention of infection in burn patients (0390).

Table 4.

Association between the level of nurse's knowledge and practice regarding prevention of infection in burn patients (n = 51).

Items	Practice level
	Unsatisfactory		Satisfactory		Total		P value
	F	%	F	%	F	%
Knowledge level
Inadequate	40	88.9 %	5	11.1 %	45	100	0.390
Adequate	6	100.0 %	0	0.0 %	6	100

Chi-square test P. value < 0.05 level of significance.

Discussion

According to the study's findings, nurses in the study locations don't know enough about or practice infection control with burn patients. In-service education programs must be developed to prepare nurses for infection prevention, even though they learned this information from experience.

An illness that is acquired from the surroundings or personnel of a medical facility is known as a nosocomial infection. It constitutes an excessive financial burden that raises hospitalization rates, expenses, and the need for antimicrobial drugs while also significantly increasing morbidity and death. It has numerous negative effects on patients and healthcare professionals. Burn patients frequently develop nosocomial infections (NI) as a result of their weakened immune systems, severe clinical conditions, prolonged hospital stays, and numerous invasive diagnostic and treatment procedures.⁸ Few initiatives have been made in Yemen to educate hospital administrators and healthcare professionals on infection control measures. Furthermore, there is a lack of regulations and policies in place to shield healthcare personnel from exposure.⁹ So, the current study aims to assess the nurse's knowledge and practice regarding infection prevention in burn patients.

In the present study regarding the age of the sample, most of the nursing staff were young and their age ranged from 20–35 years old. More than one-half of the nurses were male followed by nurses who were female. That affects some of the nursing care because the female can do specific care (general care, cleansing, bed preparation, female catheterization). These findings agree with Mussa & Abass who reported that the age group (30–35) year represents a higher percentage at Azady Teaching Hospital than at Western Emergency Hospital, where (60 %) of nurses were in the age group (24–29). Both Azady Hospital (75 %) and Western Hospital (70 %) had two-thirds male nurses.¹⁰ Also, this result is supported by Haza’a et al. the study conducted in Yemen, who mentioned over half of the nurses were unmarried, and two-thirds of them were female. Of these, 40.9 % were between the ages of 20 and under 25.¹¹

Regarding the qualification of the sample, more than two-thirds of nurses had diplomas, followed by less than one-third were had, bachelors. That affects some cares because those who have high degree qualifications have more knowledge and practice, comparable with Bibi et al. agree with our results that documented the majority of participants in the study have a diploma in general nursing, with a smaller percentage holding diplomas or degrees in midwifery or nursing. A small percentage of participants held a Bachelor of Science degree in nursing, either as a post-RN qualification or as a generic degree.¹

Regarding the experience of the sample, more than two-thirds of the nursing staff had ≤5 years of experience followed by less than one-third who had ≥5 years of experience. That affects some care because experience develops nurse skills. Comparable to Bibi et al., who backed up these findings by mentioning the participants' experience the majority of nurses 62 (36.7 %) have 7–9 years of experience, 38 (22.2 %) have 4–6 years of experience, and 39 (22.8 %) have 1–3 years of experience.¹

Nurse's Infection control awareness plays a crucial role in preventing hospital-acquired infections among burn patients by implementing proper infection control measures. The finding has an inadequate level of knowledge indicating an adequate knowledge score of 11.8 %. The results are similar to previous research on nurses' adherence to infection control protocols, which found that participants had a poor understanding of infection control guidelines.¹² Similarly, for burn patients, the most effective treatment recommended to eliminate hospital-acquired infections is a chlorhexidine bath program administered twice daily.¹³

The study found that there is a lack of knowledge regarding necessary precautions, particularly contact precautions, which are crucial for patients with MRSA. The results are in line with the study conducted by Alrefaee in Saudi Arabia which revealed that nurse's knowledge and practices of infection control measures had fair knowledge and practices.¹⁴

The study also highlighted that 60.8 % of the participants required additional education on infection control. Emaneini et al. have also supported this finding, stating that burn patients carrying resistant organisms such as MRSA can act as a source of infection transmission to other patients.¹⁵ Therefore, it is crucial to take multiple precautions, particularly contact precautions, when dealing with these patients.

The current study shows the vast majority of participants do not apply preventive measures for infection in burn patients such as Chlorhexidine baths, while more than three-quarters of nurses, not proper disinfection of medical devices thermometers, sphygmomanometers, followed nurses were observed safe disposal of needles and sharp materials. As for Horizontal surface disinfection, more than two-thirds of participants were observed not done. Followed by more than two-thirds of participants observed not done as walls disinfection. The Preventive measure of infection as hand washing equal observed by nurses for done and not done. There are various factors that could contribute to these findings, including but not limited to inadequate nurse-to-patient ratios, limited access to burn centers, lack of experience in treating burns, insufficient opportunities for in-service training, limited institutional resources, and the absence of established protocols. The current study disagrees with Parveen et al. study conducted in Pakistan which documented that half of the participants, 86 (50.3 %) observed to give chlorhexidine bath, 85 (49.7 %) did not give chlorhexidine bath.⁷

Other studies in line by El-Sayed et al. conducted a study in an Egyptian burn center and confirmed that only a small proportion of the participants demonstrated adequate knowledge and practice in preventing infection among burn patients.⁵ Alhumaid et al. mentioned Only 14 % checked 2 % aqueous chlorhexidine as the recommended disinfection solution.¹⁶

The study found that nurses' adherence to routine infection management precautions in burn patients was suboptimal, which may be attributed to inadequate staffing and limited resources. Abdulraheem et al. have also reported similar findings, indicating that healthcare workers exhibit inadequate adherence to standard precautions while providing patient care.¹⁷

The first crucial step towards effective infection control in any healthcare setting, including Burn Centre, is proper hand hygiene. However, the findings revealed that all nurses had insufficient hand washing practices, with only half of nurses displaying positive hand hygiene practices, while the remaining did not follow the recommended hand washing steps. The low compliance rate with hand hygiene practices is consistent with other studies, such as Karaaslan et al., which also found a compliance rate of only 41 %.¹⁸ Also, our findings agree with Isse et al. who reported compliance is still low even with sufficient awareness of hand hygiene procedures, which is influenced by things like training and resource availability.¹⁹

The study highlighted that nurses in Burn Centres need to improve their compliance with hand hygiene practices and the use of PPE to prevent the spread of infections. While most participants used gloves and masks, the non-compliance rate for wearing gowns was significant, which could lead to cross-contamination between patients. Healthcare facilities must implement strict protocols for PPE use and provide ongoing education and training to ensure healthcare workers have the necessary knowledge and skills to comply with infection control measures. Previous studies have also shown low compliance rates with PPE among healthcare workers, emphasizing the need for continuous improvement in this area.²⁰ Parveen et al. study conducted in Pakistan who reported the study showed very low compliance with it.⁷ Ariyo and Olorunfemi also recommended their study hand hygiene, the use of personal protective equipment, contact isolation, frequent room cleaning, daily assessment of invasive lines and devices, burn unit antibiograms, and topical antimicrobial medications are evidence-based infection control techniques that nurses should implement.⁴

The study underscores the significance of proper cleaning and disinfection of medical devices to avoid the proliferation of microorganisms on such devices. Neglecting to disinfect devices properly may encourage bacterial growth, posing a serious threat to patients' health. Regrettably, over 75 % of respondents in the study failed to disinfect thermometers and sphygmomanometers adequately, contrasting a prior study by Quinn et al., which showed that around 25 % of nurses' work hours were spent cleaning equipment.²¹ This highlights the need for healthcare institutions to implement proper protocols for disinfecting medical devices and train their staff on such practices continually.

The study revealed that many nurses lacked sufficient knowledge about preventing infections in burn patients, as most participants had inadequate knowledge. This may be due to a lack of regular in-service training courses in infection control. The results are consistent with a study conducted by Mohammadzadeh et al. in Iran, who showed inadequate understanding of infection control measures among healthcare workers.²² However, they contradict Joshi et al. research, which indicated that most of the study's participants (staff) had satisfactory knowledge of hospital-acquired infection prevention.²³ In addition, Holden et al. revealed that the overall level of core competencies of Nurses in Burn Departments was moderate.²³ These findings supported by Alwabr and Al-Salehi a study conducted in Yemen mentioned more than half 64.7 % of nurses had poor practices of standard infection control procedures.⁶

Our study shows the vast majority of unsatisfactory participants practice preventive measures in burn patients, while (9.8 %) of nurses practice preventive measures. These results are consistent with those of Bibi et al. who found that nurses' knowledge and practice improved greatly after an educational intervention and practical observation,¹ as well as Buksh et al. who found that nurses in burn units at three hospitals in Lahore, Punjab, had limited knowledge and practices for preventing infections in burn patients.³

The study also indicated that the nurses in the study area had insufficient knowledge and unsatisfactory practices regarding infection control in burn patients. Although they learned through practice, there is a necessity to develop in-service education programs to prepare nurses adequately to prevent infections.

The present results show there is a significant association between the level of nurses' knowledge regarding the prevention of infection in burn patients with age group and experience years of nurses (0.048, 0.047) respectively. The conclusion that nurses' practices did not have an adequate effect on years of age and experience may have resulted from the fact that nurses were not adequately trained in standard infection control precautions during their prior years of employment. This is because knowledge influenced years of age and experience, while nurses' practices did not have an adequate effect on years of age and experience.

This finding is supported by the study conducted by Mohammadzadeh et al. in Iran who reported a positive linear correlation was observed between knowledge and practice (p-value 0.01 correlation coefficient 0.173).²² Another study by Holden et al., found that there were significant differences in the average total scores of the Nurses in Burn Departments Core Competencies Self-Rating Scale (NBD-CCSS) based on factors such as age, experience in the burn department, educational level, length of employment, and professional title.²⁴ Another study in opposite by Gawad A. conducted in Yemen mentioned there is no link between knowledge and years of experience (P = 0.537), but there is a link between practices and years of experience (P = 0.047).⁹

Limitations

Our study has various limitations. First, the study depended on a “self-administration questionnaire”––that may be prone to reporting bias and may also be prone to recall bias because nurses are asked to recall events or experiences from the past. Second, Because of the small sample size, the fact that it was chosen from a single region, the low nurse-to-patient ratio, the fact that there is only one burn center, the lack of in-service training programs, the limited institutional resources, etc., these results cannot be broadly applied.

Figure 1.

Distribution of nurses according to Level of knowledge regarding prevention of infection in burn patients (n = 51).

Figure 1 shows the Level of nurses' knowledge regarding the prevention of infection in burn patients, the majority (88.2 %) of participants have inadequate knowledge followed by (11.8 %) of participants who have adequate knowledge.

Figure 2.

Distribution of nurses according to Level of practice regarding preventive measures of infection in burn patients (n = 51).

Figure 2 shows the Level of nurses' practice regarding preventive measures of infection in burn patients, the vast majority (90.2 %) of participants had inadequate practice preventive measures in burn patients, while (9.8 %) of participants had adequate practice preventive measures.

Conclusion

Based on the study's findings, we conclude more than three-quarters of participants had an inadequate level of knowledge regarding the prevention of infection in burn patients. The vast majority of nurses had unsatisfactory practices regarding preventive measures for infection in burn patients. There is a significant association between the level of nurse's knowledge regarding the prevention of infection in burn patients and the age group of nurses p. value of (0.048), There is a significant association between the level of nurse's knowledge regarding prevention of infection in burn patients and experience years (0.047).

Recommendations

• •For future research, an education program should be provided to update and refresh nursing knowledge and practices related to the care of burn patients.
• •We recommended that regular training courses be made mandatory on an annual basis, and the completion of such courses should be a requirement for yearly nursing registration in hospitals and burn centers by the continuing education unit in the hospital.
• •Additionally, an infection control manual should be available in burn units to ensure that all healthcare team members, particularly nurses, are familiar with its contents and follow up for application by the infection control unit and direct manager.

Disclosure

The author(s) report no conflicts of interest in this work.

Funding

No funding received.

Declaration of competing interest

None.