Improving Nurses Knowledge To Reduce Catheter-Related Bloodstrea
Improving Nurses Knowledge To Reduce Catheter-Related Bloodstrea
Improving Nurses Knowledge To Reduce Catheter-Related Bloodstrea
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Walden Dissertations and Doctoral Studies
2015
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Walden University
Mohammed Kadium
Review Committee
Dr. Andrea Jennings-Sanders, Committee Chairperson, Health Services Faculty
Dr. Karen Robson, Committee Member, Health Services Faculty
Dr. Jonas Nguh, University Reviewer, Health Services Faculty
Walden University
November 2015
Abstract
Hemodialysis Unit
by
Walden University
November 2015
Abstract
Central venous catheters (CVCs) are commonly used as vascular access for patients who
require hemodialysis. Infectious complications are a serious clinical problem, and they
are associated with high rates of morbidity and mortality, prolonged hospital stay, and
increased medical treatment costs. The purpose of theproject was to evaluate the
project question focused on the educational program derived from the evidence-based
guidelines recommended by the Centers for Disease Control and Prevention (CDC) to
improve registered dialysis nurses knowledge regarding CVC maintenance care. The
outcomes model. In this project, nurses considered a structural element and used a self-
study module to improve the process of providing CVC maintenance care. A paired-
samples ttest was conducted to compare knowledge scores of the participants in the
posttest (n = 56) and knowledge scores of participants in the pretest (n = 57). The ttest
was significantly higher for the posttest than scores for the pretest. The results suggested
hemodialysis unit, thus helping hemodialysis patients stay safer and possibly reducing
infectious complications.
Improving Nurses Knowledge to Reduce Catheter-Related Bloodstream Infection in
Hemodialysis Unit
by
Walden University
November 2015
Dedication
kids, AlZahra, Zainab, Kawther, Rahma, AlKadium, and Mesk, for their love and
willingness to support my passion for writing this paper. I am so grateful to have you by
dissertation chairperson, for your leadership, encouragement, and guidance. The sharing
of your expertise and excellent writing skills were very useful to me. I will be forever
grateful to you for the faithfulness you put forth to help me complete my dissertation and
Thank you to Dr. Nancy Moss for being a constant source of support and
members, Dr. Karen Robson, and Dr. Jonas Nguh, who have generously given their time
and expertise to better my dissertation, I thank them for their encouraging words, thoughtful
Thank you to Dr. Issa bin Salim Al Salmi for being my preceptor and teaching me
hemodialysis unit, for all your help in the planning and implementation of this project.
You were wonderful to work with, and this study would not have been possible if it had
not been for your significant contributions. I am greatly appreciative of all the registered
dialysis nurses who work in the hemodialysis unit for the excellent contribution and
Without the support of the following people, this study would not have been
completed. It is to them I owe my deepest gratitude: Mr. Abdallah Al- Rubaiey, Mr. Imad
Al Husami, Ms. Anna Brown, Dr. Manal Al-Zadjali, Dr. Fatima Makki, and Ms. Raia Al
Ibrawi.
I would also like to thank my family, my friends, and classmates for the support
they provided me through that long and hard journey, without whose love and
Introduction ....................................................................................................................1
Summary ......................................................................................................................11
Summary ......................................................................................................................24
i
Structure Component-Patient Characteristics ....................................................... 27
Self-Directed Learning.......................................................................................... 28
Instruments ...................................................................................................................36
Summary ......................................................................................................................52
Implications..................................................................................................................73
ii
Strengths ............................................................................................................... 76
Limitations ............................................................................................................ 77
Scholar .................................................................................................................. 78
Practitioner ............................................................................................................ 79
Project Developer.................................................................................................. 80
References ..........................................................................................................................83
Prevention ..............................................................................................................97
iii
List of Tables
Table 8. Descriptive Statistics Scores for Knowledge of Evidence-Based Practice for the
Table 10. Percentage of Correctly Answered Items for Multiple Choice Questions ........ 59
Table 13. A Paired-Samples tTest for Pretest Scores and Posttest Scores ....................... 64
Table 14. Pearson Correlations Between Demographic Variables and Knowledge Scores
........................................................................................................................................... 65
iv
List of Figures
v
1
Introduction
(CRBSIs). Complications associated with CVC use were known to increase patient
morbidity, mortality, medical treatment costs, and length of stay (Jeong et al., 2013).
Relatively little has been known about the costs and duration of stay associated with
Some studies provided estimates (OGrady et al., 2002; Pronovost et al., 2010;
Burden et al., 2012; Halton, Cook, Paterson, Safdar, & Graves, 2010). Many of these
studies came from other countries and, therefore, might not be generalizable to the Oman
population.
In general, the cost of CRBSIs in the hemodialysis unit was between $21,000 and
$24,000 (National Healthcare Safety Network [NHSN], 2013). The annual cost to the
health care system of CRBSIs in U.S. intensive care units (ICUs) was $296 million to
$2.3 billion (OGrady et al., 2002). National data from the U. S. Renal Data System
showed that hospitalizations for CRBSI among hemodialysis patients had increased 47%
hemodialysis patients died within 12 weeks of the infection. Eighty thousand CRBSIs
2
occurred in U.S. hospital ICUs nationwide, causing an estimated 28,000 deaths annually
The risk factors that helped in the occurrence of CRBSI included the type of
device, the insertion site, the adherence to preventive measures, and patient hygiene. Risk
factors also include the previous CRBSI, recent hospitalization, and the duration of
Staphylococcus aureus nasal carriage, and the immune-compromised host (Han, Liang, &
Marschall, 2010; Bisiwe, Van Rensburg, Barrett, Van Rooyen, &Van Vuuren, 2015).
increased nurses knowledge regarding the care of the patient with CVC, thereby
The Centers for Disease Control and Prevention (CDC) are published guidelines for
preventing CRBSI (CDC, 2011), which was the benchmark for all CVC care
recommendations.
personnel protection equipment (PPE), chlorhexidine for skin preparation, catheter site
dressing regimens, and the site chosen for catheter placement. Several studies had
validated these factors in reducing CRBSI (Kim, Holtom, & Vigen, 2011). This study
Problem Statement
CVCs are commonly used for vascular access in patients who required
hemodialysis. Using CVC was usually associated with bloodstream infections because of
skin breaks during insertion (OGrady et al., 2011). CRBSI contributed to hospitalization
Like many hospitals, the hemodialysis units had struggled with CRBSIs for many
years. The efforts to treat this problem focused on treating infection with antibiotics or
removing the catheter and replacing it with another one. A total of 148 bacteremic
episodes were recognized in 102 patients. The CRBSI rate was 0.52 per 1,000 patient
days. Of the 148 episodes, 28 were in patients with permanent tunneled central catheters
(1.03/1,000 patient days) and 67 were in those with a temporary catheter (3.18/1,000
patient days).
The CRBSI ratio was 4.85 with a permanent CVC (p < .001), and 14.88 with a
organisms were responsible for 96 episodes (65%); the infection was polymicrobial in 14
episodes (9.5%). During hospitalization, 18 patients (18%) died. Septic shock (p < .001)
The need for more innovative strategies to tackle this ongoing, complex problem
is a very critical issue. Significant attention was paid to CRBSI prevention; the priority of
the Ministry of Health in Oman (MoH) was to maintain patient safety and reduce
morbidity and mortality among patients. In the last few years, many attempts to stop
CRBSI were done in different regions of the world, but in Oman, a limited published data
The registered dialysis nurses were responsible for applying their knowledge to
Tanner, and Pierce (2005) found that not every nurse was skillful in database searching to
Further, professional literature was not available to the nurses in the workplace.
Also, the lack of time was regarded as a barrier to applying research to practice. Labeau
education programs might also result in a significant reduction in the cost of medical
treatment and patient morbidity if they are implemented on a mandatory basis (Warren et
al., 2004).The focus of this study was to educate registered dialysis nurses regarding
educating registered dialysis nurses regarding CVC maintenance care to reduce CRBSI in
The study was the first nurse-led intervention project to seek to improve clinical
practice in the hemodialysis units in Oman. It was important to assess the ability of
nurses to create positive change in the practice. The continuous advances in technology
increased the complexity of hemodialysis treatment and put patients at a higher risk for
CRBSI increased the likelihood of mortality, cost, and length of stay (Cooper et
al., 2014; Burden et al., 2012). Patients and families demanded evidence-based care to
reduce risks and complications. The findings of this study were significant to MoH,
education institutions.
6
The registered dialysis nurses are dependent knowledge workers, and education
plays a critical role in the quality of health care today. Improving nurses knowledge
results in nurses high self-efficacy when providing CVC maintenance care, and it is
The registered dialysis nurses with high self-efficacy structured the situation of
unique population, and their survival depending on the quality of hemodialysis treatment
and the responsibility of health care providers, particularly registered dialysis nurses.
Patients put high trust in registered dialysis nurses who provided high-quality of care, and
The financial costs impacted the quality of services. CRBSIs added a significant
burden and increased risk of positive patient outcomes (Al-Lawati, Mabry, &
Mohammed, 2008; Al Riyami et al., 2012). Prolonged hospitalization increased the costs
to the MoH, and the resulting financial burden could affect resource allocation within the
MoH, which operates on a finite budget. Cost containment and a reformed health care
Implementing and adhering to the CDC guidelines has helped reduce CRBSIs and
has potentially freed up resources. MoH in Oman is concerned with the health of the
population and provides universal coverage health services to the entire population. MoH
continuously assesses the system to look for the effectiveness and safety of the services.
Nursing sensitive indicators, such as the incidence rates of CRBSI, were measures
maintenance care to reduce CRBSI incidence rate helped to improve the outcomes of
hemodialysis patients.
risks included increased length of stay, the risk of long-term complications, and even
death. Systemic issues included increased expenses and the inability to meet quality and
Project Question
The project question was: Will the education program for 1 month, based on the
(SHEA/DSA) (2008), CDC (2011), and Agency for Healthcare Research and Quality
(AHRQ) (2013) provided guidelines for best practices regarding prevention and
monitoring CRBSI in hemodialysis units before, during, and after CVC care.Guidelines
were used to reduce the discrepancies in the delivery of care and to ensure it was high
quality and evidence-based care. Further, they provided a means by which registered
dialysis nurses could be held accountable for clinical activities (Vanholder et al., 2010).
8
The project could improve registered dialysis nurses knowledge regarding CVC
maintenance care. Registered dialysis nurses played a significant role in the hemodialysis
treatment; they contributed to the preventive, promotive and curative aspects of the
dialysis unit. The CVC maintenance care promoted when nurses used what they learned
for the hemodialysis units. The study provided evidence for conducting studies to
determine the rates of CRBSIs in hemodialysis units in Oman. The content of the
educational program in this study could be appropriate for nursing education in nursing
schools.
Participants in the study could be a role model and preceptors for other dialysis
nurses. The study had relevance for the educational programs in healthcare institutions.
The study could improve registered dialysis nurses knowledge regarding CVC
maintenance care that leaded to save lives, improve quality of care, result in better patient
outcomes, reduces CRBSI rates,improve satisfaction for the nurses, physicians, clients,
Definitions of Terms
For the purpose of this project, the following terms were defined below.
with an intravascular catheter with at least one positive blood culture obtained from a
hypotension), and no apparent source for the BSI except the catheter.One of the
quantitative (>103 CFU/catheter segment catheter) culture, whereby the same organism
(species and antibiogram) is isolated from the catheter segment and peripheral blood;
simultaneous quantitative blood cultures with a > 5:1 ratio CVC versus peripheral; or a
differential period of CVC culture versus peripheral blood culture positivity of >2 hours
Catheter care bundle: a structured way of improving the processes of care and
food, medications, blood or fluid. The steps are simple, common sense tasks: using
proper hygiene and sterile contact barriers; properly cleaning the patients skin; finding
the best vein possible for the IV; checking every day for infection; and removing or
changing the line only when needed (Institute for Healthcare Improvement, 2014, n. p.).
Central venous catheter (CVC): catheter inserted into a centrally located vein with
the tip residing in the vena cava; permits intermittent or continuous infusion and/or
access to the venous system. (Association for professionals in infection control and
Dialysis nurses: registered nurses who are working in the nephrology nursing
specialty, addressing the protection, promotion, and optimization of the health and well-
being of individuals with kidney disease. These goals are achieved through the
10
prevention and treatment of illness and injury and the alleviation of suffering through the
2011, p.1).
usually based on scientific evidence, to assist practitioners and patient decision making
about appropriate health care measures for specific clinical circumstances (Marquez,
2001, p. 5).
modeling and mentorship, intuition, reasoning, and research (Grove, Burns, & Gray,
2013, p.698).
Registered nurse (RN): a nurse who has graduated from an accredited school of
nursing and has been registered and licensed to practice by state authority (Medical
Self- directed learning:a process in which individuals take the initiative, with or
without the help of others, in diagnosing their learning needs, formulating learning goals,
appropriate learning strategies and evaluating learning outcomes (Knowles, 1975, p. 18).
The project faced some limitations because the duration of the study was
relatively short and small sample size. Participants learning styles did not assess. In pre
and post-intervention of this nonrandomized study, there was a possibility that changes in
the registered dialysis nurses knowledge might be due to the awareness that the outcome
was being measured. The study carried out in a single hemodialysis unit. The results did
not correlate with those from other groups with different populations and medical
policies. Therefore, the results were not generalizable to any other population other than
The study sample selected from the registered dialysis nurses who were working
in the largest hemodialysis unit in Oman. There were characteristics of this group that
differed both individually and significantly from dialysis nurses working in hemodialysis
Summary
CVC infection was among the most frequent healthcare-associated infections and
causes significant morbidity and mortality, as well as increased costs to the health care
system.The section highlighted the dilemma of CRBSI and presented its significance for
Through this project, registered dialysis nurses would better understand the need
literature review had performed before the project started to enhance the project methods
and provide a context within which to evaluate the results. A literature review presented
in Section 2.
13
interventions to reduce CRBSI in hemodialysis units. Also, the section highlights the
Search Methods
Literature was searched via the e-journals of the Walden University Library.
Databases included the Cumulative Index to Nursing and Allied Health Literature
articles were retrieved and examined by reviewing the abstracts. The keywords used in
the search included CVC infection, educational intervention, nurses knowledge, CRSBI
Inclusion and exclusion criteria were developed to define the eligibility of studies
to be included in the review. The search focused on selecting only studies that met the
inclusion criteria. The literature was excluded if it did not meet any one of the inclusion
criteria. 1The inclusion criteria included primary studies, text written in English, articles
with full text available, studies with participants who were adult patients with CVC
(aged 18 years and older), and articles on CVC infection and reported educational
Review of Literature
these studies was based on the inclusion and exclusion criteria, and 18 studies were
14
potentially eligible. The 18 studies fulfilled the selection criteria, and no relevant local
studies (studies that were concerned with the analysis and solving of CRBSI nationally or
regionally) were found.The following literature review consists of two sections: a general
Boonma et al. (2014) conducted a target surveillance study to reduce the rate of
CRBSI. The result indicated that CRBSI incidence rate in 2010 approached zero per
1,000 catheter days. The study demonstrated the contents of educational intervention and
method of education without indication of the duration and frequency of education. The
study suggested that all healthcare personnel must take responsibility for preventing
nosocomial infections.
review to estimate the additional costs and health benefits from introducing such
interventions and the costs associated with CRBSI. A comparison was made between
introducing an educational intervention with clinical practice and clinical practice without
the intervention. The result showed that the educational intervention to prevent CRBSI
study. The study was comprised three phases (preintervention [baseline], intervention,
collaborative of 37 adult non-ICU wards at six hospitals in the Rochester, New York,
area.
education of nursing staff, and standardization of best practices for CVC care and
hospital and tracked electronically. More than 90% of nursing staff on the surveyed units
The result indicated that the overall CRBSI rate for all participating units decreased from
compared with the preintervention period (p = .0179).The authors noted that engagement
resulted in a sustainable reduction in CRBSI rates outside the ICU in six diverse
hospitals.The sample size was large which may increase the statistical significant of the
data. The outcomes were clearly defined and the results of this study directly applicable
(HD) nurses practicing in Khartoum State. Nurses selected randomly from four HD
centers. The purpose of the study was to evaluate nurses awareness and practice of HD
access care in Khartoum state, focusing on the application of proper hand hygiene and
16
HD access care. Data collected between July and September 2010 in two stages. Nurses
gloves and HD access care. The result showed that females composed 72% of study
participants, and 85% were university graduates, and 50% of the participants had more
than two years experience in HD work. Structured training on HD access care received
by 56%. The participants reported that proper HD access care helped prevent access
infection, but only 54% indicated that it assisted in preserving access function. Nurses
with a bachelor degree tended to be more adherent to hand hygiene (72.5 versus 42.9%, p
= .1) and the use of gloves (100% versus 85.7%, p = .1) compared to nurses with a
diploma degree, but the difference was not statistically significant.The outcomes were
clearly defined, and the study suggested that HD units required organizing adequate
Chu, Adams, and Crawford (2013) conducted a project aimed to use a practice
development framework derived from New South Wales 2009. The study addressed an
appropriate and clearly focused question, and comparison of two consecutive 12 months
was done to assess the effects of the practice development framework. The result
indicated that rates of dialysis CRBSI have decreased from 4.39 per 100 patient-months
to 3.42 per 100 patient-months (p < .001) 12 months after the implementation of the
project. A statistically significant association existed between improved staff practice and
practice and CRBSI addressed adequately. The outcomes were clearly defined and the
results of this study directly applicable to the patient. Confidence intervals did not
provide.
Khanna et al. (2013) conducted a case-control study in the tertiary care hospital.
The number of participants in this study was 50 cases and 50 controls.The purpose of the
infections, and to determine the predisposing factors for the development of such
infections and antibiotic sensitivity pattern of the isolated organisms in tertiary care
hospital.The results indicated that the commonest premorbidity among the controls and
patients with CRBSI were a renal failure (36% versus 36.4%) while that among the
patients with local catheter infections was diabetes (28.2%).The study highlighted the
increasing rate of CRBSI and helped in the better management of patients as well as in
organisms.
between the levels of nurse-to-patient staffing, nurse work environment, nurse education
and inpatient mortality and failure to rescue across 665 adult acute care general hospitals.
The study addressed a clearly defined research question, and a comprehensive literature
search carried out. Descriptive statistics provided to show characteristics of the study
hospitals, and logistic regression models used to estimate the effects of nurse staffing,
18
nurse work environment, and nurse education on patient outcome. The result of this study
was directly applicable to the patient and indicated positive effect of increasing
percentages of BSN nurses was consistent across all hospitals, lowering the patient-to-
nurse ratios markedly improves patient outcomes in hospitals with healthy work
conditions. The study used appropriate methods to combine the individual research
findings.
provided an educational intervention for nurses. The purpose of the study was to evaluate
the long-term impact of bundled infection control practices on the reduction of CRBSI in
a tertiary care center in Thailand. The results recorded in the first period, 88 episodes of
CRBSI, and the CRBSI rate decreased by 54.1 %in the second period, and then 78% in
the third period. The study focused on conducting the educational course periodically,
and the components derived from CDCs Healthcare Infection Control Practices
Advisory Committees and WHOs hand hygiene guideline. The study supported the role
Guerin, Wagner, Rains, and Bessesen (2010) conducted surveillance for CRBSI
by trained infection preventionists using National Health Safety Network case definitions
and device-day measurement methods. The sample size was large; more than 1,000 and
post insertion care bundle on the incidence density for CRBSI. After the implementation
of the interventions, 3 CRBSIs were recognized in a total of 2825-days, and the incidence
density was 1.1 per 1000 catheter-days. The relative risk for a CRBSI occurred during the
19
postintervention period compared with the preintervention period was 0.19 (95%
confidence interval, 0.06 0.63; p = .004). In the study, the basic clinical characteristics
of the patients in both periods were similar. The surveillance methods described clearly.
The potential confounding factors of the observed relationship between catheter insertion
and infections addressed adequately, for example, nurse-to-patient ratio and some critical
of a CVC bundle in ICUs. An education program initiated by nursing staff and fellows in
the ICU about CVC bundle as well as their importance. The result indicated that
changing the CRBSI rate was better with the use of a CVC bundle that could improve
patient care while reducing hospital stays, costs, and possible mortality (p = .05). The
potential confounders explicitly addressed, for example, antibiotic use before the
infection.
to reduce the incidence of CRBSI in a medical-surgical ICU and two step-down units
(SDUs). The result of the study indicated that the mean incidence density of CRBSIper
1000 catheter-days in the SDUs was 4.1 in period one and 1.6 in the period two at p
=.005.In this study, the clinical characteristics of the patients in both settings were
similar. The intervention methods described clearly. The potential confounding factors of
an observed CRBSI addressed adequately, for example, nurse-to-patient ratio and some
critical steps of routine CVC care. The study suggested that reducing CRBSI rates in an
20
ICU setting was a complex process and required multiple interventions that could apply
to SDU settings.
in the U.S. state of Michigan. Intervention conceptual model used to develop clinicians
showed there was a significant decrease in incidence rate ratios of CRBSI 0.68 (95%
confidence interval 0.53 0.88) at 03 months to 0.38 (0.26 0.56) at 1618 months and
0.34 (0.24 0.48) at 3436 months post implementation. The potential confounders did
not address, for example, previous antibiotic therapy, and the sample size was large
pretest posttest design.The sample size for the study was 60 purposive sampling method
by the investigator. The purpose of the study was to assess the impact of structure
education on knowledge and practice regarding venous access device among nurses. The
study conducted in three phases. The result showed that the structured education was
useful in knowledge and practice of staff nurses regarding venous access device car. The
sample size was not large enough; only30 in the control group and 30 in the case group; a
small sample size may reduce the statistical significant of the data.
recommendations concerning the nursing care of the patient with CVC among staff
21
nurses working in ICU. The sample size was 50 staff nurses working in intensive critical
care units, coronary ICU, and cardiovascular ICU. The result showed that a significant
increase in the staff nurses knowledge scores after the self-instructional module. The
pretest mean score was 9.80%, and the average posttest score was 16.58% and the
difference between pretest and posttest knowledge scores was 6.78%. The study indicated
that the staff nurses in posttest were having an average of moderately 30% knowledge
and adequate 70% of knowledge regarding the nursing care of patients with a CVC.The
self-instructional module was useful in increasing the knowledge regarding the nursing
care of patients with CVC among staff nurses. The potential confounder addressed, for
example, the behavior changes and the compliance of personnel. The sample size was not
large enough; a small sample size may reduce the statistical significant of the data.
intervention in improving nurses knowledge regarding the care of patients with CVC
the study. The results indicated that there was a significant difference between the
preintervention and postintervention knowledge score (p = .039). The study showed that
about the care of the patient with CVC. Overall, mean knowledge score between
clearly defined and the results of this study directly applicable to the patient. Confidence
place from September to December 2008; the target population comprised health care
workers (HCW) who insert CVCs and responsible for CVC management. The purpose of
the study was to acquire information about the level of knowledge, attitudes, and
CVCs for the prevention of CRBSI. The anonymous self-administered instrument for
data collection included questions designed to capture information in the following areas:
(1) sociodemographic and practice characteristics, including queries about gender, age,
ward of activity, position, and total number of years of practice; (2) knowledge, attitudes,
and practice regarding evidence-based procedures associated with insertion and care of
CVC for the prevention of CRBSI; (3) formal education received by HCWs and principal
sources of information concerning CVC insertion, use, and care; (4) availability of
The result showed that correct answers about the knowledge of physicians and
nurses ranged from 43% to 72.9% and were significantly higher in respondents who
worked in ICU wards in hospitals that had a written policy about CVC maintenance and
had active formal training. The study illustrated that written policies, formal training, and
intervention study in surgical and emergency ICUs. The patients with CVC, health care
23
providers, working in ICU enrolled in the study and the study performed at three periods.
The results showed there was statistically significant improvement in physician practice
reduced CRBSI by 50% in ICUs during the period of the study. The patient
postintervention study during the period from February 2006 through August 2007 in 3
adult ICUs.The aims of the study were to analyze the effect of a single, evidence-based
frequencies and to assess the knowledge of standards for CRBSI prevention among
healthcare workers in a large teaching hospital. Researchers gave 30 lectures, covering all
shifts in all three ICUs. Six months after the educational intervention, 74 healthcare
workers completed the postintervention tests. The mean duration of work experience
among ICU staff was 8.9 years (95% CI, 7.810.1 years) for nurses and 8.1 years (95%
CI, 5.310.8 years) for physicians. The results showed that the overall incidence of
CRBSI in all 3 ICUs was significantly lower during the post-intervention period: 34
CRBSI episodes diagnosed during 11,582 CVC-days (2.94 episodes per 1,000 CVC-
days) after the intervention.The outcomes were clearly defined and the results of this
Summary
There had been a great deal of studies on CRBSI prevention, but the majority of
them focused on the ICU setting and very limited on hemodialysis setting. Studies
demonstrated many prevention strategies for CRBSI prevention particularly at the time of
catheter insertion. Although, these strategies; the incidence rates were very high
Studies reported critical interventions to reduce CRBSI, and the central theme was
barriers. Most of the studies had their research purpose or objective clearly stated, and
some of them aimed to examine the effects of the intervention for preventing CRBSI.
Outcome measures were entirely consistent with the reviewed studies. Studies provided
provided training modules to develop the required skills for health workers.
For CRBSI reduce, it was necessary to look at the evidence to support equipment
that could leverage success with other efforts in infection prevention such as
greater part of the studies proposed that the educational intervention could improve or
In all of the studies reviewed, preintervention data about the CVC maintenance
care considered acceptable for the time leading up to the educational intervention. One
could no longer at once accept the practice as usual for CRBSI prevention. Based on the
25
evidence, there understood about any intervention to prevent CRBSI was better than no
intervention at all. The individual studies and evidence-based guidelines may serve as a
guide, and the responsibility of dialysis nurses was to implement these guidelines
successfully to reduce CRBSI to improve safety and quality for CVC dependent patients.
In conclusion, this section had reviewed the evidence regarding CRBSI reducing
and had identified the gaps in the literature. A project designed to address the disparities
in the literature and to build on the work of the previous studies. A lack was in the
directed at ICU doctors and nurses on the theoretical knowledge of prevention of CVC-
related infections.
Theoretical Framework
The conceptual framework for this project based on Donabedians model (Figure
1). The components of the model were structure, process, and outcome. Donabedian
(1997) explained that the structure denoted the attributes of the settings in which care
occurs. This included the characteristics of material resources (facilities, equipment, and
funds), human resources (medical staff and qualifications of dialysis nurses), and
The process was defined as the actual action in providing care. It included a
The evidence supported the linking between nursing care (process) and patient
outcomes (Duffy & Hoskins, 2002, Deshmukh & Shinde, 2014). The inference was that
the three-part approach to quality assessment was possible only because significant
structure increases the likelihood of proper process, and the right process increases the
In this project proposal, nurses were regarded a structural elements and used a
infection. It was important to identify the literature that supported the particular
providing the CVC maintenance care. The structural component of Donabedians model
characteristics.
that dialysis nurses provided; in this project, it included the CVC maintenance care.
Outcomes were the effects or results of the health care process (Duffy & Hoskins, 2003).
In this project, the data collected about nurse characteristics include age, gender,
education, years of experience, infection control training, and hours worked. Then the
health outcomes. The specific features included nurse education and years of experience.
An increase in the percentage of nurses with higher educational degrees decreased the
risk of mortality and failure to rescue (Aiken, Clarke, Sloane, & Silber, 2003). Aiken et
al. (2003) found each 10% increase in the proportion of nurses with higher degrees
suggesting nursing units with more experienced nurses provide higher-quality care
(Blegen, Vaughn & Goode, 2001). The quality of nurse communication was higher on
units where nurses had a higher level of education (Doran, Sidani, Keatings, & Doidge,
2002).
The literature identified numerous risk factors that associated with increasing
patients risks of CRBSI. In an article published the most common risk factors that
skin, and presence of distant infection recently (Shah, Bosch, Thompson, & Hellinger,
2013).
practices that registered dialysis nurses offered (Duffy & Hoskins, 2003). The project
28
focused on the effect of the CVC maintenance care on patient outcomes. A catheter care
The bundle contained the five elements of evidencebased guidelines for CRBSI
prevention: hand hygiene, use of maximum sterile barriers with catheter maintenance, use
of chlorhexidine for skin preparation, avoiding use of the femoral and jugular sites for
Self-Directed Learning
Self-directed learning (SDL) was an essential skill for nurses to meet the
challenges in today's healthcare environment. In SDL, learners took the initiative and
responsibility in using learning resources (Ramnarayan and Hande, 2005). The aim of
SDL was to develop the skills and acquire new knowledge. The concept supported the
intervention of the project that in turn helped the process that defined by Donabedians
framework.
In the conclusion, this section reviewed the existing literature on research related
maintenance care in a hemodialysis unit. Also, the section discussed the conceptual
structural, process and outcomes presented and served as a basis for the development of
outcomes. In this project, nurses were considered as a structural component, and the
registered dialysis nurses knowledge. The method used to carry out the project
prescribed in Section 3.
30
Section 3: Methodology
outcome in a natural setting (Grove, Burns, & Gray, 2013). The purpose of the
educational intervention was to improve the knowledge of the registered dialysis nurses
regarding CVC maintenance care. I contacted the nurse manager of the hemodialysis unit
to discuss the recruitment of the registered dialysis nurses who met the inclusion criteria.
The manager introduced me to the staff working in the hemodialysis unit, and I
verbally announced in the hemodialysis unit inviting all registered dialysis nurses for
I provided verbal information about the significance and the purpose of the study,
and I explained what the subject would be asked to do,the time commitment needed, the
name and address of the investigator, the setting of the project, and the name of the
person to contact for further information. I did not have any influence on the employment
of the participants, and they had their nursing manager for supervisory functions. No
element or hint of coercion existed. It was a meeting for only providing information and
clarifications.
The plan for implementing the educational intervention was shared with the
hemodialysis unit and a signed approval was obtained on September 15, 2014 (Appendix
E). The hemodialysis unit provided excellent support to facilitate the implementation of
31
development nurse, a statistic nurse, and the medical director of the hemodialysis unit
was provided for administrative assistance to the investigator during the period of the
study. The educational program was implemented after obtaining the approval of the
Institutional Review Board (IRB) at Walden University. The study conducted in three
phases.
the conference room. The conversation encompassed information regarding the study
for the investigator, and knowledge that participation was voluntary. Following the
Each participant was given an envelope with the information letter and a
demographic sheet. The information letter informed the participants that the proposed
study had approved by the Walden Universitys IRB. The IRB was responsible for
ensuring that all Walden University research complied with the universitys ethical
standards.
IRB approval was obtained before collection of any data. Walden University did
not accept responsibility for research conducted without the IRBs approval. Also, the
university did not grant credit for any student work that failed to comply with the policies
The study participants were asked to read and sign the informed consent form. No
time limitation for completing the demographic sheet; however, 5 minutes was a
sufficient amount of time for completion. Each participant was instructed to put their
study number on the demographic sheet and to return it, sealed in the envelope provided,
whether or not the questionnaire was completed. This process allowed participants to
The envelopes were placed in a collection box and kept in a locked cabinet in my
office in a more secure and confidential location because the investigator was the only the
person who knew the details of the office and can access it easily.
shared in the scheduling of the pretest, the educational intervention, and posttest to
minimize scheduling difficulties. The pretest session was held at the conference room in a
hemodialysis unit, and 57 participants completed the survey. The participants allowed 30
minutes of their working hours; their patients and other duties were assigned to other staff
while they were taking the test. The test time was organized by the manager of the
dialysis unit in collaboration with the investigator. I distributed the questionnaires to the
study participants.
I collected all the envelopes, placed them in a collection box, and kept them a
locked cabinet separately from the completed demographic sheets in the investigators
office. I performed the task of the test grading to avoid placing the data at risk
particularly the confidentiality. The test grading was manual. The quantitative data coded,
33
entered, and analyzed using IBM SPSS Statistics for Windows (Version 20.0. Armonk,
distributed. The duration of this stage was 30 days to allow participants sufficient time
for completing the self-study module. The education program consisted of a one-hour
The learning objective was to improve registered dialysis nurses knowledge regarding
subheadings from the CDC evidence-based clinical practice guidelines to prevent CRBSI:
Introduction.
Sources of CRBSIs.
Pathogenesis.
Prevention of CRBSI.
34
o Hand hygiene.
o Chlorhexidine.
o Subclavian vein.
o Hub/clave.
o Dressing changes.
o Line necessity.
CRBSI criteria.
The hemodialysis unit oversaw the quality of the lecture content. Views and
opinions expressed were those of the investigator and did not necessarily represent the
views and policies of the hemodialysis unit. I did not disclose any conflicts of interest
one month following the pretest phase with the 56 completed surveys (N = 56). The
allocated time of the test was 30 minutes. The participants allowed 30 minutes of their
working hours; their patients and other duties assigned to other staff while they were
I distributed the post-test questionnaire. For the posttest, each participant was
given an envelope containing the survey. The questionnaire was identical to the pretest.
Each participant asked to return the questionnaire to the investigator sealed in the
provided envelope, whether they completed the survey or not. The participants instructed
to use same study number on the posttest questionnaire. I collected the completed
questionnaires, graded each test manually, and stored in a locked cabinet separately. The
quantitative data coded, entered, and analyzed using IBM SPSS Statistics for Windows
Topics that covered in the pretest, posttest, and self-study module included (a) the
epidemiology of CRBSI, (b) aseptic technique; the use of maximal barrier precautions
during CVC maintenance care, (c) the need to avoid femoral insertion sites, (d) proper
technique for obtaining blood cultures, and (e) guidelines for changing dressing. The
investigator developed the self-study module and reviewed by the medical director of the
hemodialysis unit.
The self-study module discussed the necessary knowledge that was needed for a
competent registered dialysis nurse when working with CVCs. The module covered the
most common types of CVCs short-term and long-term. The emphasis was undertaken
signs and symptoms, CRBSI definition according to CDC/ NHSN surveillance definition,
potential routes of infection, modifiable risk factors for CRBSI, and CRBSI prevention
grouping of best practices that individually improve care and when applied together
36
results in greater improvement. Every component of the bundle was essential and
indispensable. The CRBSI bundle consisted of five essential elements: (a) hand
hygiene;(b) maximal sterile barrier precautions including large sterile drape, sterile gown
and gloves, mask, and a cap;(c) selection of optimal catheter insertion site with avoidance
of the femoral vein for access in adults; (d)chlorhexidine skin antisepsis; and (e) daily
registered dialysis nurses in the hemodialysis unit utilized. The expected outcome of this
educational intervention was improving the knowledge about CVC maintenance care.
posttest after completing a self- study module. There was a 25-question posttest of
knowledge regarding CVC maintenance care (Appendix A). There was seven question
demographic questionnaires.
gender, the level of education, years of experience, infection control training, and the
amount of hours the nurse works. The participant filled out the demographic sheet before
Instruments
correct answer carried one score; the total scores were 25. The level of knowledge score
converted into a percentage, and overall adequacy of knowledge graded according to the
following criteria: if the score was > 75%: high level of knowledge, if the score was 50%
37
to 75%: moderate level of knowledge, and if the score was < 50%: inadequate level of
knowledge.
The reliability of test scores estimated from a single administration of a test using
Kuder-Richardson Formula 20 (KR20). The experts assessed the content and face
The reliability of test scores estimated from participants responses to the items on
the pretest. Kuder-Richardson Formula 20 (KR20) and Cronbachs coefficient alpha used
1 showed the descriptive statistics for Cronbachs alpha. In this statistical method, the
variance for each item and the variance for the total scores computed.
Table 1
All the items in the questionnaire scored1 if the answer was right and 0 if the
answer was wrong or missed. The reliability coefficient should be greater than .70
(Grove, Burns, & Gray, 2013; Polit and Beck, 2010). The result showed a positive
because the investigator designed the tool; it had not tested previously. Grove, Burns, &
Gray (2013) reported the new instruments might have internal reliability from 0.60 to
0.69 (p. 392). Table 2 presented the Cronbachs alpha for the 25-items of the
knowledge-based questionnaire.
and 24 with the overall test is .141, .071, .013,.087, and .064, while all other items
correlate at .63 or better. By considering the alpha if deleted, the reliability of the scale
(alpha) would increase to .759 if these items removed (Polit, 2010). Thus, the overall
Table 2
(table continues)
40
Expert Validation
Test for face and content validity was important to appreciate whether the
relevance and clarity of items covered the material that it supposed to measure. Before
conducting the intervention, the self-study module and questionnaire handed to a team of
three experts for face and content validation. Each expert had at least ten years of
The experts together decided to employ Content Validity Index (CVI) to calculate
the validity score for the questionnaire and self-study module. The CVI developed to
obtain a numerical value that reflects the level of content-related validity evidence for a
measurement method (Grove, Burns, & Gray, 2013). Consistent with the experts desire,
the investigator designed an evaluation form about relevance and clarity and emailed it to
the experts for calculating the CVI. Each expert rated each item independently.
To achieve face validity, experts asked if all questions clearly worded and would
not be misinterpreted.For the nursing relevance of all items, the experts marked an X to
the most appropriate score, 1 = not relevant; 2 = appropriate but not necessary, and 3 =
necessary.
The experts decided to sum only the items scored 3 the percentage of agreement
with all items. The CVI for the instrument was the percentage of the total items rated as a
three (Zamanzadeh et al., 2014; Yaghmale, F., 2009). However, an acceptable level of
experts agreement value greater than or equal to 0.80 (Zamanzadeh et al., 2014), the
computed CVI achieved 0.88. It was higher than the minimum CVI of 0.80.This result
42
ascertained the content of the questionnaire was appropriate and relevant to the study
Item Analysis
The results of the participants accomplishment in the pretest utilized to assess the
quality of the items through measuring the difficulty index and discrimination index of
each multiple choice questions and True/False questions. The item difficulty index
calculated as the percentage of participants that correctly answered the item (Sabri, 3013;
Oluseyi et al., 2012; Instructional Assessment Resources, 2011; Labeau et al., 2010;
Mitra et al., 2009). It calculated using the formula P = R/T, where P was the item
difficulty index; R was the number of participants who got an item correctly, and T was
the total number of who answered it (Instructional Assessment Resources, 2011; Labeau
et al., 2010).
The item considered difficult when the difficulty index value was below 0.20, and
the item found to be easy when the index value was above 0.90 (Instructional Assessment
Resources, 2011).The item discrimination index measures the power of test item to
distinguish between participants who were knowledgeable and those who were not. The
Assessment Resources, 2011; Sabri, 3013; and Grove, Burns, & Gray, 2013).
(Grove, Burns, & Gray, 2013) computed to determine the relationship between
participants performance on each item and their overall test scores. The Statistical
Package for the Social Sciences (SPSS) version 20 utilized to compute the discrimination
43
coefficient, the Pearson, r for each item. The Pearson, r coefficient ranges from 1.00 to
discriminating item revealed that participants with high score got the item right, and
In general, values for the item, the difficulty was moderate with values ranging
between 0.39 and 0.72. Values indicating the quality of the response alternatives ranged
from 0 to 16, thus demonstrating an overall good quality. Sixty-four percent of the items
showed to discriminate adequately between low scores and high scores in a good to very
good way. Table 3 provided the results obtained from the analysis of the item difficulty
The experts conducted the analysis process and unanimously declared the
outcomes of the content and clarity. The investigators responsibility was to ensure that
data analysis was suitably treated e.g. anonymized and in a format suitable for sharing.
demographic data of the participants, which included age, gender, level of education,
years of experience, infection control training, and the amount of hours the nurse
Table 3
Items
A B C D E F
(table continues)
45
A B C D E F
(table continues)
46
A B C D E F
Data Collection
The plan for collecting data included the procedures to collect data, the required
time, and the cost. Then data collection forms developed to facilitate data entry. Also, the
database.Moreover, the Institutional Review Board (IRB) approval secured prior to any
data collection. Prior data collection, the demographic data sheet designed to record the
demographic data. The data collected in raw form at the time of collection and then
coded.
Coding was the process of transforming data into numerical symbols that entered
quickly into the computer. The codebook developed before initiating data collection. The
codebook identified and defined each variable in the study. Variable gender categorized
and gave numerical labels; the male identified by a 1 and the female category by a 2.
for Nephrology NursingDiploma and a 3 for BSN. Variable infection control training
course categorized and gave numerical labels, Yes category identified by a 1 and No
category identified by a 2.
A master list of participants and their code numbers developed and stored in a
separate location and encrypted in an electronic file as well as they locked in a file drawer
to ensure the participants privacy.The investigator handled coding the data. The data
collection forms and questionnaire put together in a booklet to minimize the likelihood
All the data from a single participant kept together until analysis initiation. The
Participants study number wrote on each form, and the forms checked to ensure that they
present. Furthermore, the database backed up and stored on an encrypted flash drive to
avoid loss of all data due to the computer crashing. The study completed on the
The timeline for the educational intervention described in Table 4. The schedule
involved the conducting of the pre, posttest data, and collecting participantsdemographic
data. The practical and operational responsibility for study data throughout the life cycle
of the project was in the hands of the investigator. The investigator held the responsibility
of distributing the pre/ post instruments to ensure the data management plan had
Table 4
April 9 April 14 I contacted the nurse manager of hemodialysis unit to discuss the
recruitment of the registered dialysis nurses who met the
inclusion criteria. The manager introduced me to the staff
working in the hemodialysis unit, and I verbally announced in the
hemodialysis unit invited all the registered dialysis nurses for
voluntary participation in the current study. I communicated
privately with participants at convenient times in the dialysis unit.
I provided verbal information about the significance and the
purpose of the study, explained what the subject would be asked
to do, the time commitment, name and address of the investigator,
setting of the project, and the name of the person to contact for
further information
April 16May 15 Delivered the educational lecture for one- hour, and distributing
the self-study module, the duration of this phase was 30-days to
allow participants sufficient time for completing the self-study
module.
Data Analysis
identify the predicted relationships between the nurses knowledge of the evidence-based
education, infection control training). The ttests conducted to analyze the pretest and
posttest results of the 25- questionnaire of knowledge regarding CVC maintenance care at
p <.05% by using IBM SPSS Statistics for Windows (Version 20.0. Armonk, New York:
IBM Corp).
Review Board as well as the Research and Ethical Review & Approve Committee
(RERAC) Directorate of Research and Studies in the MoH in the Sultanate of Oman.The
preparation via Walden University completed regarding protecting human subjects in the
study.
obtained. The informed consent form contains all relevant material, including purpose,
confidentiality, and any contact information. Collected data coded with numbers one to
60 for nurses and entered without any verifying information into a computerized database
The consent forms kept in a locked file cabinet. Prior to implementing the
intervention, permission from RERAC was obtained, and approval from the IRB at
51
Appendix F.
The evaluation was a systematic investigation of the value and significance of the
project. It facilitated recognizing the progress and effectiveness of the project. The
purpose of the evaluation plan was to provide information for actions such as educational
entire picture of the project, including insight into the relationships between educational
Project evaluation assessed all the activities that were designed to achieve the
comparing the pre-test and posttest dialysis nurses knowledge scores about CVC
maintenance care. Feedback was a critical part of the evaluation process to ensure that the
results of evaluations were used for the program expansion and sustaining.
For this reason, feedback mechanisms established, for instance, seminars and
workshops, and follow-up procedures of CVC maintenance care. Informal means such as
Summary
nurses were surveyed prospectively for knowledge regarding CVC maintenance care.
The program consisted of a 25-page self-study module on risk factors and practice
Each participant was required to complete a pretest before reviewing the study module
and an identical test after completion of the study module. The posttest occurred
Summary of Findings
central concepts and findings arising from the present study. The target population of the
study was registered dialysis nurses who employed full-time in the hemodialysis unit and
provided CVC care daily between April and May 2015. For the purpose of the study, the
population included only registered dialysis nurses who completed both the pretest and
the posttest.
from the population surveyed, almost all participants, 93% were women, and 7% were
men. The study participants asked to provide their age. As displayed in Table 5, the
reported years of age ranged from 2350 years. Using the study year (2015) and the mean
(SD) age of participants estimated at (M = 30.75 years, SD = 7.27) for the entire sample,
(M = 33 years, SD = 6.58) for the men, and (M = 30.58 years, SD = 7.35) for the women.
demonstrated that the most predominant level of education was Basic Diploma in general
nursing. The distribution of education level was Basic Diploma in general nursing (n =
36, 63.2%), specialized nephrology nursing diploma (n = 19, 33.3%), and BSN (n =
3.5%).
54
Table 5
Sex
Men 4 7
Women 53 93
Age
22 -27years 18 31.6
28 - 32 years 15 26.3
BScN 2 3.5
1 -5 years 20 35.1
6- 10 years 22 38.6
Yes 22 38.6
No 35 61.4
55
registered dialysis nurse showed in Table 5. It explained that a large portion of the
participants 35.1% had less than five years of dialysis nursing experience.
They completed their Basic Diploma in general nursing recently without having
the sufficient experience of caring for patients depend on CVC. They were only Nursing
Diploma holders, and they did not prepare to deliver hemodialysis care. Additionally, it
revealed that only 26.3% of participants had greater than 10 years experience in
hemodialysis nursing. This was a significant feature of the study participants, but that
differences between measures of two samples. The ttest analysis techniques exist for
dependent and independent groups (Grove, Burns, & Gray, 2013; Polit, 2010). A one-
sample ttest run to determine whether the male nurses years of experience was different
Men (M = 9.25 years, SD = 6.45) was longer than women (M = 7.41 years, SD =
5.43), a statistically significant difference of 1.84 (95% CI, 5.85 to 9.23), t(56) = 8.95, p
= < .001. However, the number of work experience as a registered dialysis nurse for the
entire sample was (M = 7.54, SD = 6.36) did not significantly differ from men and
Table 6
N Minimum Maximum M SD
Hemodialysis unit used to conduct infection control course for a short period 1-3
days from time to time to prepare the registered dialysis nurses to prevent and monitor
the spread of infection. The content of the course covered using the current knowledge of
the chain of infection, standard precautions, and transmission-based precautions and work
practice controls.The registered dialysis nurses who completed the course earned a
certificate of completion for this continuous education (CE) activity. The information
provided in that course used for educational purposes only. It did not intend as a
The participants asked to indicate if they had ever received formal or informal
training in infection control. Table 7 presented the analysis of this data. The participants
reported only 22(38.6%) took infection control training course. A small proportion of
participants with a Basic Diploma (n = 9, 25%) indicated they took infection control
Table 7
yes No
BSN 2 0 2
Total 22 35 57
The analysis performed to determine the results of the registered dialysis nurses
conducted into two phases, pretest, and posttest. The pretest scores ranged from 36 68
(M = 52.17, SD = 9.36). (See Table 8). It determined that 46% of participants in this
study rated their knowledge as being inadequate, with 54% rating their knowledge as a
moderate level of knowledge. Table 9 showed none of the participants rated their level of
knowledge as high.
58
Table 8
Descriptive Statistics Scores for Knowledge of Evidence-Based Practice for the CVC
Pretest 57 36 68 32 52.17 9. 63
Table 9
Participants Knowledge Level on the Pretest
Level of Knowledge n%
Total 100%
59
The survey consisted of nine multiple-choice questions with three to five possible
answers to each question. The participants instructed to choose the answer that they
believed to be the correct response to each question. The questions related to various
Table 10 showed the distribution of percentage scores for each item. These
this study population. These items achieved the lowest overall percentage scores from the
knowledge deficit.
Table 10
Q4 36.8%
Q5 50.9%
Q6 35.1%
Q8 61.1%
Q9 47.4%
Q 11 50.9%
Q 14 57.9%
Q 15 35.1%
Q 18 31.6%
60
There were 16 true or false statements; each participant put a circle on the answer
that they believed was the correct response for each item. Table 11 presented a
breakdown of the percentage of correct scores for each of the individual 16 items in the
survey. The analysis discovered that only one of the 16 items received an unsatisfactory
answer rate of 42.1%. As shown in Table 11, it observed that 15 items were a correct
percentage score of 51% and above. These questions revealed a moderate level of
Table 11
QI 61.4%
Q2 61.4%
Q3 65%
Q7 58%
Q 10 63.2%
Q 12 63.2%
Q 13 61.4%
Q 16 66.7%
Q 17 65%
Q 19 58%
Q 20 51%
Q 21 70.2%
Q 22 70.2%
Q 23 68.4%
Q24 68.4%
Q 25 42.1%
62
differences among two or more groups by comparing the variability between the groups
with the variability within the group (Grove, Burns, & Gray, 2013; Polit, 2010). A one-
completion of infection control course, and years of experience on the pretest scores.
the pretest scores at the p < .05 level F(1, 55) = 9.10, p = .04. Also, there was a
significant effect of years of experience as a registered nurse on the pretest score at the p
< .05 level F(2, 54) = 3.47, p = .038. There was no significant effect of level of education
on the pretest scores at the p < .05 level F(2 54) = 1.82, p = .173. Overall, these results
suggest that high levels of education do not have an effect on the pretest.
The posttest scores ranged from 44 80 (M = 60.85, SD = 9.04). (See Table 8). It
determined that the majority of the participants in the study (78.6%) rated their
knowledge as good, with 7.1% rating their knowledge as excellent, and 14.3% rating
Table 12
Participants Knowledge Level on the Posttest
Level of knowledge n%
Total 100%
A paired-samples ttest is a statistical test used for comparing group means when
people in the groups being compared are same or are paired (Grove, Burns, & Gray,
2013; Polit, 2010). A paired-samples ttest conducted to compare knowledge scores in the
pretest and posttest t(55) = 4.46, p < .001. A paired-samples ttest indicated that scores
were significantly higher for the posttest (M = 60.85, SD = 9.04) than for the pretest (M =
registered dialysis nurses knowledge followed the educational intervention. (See Table
13).
64
Table 13
Paired differences
95% Confidence
interval of the
difference
Sig. (2-
M SD SEM Lower Upper t df tailed)
Pretest -
8.61 14.44 1.92 12.47 4.74 4.46 55 .000
posttest
relationship between the demographic variables and knowledge scores on the pretest.
There was insignificant correlation r(57) = .14, (p = .31) between age and the total
years of experience and the pretest scores r(57) = .15, p = .28. The level of education
variable and the pretest scores was existed, Pearson Correlation r(57) = .38, p < .001.
knowledge scores.
65
Table 14
In summary, the section introduced the findings in the analysis of data collected
from the current study undertaken in a hemodialysis unit. The results and conclusions
from the present study formed a basis for future research initiatives. The study revealed
subject of CVC maintenance care. The reasons for the knowledge deficit discussed the
next part. Also, the next part highlighted the limitations of the study, recommendations
Model (1997). The purpose of a theoretical framework was to guide the research process
through an explanation of the relationships between study variables (Wood & Ross-Kerr,
regarding CVC maintenance care, and hence improved outcome by reducing CRSBI.
nurse education and years of experience. Nurses experience was associated with fewer
patient deaths (Tourangeau et al., 2002). Nursing units with more experienced nurses had
lower medication error rates and lower fall rates (Blegen, Vaughn & Goode, 2001).
between them and the registered dialysis nurses knowledge score on CVC maintenance
care. The study clarified some process and structural deficiencies within hemodialysis
completed the pretest, and 56 registered dialysis nurses completed the posttest. The
67
survey reflected a high response rate because the participants believed if they shared in
the survey, they gained a better understanding of the practices, and updating of their
knowledge regarding CVC care could occur. Also, the discussion regarding CRBSIs
produced in the hemodialysis unit and manager encouraged registered dialysis nurses to
participate in improving the quality of care that provided to patients with CVCs in their
unit.
The proportion of male participants in the study was (7%), which was comparable
to the (16.67%) reported by Deshmukh and Shinde (2014), and 33.8 reported by Bianco
et al. (2013). According to the Annual Health Report 2013 of the MoH in Oman, the
predicted, the educational intervention considerably improved the knowledge level of the
CRBSI in a hemodialysis unit. The scores in the posttest were overall better than the
scores of the pretest. The results of the pretest revealed that the majority of the
maintenance care.
The reasons might be due to the background of the participants. A greater part of
(61.4%) did not train in the infection control training course because the authority
68
provided a limited number of places. The curriculum in both basic diploma and a
control.
The focus on evidence-based practice and knowledge regarding CVC care and
prevention included in nursing programs would be one factor for lower knowledge in this
The findings were congruent with the conclusions of the previous studies that
showed nurses knowledge influenced by professional education and training (Uba et al.,
2015; Deshmukh and Shinde, 2014; Pushpakala and Ravinath, 2014; Bianco et al., 2013;
Shrestha, 2013; and Meherali, Parpio, Ali, & Javed, 2011). Another study found that
knowledge could acquire through basic and continuing education, training, personal
experience, or in-service training (Bianco et al., 2013; Parra et al., 2010; Evens &
Donnelly, 2006). In contrast, a previous study showed that the training program did not
make any significant difference in the knowledge level of study groups (Benneth &
Weale, 1997).
nephrology diploma prepared, and only 3.5% of the study participants obtained a
baccalaureate degree. The first baccalaureate nursing program began on 2008 with very
limited numbers (Sultan Qaboos University, 2012). The opportunities for higher
education in nursing as the concepts of BScN and MScN are unfamiliar to the most of the
69
hemodialysis units. The baccalaureate degree in nursing was not the requirement for
The previous studies found that the increase in the proportion of nurses with
higher educational degrees decreased the risk of mortality and failure to rescue (Aiken,
Clarke, Sloane, & Silber, 2003; Tourangeau, Cranley & Jeffs, 2006). Aiken et al. (2003)
found each 10% increase in the proportion of nurse with higher degrees decreased the
risk of mortality and failure to rescue by 5% after controlling for patient and hospital
characteristics.
The results indicated that participants scored poorly in some critical areas, like
risk factors associated with the development of CRBSI, lack of knowledge regarding the
best method for CVC maintenance care. Only 28 participants (49.1%) correctly answered
that mask should be worn for all CVC dressing changes before the dressing is removed.
About 24 participants (42.1%) understood actions that decrease the risk of CRBSIs.
(as opposed to Povidone-iodine) associated with reduced CRBSIs rates. Only 24 of the
participants (45.6%) identified the correct time to change the transparent dressing. Only
22 of the participants (38.6%) identified the action for oozing in the CVC insertion site.
These answers indicated that participants lacked knowledge in these areas. The current
study found that participants trained to perform task-oriented nursing care rather than
feelings rather than science.The results of the current study implied that CVC
maintenance care was clinical knowledge that cannot obtain without an entire
critical thinkers if they did not have the current knowledge related to their specialty area.
The driver of their clinical decision-making was either policy and procedure or habits and
routines.
Approximately (26.3%) of the participants reported had more than ten years of
work experience. The previous undergraduate nursing education curriculum did not
experienced nurses might be less aware of the evidenced-based practice and had the low-
test scores due to the unavailability of formal, specialized training and updating courses
in a hemodialysis unit.
On the other hand, this group of participants overwhelmed by the personal affairs,
and they appeared to lose their insight into nursing knowledge slowly. Furthermore, they
acquired their knowledge of taking care of hemodialysis patients from their basic
educational programs, or from hemodialysis unit policies and procedures. They did not
The low level of nurses knowledge was due to the lack integration of learned
concepts in the clinical setting. This problem of theory-practice gap or lack of clinical
integration was not a new issue nor did it only exist in this hemodialysis unit. Moreover,
the participants were coming from different types of nursing school curricula, the various
71
In such case, the clinical education with effective mentoring was imperative
35.1%of the participants completed their diploma recently and did not have any
experience of caring for hemodialysis patient with CVC. It was critical that new nurses
be provided supervision and role models within the clinical settings to help them
integrate the learned concepts into real patients care. They also need to be prepared
The analysis showed a significant difference in the nurses knowledge before and
after the educational intervention. The positive change in the nurses knowledge after
educational intervention reflected that education could create change in knowledge level.
Other studies (Pushpakala and Ravinath, 2014; Deshmukh and Shinde, 2014; Shrestha,
knowledge of participants.
Also, the findings of the current study were consistent with other studies. Chu,
Adams, and Crawford (2013)demonstrated that dialysis CRBSI was a common, yet
preventable complication in the dialysis unit and dialysis nurses play a significant role in
preventing dialysis CRBSIs. Basic infection control standards were paramount and
should strictly follow for effective CVC care. The results also suggested that training for
registered dialysis nurses was essential for reducing CRBSI rates using education-based
intervention.
72
attitudes toward CRBSI prevention (Bianco et al., 2013). Several other studies also
savings and reduction in the rate of CRBSI (Cooper et al., 2014; Kim et al., 2011).
Bruno, Ongaro, and Fraser (2007) described the principles of knowledge retention
and found that knowledge retention fell to 7589% of its original level after a relatively
short period. In this study, the knowledge interval was one-month, as the post-test was
conducted 1 month after the pre-test. Sisson et al., (1992) assessed 33 medical students
for retention and recall of clinical information three months after taking the test on the
same topic. They found that the students mean score declined 10 percentile points from
the original test. Their findings matched the findings of the current study in which the
On the whole, the results of this study consistent with the results of other previous
studies performed in the similar domains (El-Bab et al., 2011; Marcel, 2006). The
knowledge. The educational interventions and programs should focus on the meaning and
understanding rather than memorization, along with sufficient time to learn the complex
At the end of the analysis, the findings were only specific to the sample
population and were not generalizable to anyone else other than those individuals in the
sample.
73
Implications
further efforts on CVC maintenance care that based on the evidenced-based practice
guidelines to reduce CRBSI. The revised CDC guidelines for the prevention of CRBSI
had been in use since 2002, and the practice in the hemodialysis unit was far from the
evidence. The educators and professional must provide the information in a timely
and support the informal learning style. Learning needed to facilitate using a wide variety
of methods. As noted by Benner (1984), educators must take into account the experience
of a nurse and adapt learning to the individual. More than half the registered dialysis
nurses were new, and often overwhelmed in the hemodialysis unit. They usually started
The novice registered dialysis nurses benefited from formal education as the
method using multiple methods should apply to reinforce the best practice for
experienced registered dialysis nurses, and facilitate learning for novice registered
dialysis nurses. More efforts should put to improve registered dialysis nurses knowledge,
objectively.
74
knowledge was practical to help patients. The risk for CRBSI and prevention strategies
should be an important part of educational programs and plans among nursing leadership
based care would allow students to understand what was done was purposeful.
The results of the study identified further research topics that might provide
further insight and knowledge on the role of the registered dialysis nurses. The future
research efforts should aim to explore the elements necessary for successful CVC
maintenance care. The research topic, which needed further investigation included, does
the educational intervention influence actual infection rates. Would the same results
larger sample existed, would the results vary? Would researchers conduct such a study
interesting research study. Did the registered dialysis nurses feel empowered to provide
education to patients and families regarding CVC care? Moreover, what were the barriers
that prevent registered dialysis nurses from conducting this important work?
The last informative topic that could affect the quality of care that provided to
dialysis patients related to the actions that registered dialysis nurses could take when
improper techniques observed. To what extent, the registered dialysis nurses were aware
of substandard care. All these suggested studies could contribute to improving registered
75
unit.
that helped improving nurses knowledge in hemodialysis unit, thus helping hemodialysis
patients stay safer, and possibly reducing infectious complications. The cost of CRBSI
education was likely to reduce the incidence of CRBSI and reducing hospital stays, costs,
and possible mortality (Cooper et al., 2014; Burden et al., 2011; Kim et al., 2011;
The study provided evidence for conducting studies to determine the rates of
CRBSIs in hemodialysis units through the country. The content of the educational
program in this study was appropriate for nursing education in nursing schools. The risk
curriculum associated with CVCs as well as an orientation for the nurse new to the
hemodialysis care practice. Participants in this study could be a role model and preceptors
The study had relevance for the educational programs in healthcare institutions.
share experiences and insights with the community, they could advocate for patients
The study could help registered dialysis nurses become great partners to effect
Hemodialysis units could use the instrument of this study to assess their educational
needs, and to measure their clinical registered dialysis nurses information regarding
CVC maintenance care. Finally, the study could help in changing the role of the
registered dialysis nurse that include the use of evidenced based practice and caring for
Strengths
The main strength of the study was the thoughtfulness in hemodialysis unit
because the majority of the previous information in published literature were on ICU. The
project provided knowledge to the registered dialysis nurses regarding CVC maintenance
care to reduce CRBSI in hemodialysis unit about which was very little written.
nurses was a notable strength. The success of the intervention was noted a significant
difference in pretest and posttest scores. The self-study module, purpose, and the
intervention.
77
Another major strength was the low attrition rate < 7% though the initial sample
size was adequate. A further strength of this evidence-based practice project was that the
information obtained through the survey provided invaluable information and guidance to
the efforts regarding CVC maintenance care to reduce CRBSI in a hemodialysis unit.
Limitations
The limitations of the study related to the sampling strategy, instrumentation, and
demographics. The current study performed within a single hemodialysis unit from which
the participants recruited. The use of a convenience sampling method which although
sampling because it provided little opportunity to control for bias (Grove, Burns, & Gray,
2013). Therefore, findings could not generalize to all registered dialysis nurses in
hemodialysis units.
Despite a team of experts validated the tool, there was a chance that participants
five questions could interpret in different ways that led to difficulty when assessing the
results. The investigator designed the tool; it had not tested previously and because of
this, the reliability and validity of some of the questions might be problematic. Also, the
tool contained only nominal and interval level variables without any ratio level.
yet there was possible for historical effects. Participants were fatigued because they asked
to complete the pre/posttest during work time and guess on tests could result in unreliable
data (Creswell, 2012). The demographic data in the study provided a superficial
description of the participants because the limited information obtained from the
78
participants. When comparing the number of years that the participants had practiced and
the responses to the questionnaire, there was no correlation demonstrated. Being able to
correlate the years of experience as registered dialysis nurse, and the question responses
Despite these limitations, the study resulted in significant findings with respect to
unit.
the incidence rate of CRBSI in hemodialysis unit pre and post the educational
intervention. This method could add an important data to the effectiveness of the study
regarding participants knowledge and attitude; this approach could add significant
quantitative and qualitative data. For further research, the use of the representative
sample comprised the participants from different dialysis units throughout the country
Analysis of Self
Scholar
The term scholar was defined as a learned person, who is specialized in an area
of knowledge; one who has gained mastery in a particular discipline (Chism, 2013, p.7).
The investigator took this definition and applied to the DNP project. DNP project
provided the means through which the investigator demonstrated advanced knowledge in
79
educating registered dialysis nurses regarding CVC maintenance care to reduce CRBSI in
a hemodialysis unit.
intervention to examine the evidence for educational intervention that improves nurses
knowledge. As a scholar, the DNP must not only consult the literature related to practice,
practice gaps, and potential interventions but also search for information in a variety
sources as necessary. I designed nurses knowledge survey that highlighted the additional
research into practice, as well as knowledge dissemination and integration, are the critical
Practitioner
healthcare organizations, and the development and implementation of health policy (p.
1). The DNP roles were essential to the success of this project. The DNP as a clinician
hemodialysis unit leaders formed to make a clear case for the project. The DNP as an
advocate had the responsibility to improve the quality and safety of care for catheter-
dependent patients. The role of the DNP as educator related to the designing an
80
educational program for the registered dialysis nurses in hemodialysis unit to improve
their knowledge regarding CVC maintenance care to prevent CRBSI. Education had not
and made the case for reducing CRBSI incidence rate and improving the quality of care
that provided for the patients. The DNP as a role model established an example for others
and mentoring nurses in the practice setting and encouraging further education.
Project Developer
The DNP prepared me for the advanced nursing practice through understanding
the scientific foundation of the discipline. I began the project with the searching and
reviewing of the related literature. I built the educational program using nursing science
as its foundation, through the integration of Donabedians health model (1997) and Self-
Learning Theory. I utilized the evidence-based guidelines from the CDC to highlight the
correct nursing practice regarding CVC maintenance care. Their concepts used to guide
regarding CVC maintenance care and evaluated the outcomes of the educational
clinical practice improvement in a manner that was fitting to the practice environment.
81
The study presented an insight into the knowledge of registered dialysis nurses.
Overall, the findings of the current study showed inadequate knowledge of nurses
working in a hemodialysis unit. The results revealed that participates knowledge of CVC
maintenance care was far from optimal. The mean scores on pretest in the study were
only 52.17% that was significant below the limit of 75% that indicated the desired level
at which the dialysis nurses delivered the appropriate care to prevent CRBSI.
maintenance care. It was worrying because CRBSI prevention was dependent on the
knowledge of registered dialysis nurse. The most important areas which showed
noteworthy knowledge deficits centred on: the risk factors associated with the
development of CRBSI, lack of knowledge regarding the best method for CVC
maintenance care; the mask should wear for all CVC dressing changes before the
dressing is removed; the actions that decrease the risk of CRBSIs; chlorhexidine as a skin
preparation (as opposed to Povidone-iodine) associated with reduced CRBSIs rates; and
The self-study module was one of the efficient methods of promoting and
updating the knowledge regarding CVC maintenance care. The findings of the study
demonstrated that there were significant improvements in the posttest knowledge scores
dialysis nurses should know the methods for the prevention of CRBSI. The importance of
82
conducting education programs was a need for improving the quality of care in
knowledge.
Nursing Institute. See Appendix H for certification. I submitted an abstract for the 23rd
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Answer all the following questions. Each correct answer rewards one grade.
Please, do not write your name. Your answer will store with a high degree of
security. Circle the correct answer to the following questions:
a. True
b. False
a. True
b. False
3. The femoral site is the best site for a central vascular catheter if the subclavian
site cannot be used.
a. True
b. False
4. Infections associated with the use of central venous catheters can increase
a. Morbidity
b. Mortality
c. Hospital length of stay
d. Costs
e. All of the above
6. Risk factors for CRBSIs include placement for more than 72 hours, inexperience
of personnel inserting the central venous catheter, colonization of the catheter
with organisms prior to insertion and
7. The antimicrobial ointment should not be applied to the exit site of hemodialysis
catheters because it does not help to decrease the incidence of CRBSIs.
a. True
b. False
9. In the insertion of a central venous catheter, the insertion site is oozing. You
should:
10. You are not required to wash or gel hands if you wear clean gloves when
checking the insertion site or changing the dressing of a central venous catheter.
a. True
b. False
11. When inserting a central venous catheter, maximal sterile barriers are required.
This includes:
a. 1, 2, 3, 4
b. 1, 2, 4
c. 1, 2, 3, 5
d. 1, 2, 5
e. All of the above
12. After applying the ChloraPrep to the insertion site, one should wait until the
site is completely dry without fanning or blotting before proceeding.
a. True
b. False
13. The use of chlorhexidine as a skin preparation (as opposed to Povidone-iodine) is
associated with decreased CRBSIs rates in studies.
a. True
b. False
14. Of the following, which actions will decrease the risk of CRBSIs.
a. 1, 2, 3, 4
b. 2, 3, 4, 5
c. 1, 2
d. 3, 4
e. 1, 2, 5
f. All of the above
15. Ms. M has an unexplained fever, and you suspect a Blood Stream Infection.
Upon inspection of her internal jugular catheter insertion site, you see the
erythema and a small amount of pus. What should you do?
b. If the catheter is still necessary, remove the current catheter and replace it with
a guidewire exchange and assess the need for antibiotics
c. If the catheter is still necessary, remove the current catheter and place another
on a new site and assess the need for antibiotics
16. When requesting a catheter culture, submit a 5 cm segment that includes the tip.
a. True
b. False
17. If a catheter culture comes back positive, but the blood sample cultures are
negative, evaluate the entire picture. Reassess the patient before giving
antibiotics.
a. True
b. False
18. When attempting to diagnose CRBSIs, two sets of blood samples should be
drawn for culture. The proper sites to culture are:
19. The proper procedure to culture blood from a suspected source is to draw 20cc
of blood and place 10cc in each of two bottles.
a. True
b. False
20. The needleless access device should be scrubbed10-15 seconds, every time the
catheter is accessed thoroughly.
a. True
b. False
21. If dressing is loose, you should reinforce it with tape until the next scheduled
dressing change.
a. True
b. False
101
a. True
b. False
23. The two common sources of CVC infections are from patients skin flora and
health workers hands.
a. True
b. False
24. Mask should be worn for all CVC dressing changes before the dressing is
removed
a. True
b. False
a. True
b. False
102
Education level, e.g. Basic Diploma in general nursing, Nephrology nursing Diploma,
Care
Educational
intervention
Self- study module
The three-point scale was used to rate the Relevance and Clarity of the face and
Please marks an X just next to the most appropriate scale, e.g. if you want to rate 3,
2 1 2 3 1 2 3
3 1 2 3 1 2 3
4 1 2 3 1 2 3
5 1 2 3 1 2 3
6 1 2 3 1 2 3
7 1 2 3 1 2 3
8 1 2 3 1 2 3
9 1 2 3 1 2 3
10 1 2 3 1 2 3
11 1 2 3 1 2 3
12 1 2 3 1 2 3
13 1 2 3 1 2 3
108
14 1 2 3 1 2 3
15 1 2 3 1 2 3
16 1 2 3 1 2 3
17 1 2 3 1 2 3
18 1 2 3 1 2 3
19 1 2 3 1 2 3
20 1 2 3 1 2 3
21 1 2 3 1 2 3
22 1 2 3 1 2 3
23 1 2 3 1 2 3
24 1 2 3 1 2 3
25 1 2 3 1 2 3
Demographic Data 1 2 3 1 2 3
1
2 1 2 3 1 2 3
3 1 2 3 1 2 3
4 1 2 3 1 2 3
5 1 2 3 1 2 3
6 1 2 3 1 2 3
7 1 2 3 1 2 3
Self-study module 1 2 3 1 2 3
109
Slide 1
An Education Intervention to Improve
Nurses Knowledge to Reduce Catheter-
Related Bloodstream Infection In
Hemodialysis Unit
Slide 2
Duration: One-hour
Time: 10:00 a.m.- 11:00 a.m.
Venue: The conference room in hemodialysis unit
Slide 3
Slide 4
Slide 5
Slide 6
Slide 7
CRBSIs are:
1. Associated with increased morbidity
2. Associated with mortality rates of 10% - 20%.
3. Associated with prolonged hospitalization (mean of
7 days) and increase in medical costs $28,000 -
$47,000.
Slide 8
Slide 9
A central venous access catheter, also called a central
line, is a long, thin, flexible tube used to give
medicines, fluids, nutrients, or blood products over a
long period of time, usually several weeks or more. A
catheter is often inserted in the arm, neck or chest
through the skin into a large vein. The catheter is
threaded through this vein until it reaches a large vein
near the heart.
113
Slide 10
Slide 11
Slide 12
114
Slide 13
Slide 14
Key Components:
1. Hand hygiene
2. Maximal barrier precautions (both for the patient and the
inserter) when placing a central line
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection (subclavian preferred site)
5. Daily assessment of line necessity with prompt removal of
unnecessary line
Slide 15
Slide 16
Slide 17
For Provider:
Hand hygiene Improper Proper
Non-sterile cap and
mask
All hair under
cap
Mask covers nose
and mouth tightly
Sterile gown/gloves Image provided by author
116
Slide 19
In a study from 1991, preparation of central venous and
arterial sites with a 2% aqueous chlorhexidine gluconate
lowered BSI rates compared with site preparation with 10%
povidone-iodine or 70% alcohol. Since that time, there has
been growing evidence that chlorhexidine-containing skin
preparation is superior to other options. A meta-analysis from
2002 that pooled results of these studies demonstrated use of
a chlorhexidine-containing preparation decreased central
catheter related infections by 49% relative to povidone-iodine
preparations. Because a smaller effect of chlorhexidine was
seen in studies using a 0.5% concentration of chlorhexidine,
preparations with greater concentrations are recommended .
Joint Commission CLABSI Fact Sheet
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Intrinsic Risk Factors Extrinsic Risk Factors
(nonmodifiable characteristics of the patient) (potentially modifiable factors associated with CVC
insertion or maintenance)
Multilumen CVCs
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Prior to accessing the port, clean it per the
manufacturers guidelines
(10 twists with 70% alcohol) and allow
to air dry before accessing the system.
(No blowing or fanning).
Cap all central line ports when not in use.
Change caps no more frequently than
every 72 hours and at least every 7 days
or according to the manufacturers
recommendations.
EXCEPTION: Change the cap when: it has been removed for any reason or any time the
cap appears damaged, is leaking, blood is seen in the catheter without explanation, blood
residue in the cap or when cap has been laid down on a non-sterile surface.
120
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http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_C
LABScurrent.pdf
http://www.ihi.org/IHI/Programs/Campaign/Central
LineInfection.htm
CDC. Guidelines for the prevention of intravascular
catheter-related infections. MMWR 2002;51(No.
RR-10)