Effect of Education Module on Knowledge of Student Registered Nurse Anesthetists Regarding Surgical Site Infection

Purpose:

The Student Registered Nurse Anesthetist is accountable for prophylactic antibiotic administration and maintenance of normothermia during the intraoperative period. CMS is closely monitoring guideline compliance and incidence of SSIs. Moreover CMS is using performance outcomes as a benchmark of quality and patient safety. Guideline compliance at community-based hospitals in South Florida mirrors rates of adherence to evidence-based guidelines seen nationwide (Medicare.gov, n.d.). Bridging the gap between research utilization and nursing practice involves a learning process that draws upon attitudes, beliefs, and behaviors (Matthews-Maich, Ploeg, Jack, & Dobbins, 2010). In order to implement clinical practice guidelines to their fullest extent an understanding of the interdependence of practitioner attitudes, beliefs and behaviors must occur. Educational interventions to foster practitioner uptake and utilization of the evidence should occur during the pre-certification phase of development in order to ensure the greatest impact on anesthesia provider practice and adherence to evidence-based guidelines. In 2003 nursing faculty were challenged by the Institute of Medicine’s report Health Professions Education to transform learning experiences that give rise to professional identity so that each graduate would be educated to deliver patient-centered care that emphasizes evidence-based practice (Cronenwett et al., 2009). Use of research evidence has long been identified as the key to providing quality care yet a definitive blueprint for how to retain and implement the evidence remains elusive. The problem, providing impactful learning experiences during the pre-certification training phase is of significance because it is a means to providing quality anesthesia care upon completing requirements for advanced practice. Three nurse anesthesia University-based educational programs exist locally where more than 300 student registered nurse anesthetists (SRNAs) are enrolled annually preparing for careers in advanced nursing practice. Students enrolled in Florida International University’s Anesthesiology Nursing Program will be the focus of this study.

Methods:

A Quasi-Experiment using a pretest-posttest design was conducted using a convenient sample of SRNAs enrolled at Florida International University.  Qualtrics, an online survey software product, was used to create and deliver the pretest and posttest surveys to all participants. SRNAs were given a pretest survey that assessed baseline knowledge of evidence-based prevention of surgical site infections.  In addition, the survey measured self-directed learning (SDL) abilities and safety attitudes of all participants via a Self-Directed Learning Instrument (SDLI) and Safety Attitudes Questionnaire (SAQ) embedded within the survey.  Thereafter, an educational module created by the researcher, regarding SSI and practice guidelines, was made available for student perusal. Qualtrics launched the posttest survey twenty-four hours after the dissemination of the education module.  A survey was utilized as the pretest and posttest to measure the knowledge base of SRNAs regarding evidence-based prevention of surgical site infection. The survey was composed of 17 multiple-choice style questions that measured knowledge of SSI, diagnosing criteria, risk factors, and epidemiology.  Clinical scenarios were utilized to measure SRNAs ability to synthesize information and make clinical decisions in accordance with EB guidelines for antibiotic selection, administration, and thermoregulation.  Additionally, the surveys incorporated the SDLI and SAQ 

Results:

 This study examined the effects of an education curriculum on the knowledge of SRNAs regarding evidence-based prevention of SSIs during advanced practice nursing education.  There were 98 SRNAs enrolled in the FIU Anesthesiology Nursing Program, all of who were eligible to participate in this study.  Forty-two respondents initiated the pretest survey and thirty-four answered all questions reflecting an 81% pretest completion rate for all who initiated an attempt.  Similarly, twenty-six respondents initiated the posttest and eighteen answered all of the questions reflecting a 69.2% posttest completion rate for all who initiated an attempt.

Multiple choice question performance was scored and reported as a percent of correctness on a 100-point scale for the pretest and posttest group.  Incomplete pretest and posttest surveys were excluded.  The knowledge pretest had a mean of 72.3 and a median score of 71.  The posttest mean was 70.9 and the median was 71.  The one-way ANOVA was used to compare differences in pretest and posttest group average performance.  This analysis produced no statistically significant result (F_o= 0, p < 1). In addition knowledge questions were grouped in accordance with the five learning objectives of the education module.

1.   Define the diagnosing criteria, risk factors, and epidemiology of surgical site infection
2. Examine the clinical consequences of surgical site infection and impact on healthcare costs
3. Identify the Surgical Care Improvement Project performance measures that target postoperative infection prevention.
4. Illustrate the appropriate antibiotic timing and dosing for general, gynecologic, orthopedic and colorectal surgeries.
5. Describe intraoperative thermoregulation and its impact on surgical site infection

One-way ANOVA was calculated for learning objectives # 1, 2, 4, and 5.  An independent t-test was calculated for learning objective #3.  All comparative analysis of the learning objectives’ comparative statistics yielded statistical significance.  Results are displayed in Tables 2-6.

The SDLI pretest and posttest means were X= 3.99 and X= 4.32 respectively (see Table 7).  The highest mean score of the four SDLI domains (X= 4.32) was in planning and implementation, and the lowest mean score (X=3.91) was in self-monitoring, as shown in Table 9.  Safety attitudes and climate were measured using the Safety Attitudes Questionnaire.  Descriptive statistics were reported for each item.  Eleven items were utilized in this study that specifically measured the safety climate domain.  The pretest response rate was 34.7% (34 out of 98 potential respondents) and the posttest response rate was 18.4% (18 out of 98 eligible respondents) as indicated in Table 10.  The 5-point Likert scale was used for all items however,  Q22_4 and Q22_11 were reversed scored (Sexton, et al., 2006).  Mean scores above 3.0 were considered positive.  A one-way ANOVA (F_o= 1.31, p <.2)  comparing the pretest and posttest group mean safety attitude scores revealed no statistically significant result (see Table 11).

Conclusion:

This study was based on several assumptions:

1. In order to provide evidenced-based care advance practice nurses must bridge the gap between research utilization and clinical practice.
2. Bridging the gap involves a learning process that draws upon attitudes, beliefs, and behaviors of nurses that are interdependent.
3. Educational experiences during the advanced practice-training phase will foster practitioner utilization of the evidence to ensure maximal impact on practice and adherence to EB guidelines.

The IOM’s report Health Professions Education challenged nursing educators to develop learning experiences that give rise to practitioners that deliver evidence-based care.  While the learning experience in this study provided no significant impact on SRNA knowledge of evidence-based prevention of SSI, transforming education opportunities during advanced practice is of primary concern (Cronenwett et al., 2009). As reflected by recent literature a promising learning opportunity may be that of Manning and Frisby (2011), who combined an evidence-based review with use of student-created educational video and targeted Doctor of Nursing Practice students.  This learning format allowed students to analyze, synthesize, and evaluate information and at the same time offered them a creative role in their learning process (Manning & Frisby, 2011).  Accordingly, the video production component allowed students to be responsible for planning and evaluating the learning process, a key precept of andragogy and Adult Learning Theory (Knowles, 2005).  Also Bridges, Nair, Ma, Shanks & Hatala (2012) found that self-directed learners retained information longer possibly because they possessed a confidence and competence not observed in instructor-led learners. 

The results of this study suggest that SRNAs are self-directed learners with entrenched safety attitudes and behaviors.  Moreover, this study demonstrates that advanced practice nursing education must provide active learning opportunities that integrate the best current evidence with clinical expertise to produce practitioners who deliver patient-centered evidence-based care. Further research is warranted to elucidate the appropriate educational methods to foster advanced practice nursing students’ evidence-based knowledge, thereby bridging the gap between research utilization and nursing practice.