systematic review healthcare professionals knowledge and awereness regarding SSIs

Nurse Education in Practice 69 (2023) 103637
Contents lists available at ScienceDirect
Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953
Healthcare professionals’ knowledge and attitudes of surgical site infection

and surveillance: A narrative systematic review
Sinéad Horgan a, b, *, Mohamad M. Saab b, Jonathan Drennan b, Danielle Keane b,
Josephine Hegarty b
a
Department of Nursing and Midwifery, South/South West Hospitals Group, Erinville, Western Road, Cork, Ireland
b
Catherine McAuley School of Nursing and Midwifery, College of Medicine and Health, University College Cork, Cork, Ireland
A R T I C L E I N F O A B S T R A C T
Keywords: Aim: This systematic review reports on healthcare professionals’ knowledge and attitudes of surgical site
Attitude infection and surgical site infection surveillance as well as interventions aimed at enhancing healthcare pro
General surgery fessionals’ knowledge and attitudes.
Guidelines
Background: Surgical site infection is a serious adverse outcome following surgery. Despite the presence of in
Health personnel
ternational guidelines, the prevention of surgical site infections remains a challenge for patients and hospitals. It
Infection control
Inter-professional education is critical that healthcare professionals have sufficient knowledge on surgical site infection and on their role in
Knowledge implementing evidence-based prevention strategies.
Quality improvement Design: This review is reported using the Preferred Reporting Items for Systematic review and Meta-Analysis
Risk (PRISMA) guidelines.
Surgical wound infection Methods: A search was undertaken in the following databases: Academic Search Complete, CINAHL, ERIC,
MEDLINE, PsycARTICLES, PsycINFO and Web of Science for studies published between January 2010 and March
2022. Studies that examined healthcare professionals’ knowledge and attitudes in relation to surgical site
infection, surgical site infection surveillance and risk factors for their development were included. We also
included studies that examined interventions that aimed to enhance healthcare professionals’ knowledge and
attitude in relation to surgical site infection, surveillance, and risk factors. We also described the impact of such
interventions on the incidence of surgical site infections.
Results: A total of 26 studies were included. Results were synthesised narratively according to the review ob
jectives. Findings from this review show that knowledge of what surgical site infection is and its prevention was
poor amongst healthcare professionals, while attitudes were positive particularly in relation to healthcare pro
fessionals’ role in prevention. Only three studies examined the effects of interventions on healthcare pro
fessionals’ knowledge of surgical site infection and surgical site infection prevention. Of those, two used
multimodal educational interventions and found statistically significant improvement in knowledge.
Conclusions: Overall knowledge of surgical site infection and its prevention is poor amongst healthcare pro
fessionals, while attitudes were positive particularly in relation to healthcare professionals’ role in prevention.
There is a need for more experimental research to evaluate interventions which aim to address healthcare
professionals’ knowledge and attitudes towards surgical site infection prevention and surveillance. Such studies
should include all healthcare professionals involved in the care of a surgical patient.
Tweetable abstract: Knowledge and attitudes of surgical site infection prevention amongst healthcare
professionals.
1. Introduction hospital resources (Ban et al., 2017; Berríos-Torres et al., 2017). The
European Centre for Disease Prevention and Control (ECDC) define SSIs
A surgical site infection (SSI) is a serious post-operative complication as infections that occur within 30 days in the area where surgery has
with adverse consequences which impacts on patient outcomes and uses been undertaken or within 90 days if an implant was inserted during
* Corresponding author at: Department of Nursing and Midwifery, South/South West Hospitals Group, Erinville, Western Road, Cork, Ireland.
E-mail addresses: [email protected], [email protected] (S. Horgan).
https://doi.org/10.1016/j.nepr.2023.103637
Received 8 December 2022; Received in revised form 24 March 2023; Accepted 4 April 2023
Available online 11 April 2023
1471-5953/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S. Horgan et al. Nurse Education in Practice 69 (2023) 103637
surgery (ECDC, 2017). factors for developing an SSI and (iv) attitudes of healthcare pro
A recent global study of 44,814 patients who underwent elective fessionals towards SSI.
surgery found a 5% SSI rate among in-patients (Ahmad et al., 2016).
However, it is widely recognised that the prevalence of SSIs is under 3. Methods
estimated with most SSIs occurring following hospital discharge(Leaper
et al., 2015). SSIs are the second most prevalent category of healthcare 3.1. Study design
associated infections in the United States of America (USA) and the third
most commonly reported infections in Europe, accounting for 18.4% of This systematic review of quantitative studies is reported using the
healthcare associated infections in a recent point prevalence study by Preferred Reporting Items for Systematic review and Meta-Analysis
the ECDC (Magill et al., 2014; Suetens et al., 2018). SSIs have economic (PRISMA) checklist available in Supplementary file 1 (Page et al., 2021).
implications. The annual expenditure for healthcare associated in
fections in the USA is $9.8billion with SSIs attributing to a third of those 3.2. Eligibility criteria
costs (Zimlichman et al., 2013). It has been estimated that each case of
SSI costs approximately $20,785 making it the costliest healthcare The population, intervention/variable of interest, comparison, out
associated infection (Anderson et al., 2014; Zimlichman et al., 2013). comes and setting (PICOS) framework was used to frame the research
Due to its prevalence, cost, and impact on patient care, key inter question and eligibility criteria and to ensure the systematic search using
national and national organisations such as the World Health Organi key words (Bennett et al., 2012). Studies were included if they met the
sation (WHO), Centres for Disease Prevention and Control (CDC), the predefined eligibility criteria as outlined in Table 1.
ECDC, and Public Health England advocate for SSI surveillance and, as
such, provide evidence-based clinical guidance to support healthcare 3.3. Search, screening strategy and information sources
professionals in implementing targeted interventions to prevent SSIs
(Berríos-Torres et al., 2017; Harrington, 2014; Plachouras et al., 2018; A literature search was undertaken in the following seven databases:
World Health Organization, 2012). Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycARTICLES,
PsycINFO and Web of Science. The search was conducted on March 24,
2. Background 2022, and was limited to studies published in English between January
2010 and March 2022. The key terms used in the search strategy related
Engagement of multiple disciplines in multicomponent quality to four concepts: SSI, healthcare professionals, knowledge and attitudes
improvement interventions, including surveillance, have been shown to and incidences of SSI. The search strategy was customised for each of the
reduce the occurrence of SSIs and maintain patient safety (Allegranzi seven electronic databases (Supplementary file 1). Search terms were
et al., 2018; Ban et al., 2017; Schreiber et al., 2018). The incidence of combined using Boolean operators “OR” and “AND,” and searched based
SSIs can be reduced by up to 60% when evidence-based measures are on title or abstract. The reference lists of the included studies were
implemented including perioperative glycaemic control, antimicrobial manually searched for additional relevant studies.
prophylaxis, education of healthcare professionals and introduction of
care bundles (Berríos-Torres et al., 2017; Meeks et al., 2011; Schreiber 3.4. Study selection
et al., 2018). Therefore, hospitals are increasingly adapting the sys
tematic approach of surveillance, which is not only an effective defence Studies were exported to Covidence an online software tool (www.
against SSIs but also a recognised indicator of quality of care (Magill covidence.org) (Covidence, 2022). Duplicates were removed automati
et al., 2014; Marchi et al., 2014; Sganga et al., 2017). Implementing cally via the searched databases and Covidence. Studies were screened
guidelines to prevent SSIs and undertaking SSI surveillance are also for eligibility based on title and abstract. All abstracts were reviewed by
recognised as being complex interventions in the clinical setting two authors (S.H. and J.H./J.D./M.M.S.) independently to ensure that
(Troughton et al., 2019). they were relevant and met the inclusion criteria. Ineligible studies were
Hospital engagement and compliance with guidelines for the then excluded, and the full texts of the remaining studies were retrieved
reduction of SSIs require individual healthcare professionals to engage and screened by three authors (S.H., J.H. and J.D.) independently.
and adapt guidelines into practice (Leaper et al., 2015). Healthcare Screening conflicts were solved by two reviewers (J.D. and M.M.S).
professionals require the knowledge of what SSIs are and an under
standing of their role in SSI prevention (Gifford et al., 2011, Storr et al., 3.5. Data extraction
2017, Troughton et al., 2019). Furthermore, Troughton et al. (2019)
argued that understanding healthcare professionals’ perceptions to Data from the included studies were extracted by one author (S.H.)
wards SSI prevention and surveillance is important as it aids in identi and cross checked by a second author (D.K.) and inputted into an elec
fying who has responsibility and interest in preventing of SSIs. tronic spreadsheet. The data extracted included: authors, year of pub
Collaboration and shared ownership are also highlighted as being lication, country, study design, healthcare professional cohort, sample
necessary for the successful implementation of strategies to reduce SSIs size, main findings on knowledge, attitudes, knowledge of risk factors,
(Su et al., 2016). Given the importance of the prevention of SSIs, SSI rates, instrument utilised, SSI criteria used, and details of any
establishing the level of knowledge and attitudes of healthcare pro intervention reported.
fessionals of SSI can support policy development and education in
terventions to address variations in practice. 3.6. Quality and risk of bias assessment
The aim of this systematic review was to identify, describe, and re
view the evidence from the literature on the knowledge and attitudes of Quality assessment was undertaken using the Mixed Method
healthcare professionals towards SSI and SSI surveillance. The objec Appraisal Tool (MMAT) allowing appraisal of various types of studies
tives of this review were to describe the: (Hong et al., 2018). In this review, the items for non-randomized studies
and quantitative descriptive studies were used. In each study type there
I. Knowledge of healthcare professionals in relation to: (i) SSI (ii) SSI are a set of seven questions to determine methodological quality and
surveillance; (iii) risk factors for developing an SSI and (iv) attitudes potential risk of bias. Voting was conducted on a “yes,” “no,” or “can’t
of healthcare professionals towards SSI; tell” basis for each of the questions. The quality of the studies was
II. Effect of interventions aimed to enhance knowledge of healthcare assessed by two authors (S.H. and D.K.) independently and any dis
professionals in relation to (i) SSI (ii) SSI surveillance; (iii) risk agreements were resolved by consulting with a third author (M.M.S).
2
Table 1 Table 1 (continued )

Search terms, inclusion and exclusion criteria outlined using an adapted PICOS PICO Search termsa Inclusion criteria Exclusion criteria
framework. framework
PICO Search termsa Inclusion criteria Exclusion criteria Setting No search terms Acute hospital Non-acute care
framework were used for settings setting (e.g.,
Population “Healthcare Doctors, nurses, Non-healthcare hospital setting community and
professionalb” OR healthcare professionals. primary care).
“healthcare students and allied Study design No search terms Quantitative Study designs:
workerb” OR healthcare and were used for descriptive studies; qualitative or
physician OR professionals. publication study design and experimental qualitative aspects
nursb OR nurse OR type publication type randomized and of mixed method
doctor OR non-randomized studies, Delphi
dietician OR studies i.e. RCTs, studies and
dietitian OR before and after systematic review.
pharmacb OR studies, quasi- Publication types:
therapistb OR experimental, time literature reviews,
surgeonb OR series analysis, protocols,
consultant OR observational/ editorials, theses,
medicb OR cross-sectional. letters,
anaesthb OR commentaries,
anesthb OR abstracts, opinion
physician OR papers.
team OR clinician Limits applied English language
Intervention/ Surgical site Surgical site Infections not in database January 2010 and
Variable of infection OR infection reported related to surgical March 2022
interest surgical wound within 30 days of wounds i.e., burns, a
Sample search terms enclosed. The full search strategy for each of the seven
infection OR surgery or within decubitus ulcers.
databases is outlined in Supplementary file 1
postoperative 90 days of surgery Infections relating b
infection OR SSI where an implant to neonatal surgery, truncation to include various word/terms endings and alternate spellings.
OR is placed. paediatric surgery.
(infection N3 SSIs reported in an Surgical wounds Risk of bias assessment was undertaken by two authors (S.H. and D.K.)
wound OR adult patient relating to
for the three experimental studies using the Risk Of Bias In
infection adj3 population over ophthalmology,
wound or the age of 16. dental, Non-randomised Studies (ROBINS-I) tool. This tool is used to assess risk
infection W3 Interventions otolaryngology or of bias in the results of non-randomised studies that compare the health
wound) which sought to ear surgery as they effects of two or more interventions (Sterne et al., 2016).
AND increase are not currently
surgery or surgical knowledge and procedures
attitudes of monitored as part of 3.7. Data analysis
healthcare SSI surveillance (
professionals ECDC, 2017). Extracted data were outlined in tabular format and subsequently
towards SSI and Experimental integrated using a narrative synthesis approach (Popay et al., 2006).
SSI surveillance. studies which tested
or compared
This helped collate and group the findings that emerged from the
specific clinical analysis of the included studies. This method allows for synthesis where
interventions such meta-analyses are not feasible due to considerable methodological and
as surgical clinical heterogeneity in the included studies. The characteristics of the
techniques, types of
included studies were outlined, and findings were synthesized according
antibiotics or
sutures. to the two predefined review objectives.
Studies where the
focus was on 4. Results
compliance with SSI
guidelines in
practice.
4.1. Study selection
Comparator No search terms Studies with and Not applicable
were used for without In total, 9426 studies were identified from the electronic database
comparator comparators were searches. After importing the papers to Covidence, 4729 duplicates were
included
removed automatically. A further 4658 records were excluded through
Outcomes Awareness OR Knowledge or Knowledge of and
knowledge OR attitudes of attitudes towards title and abstract screening. Thirty-eight studies were assessed through
attitude healthcare generic infection full text review with a further seven additional papers identified through
professionals in control practices. manual reference checks. Of those, 26 studies were included in this re
relation to SSI, SSI view. The study selection process is presented using the PRISMA flow
surveillance or the
risk factors that
diagram (Fig. 1) (Page et al., 2021).
predispose patients
to developing an 4.2. Quality and risk of bias assessment
SSI measured
either on a cross-
sectional basis or
There were two types of studies included in this systematic review:
on a pre-post-test quantitative descriptive studies (n = 23) and non-randomised studies
basis. (n = 3). All included studies had clear research questions and the data
Incidence OR SSI incidence or collected were appropriate to address the objectives.
prevalence prevalence rates.
All 23 quantitative descriptive studies utilised appropriate mea
surements and statistical analyses; however, three studies had issues in
relation to sampling with no clear information on sampling strategies,
non-response, or inclusion/exclusion criteria (Albishi et al., 2019;
3
Fig. 1. Study identification, screening and selection process (Page et al., 2021).
Brisibe et al., 2014; Tschelaut et al., 2018). Three studies self-reported et al., 2015) to 1305 participants (Zucco et al., 2019). Most studies were
the risk of selection bias (Aizman, 2021; Jocum et al., 2018; Qasem cross-sectional (n = 23). Studies were conducted in Asia (n = 8), Europe
and Hweidi, 2017). In five studies, the reasons for non-response or the (n = 8), Africa (n = 7), North America (n = 2), and Australia (n = 1).
low response rate were not outlined (Brisibe et al., 2014; Eskicioglu Nurses were the main population (n = 14), followed by doctors (n = 8)
et al., 2012; Gillespie et al., 2014; Tschelaut et al., 2018; Vu et al., 2021). and multidisciplinary healthcare professionals (n = 4). Over a third of
All three non-randomised studies utilised a pretest-posttest design. the studies (n = 10) were undertaken in countries with low to medium
The samples in the three studies were representative of the target pop human development as categorised on the United Nations Development
ulation, with all studies utilising appropriate measurement and meeting Programme Human Development Index (HDI) (United Nations Devel
most the MMAT criteria. However, the total number of individuals opment Programme, 2022). The full study characteristics are presented
approached to participate in the study and details of non-participation in Table 2.
were not disclosed in these studies (Elsharkawy et al., 2019; Nagdeo A narrative synthesis of the results was conducted in line with the
et al., 2015; Khan et al., 2021). As for risk of bias assessment for the review objectives as follows: (i) knowledge of SSI; (ii) knowledge of SSI
non-randomised studies, one was found to have a high risk of bias due to surveillance; (iii) knowledge of risk factors for developing an SSI; (iv)
were the lack of information on the intervention status and on the study attitudes towards SSI; (v) effectiveness of interventions to enhance
outcomes (Nagdeo et al., 2015). Quality appraisal results for the 26 knowledge in relation to SSI and SSI surveillance; and (vi) effectiveness
included study are reported in a Supplementary file 2 and risk of bias of interventions to enhance attitude in relation to SSI and SSI surveil
assessment is presented in Supplementary file 3. lance. Findings from the included studies are summarised in Tables 3
and 4.
4.3. Characteristics of the reviewed studies

4.4. Knowledge of surgical site infections
A total of 26 studies were included in this review, with a total of
11,220 healthcare professionals. Sample size ranged from 22 (Nagdeo A total of 23 studies examined healthcare professionals’ knowledge
4
Table 2 a study of doctors, 84% of respondents were aware that surgical anti
Study characteristics (n = 26). biotic prophylaxis was given for clean surgeries with implants, and only
Continent Asia (n = 8) 25% of the total respondents reported attaining their knowledge of
Europe (n = 8) surgical antibiotic prophylaxis from guidelines (Ahmed et al., 2019).
Africa (n = 7) The classification of wound contamination was developed by Alte
North America (n = 2)
meier (1984) and is an assessment that is recommended for surveillance
Australia (n = 1)
Design Quantitative Descriptive studies (n = 23) in a number of international guidance documents (Centers for Disease
Interventional studies (n = 3) Control and Prevention, 2022; ECDC, 2017). Knowledge of the wound
Sample (min- 22 – 1305 participants contamination classification was investigated in two studies. The first,
max) Albishi et al. (2019), reported that 48.7% of physicians correctly knew
Participants Nurses (n = 14)
the classification. In the second study, 58% of nurses knew that surgery
Doctors (n = 8)
Doctors and Nurses (n = 2) on a hollow viscus, such as bowel, uterus or bladder, in the body was
Doctors, Nurses, and Technologists (n = 1) deemed a clean-contaminated surgery (Balodimou et al., 2018).
Doctors, Nurses, technologists, Managers, and Infection Six studies reported on knowledge of guidelines, specifically in
Control Team Members (n = 1)
relation to the prevention of SSIs, reported as 36% among doctors and
Outcomesa Knowledge (n = 22)
Attitudes (n = 13) nurses (Qasem and Hweidi, 2017), 86.4% among operating room nurses
Knowledge and Attitudes (n = 9) (Ogce Aktaş and Turhan Damar, 2022) and 88% among cardiothoracic
Interventionsb,c PowerPoint education (n = 2) nurses (Moran and Byrne, 2018). The majority of the included studies
Task-based inter-professional learning (n = 1) (n = 19) recommended education and training on SSI prevention, with
Role play and group discussion (n = 1)
four studies stressing the need for continuous education (Jocum et al.,
Booklet containing education material (n = 1)
Instruments Questionnaire (n = 19) 2018; Khan et al., 2021; Kolade et al., 2017; Vu et al., 2021).
Online survey (n = 4)
Face to face interview using questionnaire (n = 3) 4.5. Knowledge of surgical site infection surveillance
a
n = number of times an outcome was measured.
b
n = number of times an intervention was measured Four studies reported on healthcare professionals’ knowledge on the
c
some interventions had multiple components. role of surveillance in reducing the incidence of SSIs. Labeau et al.
(2010), found that only 10% of nurses knew that postoperative sur
of various aspects of SSIs. Five studies reported on summative knowl veillance by itself succeeds in reducing the incidence of SSI, while
edge of SSI and prevention measures (Albishi et al., 2019; Khan et al., Qasem and Hweidi (2017) reported that knowledge of surveillance was
2021; Labeau et al., 2010; Qasem and Hweidi, 2017; Teshager et al., 27% amongst the same cohort. Knowledge of surveillance (mean±SD)
2015). Knowledge of SSI was “poor” in two similar studies of nurses was 3.13/5 ± 1.09 in a study of multiple disciplines (Khan et al., 2018).
which utilised the same questionnaire regarding SSI prevention guide In a study of colorectal surgeons, 73% believed that surveillance should
line with participants scoring 2.61/9 (Labeau et al., 2010) and 3.28/9 be in place with feedback to reduce the incidences of SSIs (Badia et al.,
(Qasem and Hweidi, 2017). Albishi et al. (2019) reported that only 6.7% 2020).
of physicians of various grades had “good knowledge” (scoring ≥80%)
of SSI whereas the remaining majority (93%) had “fair” (scoring 4.6. Knowledge of risk factors for developing a surgical site infection
50–79%) to “poor” (scoring <50%) knowledge. Another study of nurses
reported that 40.7% were “knowledgeable” of SSI prevention (Teshager Four studies assessed nurses’ knowledge of SSI risk factors. Two
et al., 2015), whilst Khan et al. (2021) reported a mean knowledge score studies found high levels of knowledge with Gillespie et al. (2014)
(mean±SD) of 49.1/100 ± 8.02 in a study of multiple disciplines. reporting that 97% of medical and surgical nurses were aware that poor
Three of the studies investigated healthcare professionals’ knowl hand hygiene, the presence of pre-existing comorbidities and subopti
edge of the correct definition of an SSI with knowledge ranging from mal aseptic technique were SSI risk factors. A further study with
6.8% (Labeau et al., 2010), through to 36% (Qasem and Hweidi, 2017) intensive care nurses found that 80.6% were aware of the risk factors
and 55% (Albishi et al., 2019). Knowledge of the correct timeframe for a (Vu et al., 2021). A study of nurses from surgical areas found that 70%
diagnosis of an SSI (i.e., 30 days) was 2.3% (Labeau et al., 2010), 25.3% identified obesity as a risk factor and 74% identified smoking as a risk
(Albishi et al., 2019), and 39.2% (Balodimou et al., 2018). Knowledge of factor (Zucco et al., 2019). In contrast, Moran and Byrne (2018) reported
signs and symptoms of SSIs varied widely, from 27.7% among cardio that only 25.2% of nurses knew the preoperative risk factors for devel
thoracic nurses (Moran and Byrne, 2018) to 80% among nurses working oping an SSI including smoking, diabetes, age or presence of chronic
in medical and surgical settings (Gillespie et al., 2014). conditions such as lung disease or heart failure. In the same study, only
Correct timing of hair removal in preparation for surgery was 8.6% of participants knew of intraoperative and postoperative risk fac
explored in six studies (Albishi et al., 2019; Brisibe et al., 2014; Labeau tors such as prolonged ventilation, blood transfusions, and poor dietary
et al., 2010; Ogce Aktaş and Turhan Damar, 2022; Qasem and Hweidi, intake (Moran and Byrne, 2018).
2017; Zucco et al., 2019) Correct answers ranged from 25.8% among
intensive care nurses (Labeau et al., 2010) to 96.5% in operating room 4.7. Attitudes towards surgical site infections
nurses (Ogce Aktas and Turhan Damar, 2022). Four studies examined
healthcare professionals’ knowledge of clipping as the correct technique Eleven studies reported findings on healthcare professionals’ atti
for hair removal. Results of correctly identifying clipping varied widely tudes toward varying aspects of SSI, including prevention (n = 7). The
from 22.7% in a study of medical physicians (Albishi et al., 2019) to 62% remainder explored barriers and enablers to SSI guideline imple
in operating room nurses (Ogce Aktas and Turhan Damar, 2022). mentation (n = 4). Overall, attitudes were predominantly positive, with
Another key SSI preventative measure is the administration of sur a mean score of 7.6/10 for attitude towards effectiveness of SSI pre
gical antibiotic prophylaxis (World Health Organization, 2018). vention practices among nurses (Zucco et al., 2019) and 95% of surgeons
Awareness of the correct time to administer surgical antimicrobial believing that SSI prevention was a central aspect of their role (Tsche
prophylaxis varied with those identifying the correct answer ranging laut et al., 2018).
from 22.8% amongst doctors and nurses (Brisibe et al., 2014) to 95.2% Khan et al. (2021) study found that nurses, doctors, and technologists
among operating room nurses (Ogce Aktaş and Turhan Damar, 2022). In had a positive attitude towards education on SSI prevention. Attitudes
examined in the study related to perceived behaviour change after
5
Table 3
Study characteristics and findings from cross-sectional studies (n = 23).
A. Author/ Year A. Healthcare Intervention A. Title B. A. Instrument used B. Name of Findings on knowledge of A. Findings on attitude
B. Country C. professional cohort B. Components C. tool C. Mode D. Question type SSI B. Surveillance C. Risk
Human Sample size Facilitators D. Duration and Scoring E. Summary scores factors D. Summative
Development knowledge
Index
A.Ahmed et al. A. Surgeons and A. N/A A. Questionnaire A. 12.5% had good knowledge 37% would contribute to the
(2019) anaesthesiologists B. N/A B. Referred to in study as on appropriate SAP. 84% were development of guidelines.
B. Sudan including those in C. N/A ‘‘questionnaire’’, developed by aware that SAP was required Good attitude to need for local
C. 0.508 training D. N/A Baniasadi et al.,0.2016 for clean surgeries with (98%) and national (100%)
B. 49 C. NR prosthesis and 74% knew that guidelines
D. Doctors answer considered SAP was required for clean
correct if in line with ASHP contaminated surgeries.
guidelines, higher score is better B. N/A
alignment. C. N/A
F. Summary scores given as D. Overall knowledge gaps in
response rate(%) SAP.
A.Aizman et al. A. Surgeons A. N/A A. Online Survey A. No 59.79% (58/97) of
(2021) B. 101 B. N/A B. Surgeons’ Attitudes towards B. N/A respondents believe that
B. USA C. N/A Prophylactic Antibiotic Use- C. N/A prophylactic antibiotics
C. 0.921 D. N/A researcher developed D. N/A prevent SSI. 25% reported that
C. Online they do not usually prescribe
D. Likert scale SAP to reduce incidence of
E. Respondents (n, %) SSI. Of the 75% who do,
prescribing patterns
frequently do not align with
advice with 40.2% uncertain
whether antibiotics prevent
SSI.
A.(Ogce Aktaş A. Operating room nurses A. N/A A. Questionnaire A. 86.4% of respondents knew N/A
and Turhan B. 228 B. N/A B. Knowing and Implementing of the guidelines to prevent SSI
Damar, (2022) C. N/A Evidence-Based Guidelines in with 56.6% stating they use
B. Turkey D. N/A Preventing Surgical Site them in practice.
C. 0.838 Infection, researcher developed B. No
based on the guidelines for the C. No
prevention of SSI. D. High level of knowledge of
C. Online (google form) evidence based practices from
D. Agree/ Disagree multiple WHO, CDC and AORN in the
choice questions areas of prophylaxis,
E. n (%) antimicrobial suture, bathing,
hair removal practices,
maintaining normothermia
and normal blood glucose
levels.
A.Albishi et al. A. Physicians, interns, A. N/A A. Locally developed A. 55.5% knew the definition N/A
(2019) residents, B. N/A questionnaire of SSI, 78.2% knew of correct
B. Saudi Arabia specialists, and C. N/A B. Awareness and level of prophylaxis timing, 22.7%
C. 0.875 consultants D. N/A knowledge about SSI and risks knew of correct hair removal
B. 119 factors for wound infections–- method, 48.7% knew of wound
researcher developed contamination classification
C. NR and 25.3% knew of the correct
D. Multiple choice question, 1 timing of an SSI
point for correct answer, 0 for B. N/A
incorrect. C. N/A
E. Obtainable points range: D. 6.7% had good knowledge
0–20, the respondents were of SSI where they had > 80%
categorized as having good correct answers with 63%
knowledge (for ≥80% correct having fair knowledge
answers), fair knowledge (for (50–79%) and 30.2% with poor
50%− 79% correct answers), and knowledge (<50%)
poor knowledge (for <50%
correct answers)
A.Badia et al. A. Colorectal surgeons A. N/A A. Survey A. Not questioned on current Good consistent association
(2020) B. 355 B. N/A B. No name specified, referred to practices between beliefs and their
B. Spain C. N/A as ‘’the survey’’ throughout. Regarding oral antibiotic practice (less than 20%
C. 0.905 D. N/A C. Online (via Survey Monkey) prophylaxis, most of difference). 70% of
D. NR respondents believe that this respondents believed that
E. n(%) measure reduces the risk of SSI, there was a gap between
either alone (55.5%) or in published guidelines and
combination with MBP clinical practice and that
(80.4%) education programmes on SSI
B. 73.3% are aware of their SSI prevention would be of benefit
rate with surgeons in colorectal and protocol for colorectal
departments receiving more patients. 60% believed in
feedback than those not evidence based guidance on
working in a colorectal normothermia, wound edge
(continued on next page)
6
Table 3 (continued )
Index
departments (74.5% vs 43.3%) protection devices and alcohol

73% state a mechanism for SSI solution for cleaning surgical
feedback should be in place, site.
only 39% say such a
mechanism is in place in their
hospital
C. N/A
D. N/A
A.Balodimou A. Nurses and assistant A. N/A A. Questionnaire A. 59.5% had not received N/A
et al. (2018) nurses working in B. N/A B. Researcher developed, tested training in surgical infections.
B. Greece surgical departments C. N/A for comprehension and Statistical significance between
C. 0.887 B. 148 D. N/A acceptability. No name given, education level and knowledge
referred to as questionnaire. of timing of an SSI,
C. NR classification of surgical
D. Multiple choice wounds, dressing usage and
E. given in %, summary scores hair removal practices.
stratified by age, education B. N/A
level, years of experience, C. N/A
experience in surgical D. Majority of respondents had
department, education in SS.I a high level of knowledge
regarding the prevention of
SSIs
A.Brisibe et al. A. Doctors and nurses. A. N/A A. Structured questionnaire and A. The correct timing for the The reasons given for non-
(2014) B. 68 in total: 33 in one B. In one hospital there observation administration of prophylactic adherence to the infection
B. Nigeria hospital and 35 in was an infection control B. Researchers developed, antibiotics and for the removal control policy include poor
C. 0.535 another. committee, adoption of derived from guidelines of the hair at the incision site supervision (39.39%) and lack
the WHO guidelines and established by WHO and CDC. were observed by 57.58% and of in-service training
an education program. No name, referred to as 69.69% respectively compared (21.21%) in the hospital
C. Members of infection questionnaire. with 22.86% (P = 0.00) and where interventions were in
control committee C. NR 0.00% (P = 0.02). place, while the respondents
D. Approximately 9 D. Multiple choice, yes/no B. N/A where no intervention
months answers C. N/A occurred gave reasons of
E. n(%) stratified by hospital. D. Knowledge scores were inadequate supply of
higher in the hospital where consumables (34.29%) and
education and an infection absence of a hospital’s policy
control committee. on infection control (22.88%).
A.Jocum et al. A. Senior and Junior A. N/A A. Knowledge-based A. 20% knew of an existing SAP N/A
(2018) Anaesthetists. B. N/A questionnaire guideline with 15.6%
B. South Africa B. 135 C. N/A B. Developed by the following a guideline, senior
C. 0.713 D. N/A authors, validity obtained by doctors more likely to follow a
consulting with a specialist guideline (p = 0.0002). 36.3%
medical microbiologist and two knew that it was only during
senior anaesthesiologists, surgery patients received SAP.
including one who is an B. N/A
expert in pharmacology. C. N/A
C. In person D. Mean score of knowledge
D. Open ended questions, yes/ regarding SAP was poor at
no questions, scored as correct 56.2%.
or incorrect
E. Given as score % Mean(SD) or
Median (IQR) or given as
‘’answering correctly’’.
Stratified by all participants.
A.Khan et al. A. Infection control team A. N/A A. Questionnaire and structured A. A score of 3.5 or higher on a N/A
(2018) members, operating B. N/A interviews scale from 0–5 was considered
B. Pakistan room managers, nurses, C. N/A B. Developed by the authors to as high. A score below 3 was
C. 0.544 technologists, surgeons, D. N/A evaluate the factors affecting the considered as insufficient, and
and anaesthesiologist’s effectiveness of the WHO Global a score in
in two hospitals Guidelines 2016 for prevention between 3 and 3½ as moderate,
B. 252 of SSIs. i.e., still needs some
C. NR improvement. Knowledge of
D. Closed questions scored by a SSI (mean, standard deviation)
6-point Likert scale. 2.74 ± 1.12. Culture 2.80
E. Mean (0–5 on Likert scale), ± 0.71
Standard deviation, no. of B. Knowledge on surveillance
respondents. 3.13 ± 1.09
C. No
D. No
A.Labeau et al. A. Intensive care nurses A. N/A A. Questionnaire A. 35% were aware that N/A
(2010) B. 650 B. N/A B. Multiple choice elective operations on patients
B. Belgium C. N/A questionnaire, developed by the with remote site infections
C. 0.937 D. N/A authors based on CDC SSI should be postponed until the
7
Index
prevention guidelines. Validated infection has resolved. 75%

by seven experts. were aware of the correct
C. In person classification of SSI and 2%
D. Multiple choice questions realised the diagnosis
with 4 possible choices, one timeframe criteria for
correct answer, two distractors superficial incisional
and one “I do not know”. infections. 26% were aware of
E. Given as no of respondents, the correct timing of
mean(%), median (IQR) preoperative hair removal.
B. 10% knew that
postoperative surveillance by
itself succeeds in reducing the
incidence of SSI
C. No
D. mean test score was 2.61 of
nine (29%)
A. Mengesha A. Nurses in surgical A. N/A A. An adapted and structured, A. No 4.6% of respondents believed
et al., (2020) units in four hospital sites B. N/A pretested, self-administered B. No they did not have sufficient
B. Ethiopia B. 409 C. N/A Questionnaire C. No knowledge on SSIs. 37.7%
C. 0.498 D. N/A B. Developed by Sickder et al., D. No that there was inadequate
2017 resourcing to implement
C. in person surgical safety checklists, lack
D. Closed end, 4 -point Likert of feedback systems 14.7%.
scale. 91% cited excessive workload,
E. Given as frequency and % for absence of training and
each point on Likert scale. support as reasons for
affecting their practice in
relation to SSI prevention.
A. Moran and A. Cardiothoracic nurses A. N/A A. Questionnaire A. 88.3% had knowledge of N/A
Byrne, (2018) in 6 hospital sites B. N/A B. Adapted from two guidelines for prevention of
B. Ireland B. 158 C. N/A questionnaires postoperative wound
C. 0.945 D. N/A (McCluskey and McCarthy, infections. 27.7% identified
2012; Stoodley et al., 2012), correctly the signs and
validated by a panel of 5 experts. symptoms of an SSI. 39.4%
C. NR would change a dressing on
D. question types NR, 1 point for day 4 if the wound was oozing
correct answer, maximum score and take a swab for laboratory
of 18. testing.
E. given as % of nurses who B. No
answered correctly, stratified by C. Low knowledge of risk
hospital type (public/ private). factors (8.6%, n = 13/152)
D. Nurses who updated their
knowledge had significantly
higher total scores than those
who had not (t = 2.02,
df=135, p = 0.046)
A.Qasem and A. Nurses working in A. N/A A. A multiple choice knowledge A. 92.5% did not know the N/A
Hweidi (2017) critical care settings B. N/A test Questionnaire based on CDC correct classification of SSIs,
B. Jordan B. 200 C. N/A and SSI prevention guidelines. 75% believed a stitch abscess
C. 0.72 D. N/A B. Developed by Labeau et al. to be an SSI, 69.5% knew that
(2010) elective surgery should be
C. Investigator administered and postponed if there was an
collected the tool on sites over infection present in the patient.
2–3 weeks. B. 73% did not know that
D. 9 multiple choice questions surveillance reduces SSI
with 4 options: one correct incidences.
answer, two distractors and one C. No
‘‘I don’t know’’, scored based on D. low level of knowledge
quartile ranking system. overall 3.28 out of nine
E. knowledge level (very low, (SD=1.72, range = 0 to − 7).
low, moderate high) given as no.
of participants, %, and quartile.
A. Sessa et al., A. Infection control A. N/A A. Face-to-face interview A. 49.5% knew that SSI was Very positive attitude towards
(2011) nurses B. N/A B. Questionnaire interview one of the most common type the
B. Italy B. 527 C. N/A guide developed by authors, of Healthcare associated guidelines/protocols for
C. 0.895 D. N/A divided in to 5 sections: infection. disinfection procedures
demographic info, knowledge, B. No resulting in a mean score of
attitude, behaviours and C. No 9.1 (range from 1 to 10).
compliance, source of D. No Nurses concern for their own
information. safety was mean of 6.6 with a
C. Face-to-face lower score of 4.4 for
D. knowledge questions used
8
Index
three-point Likert scale and yes/ transmitting an infection to a

no questions, attitude used ten- patient.
point Likert scale, behaviours
used yes/no questions.
E. Given stratified by point on
Likert scale (no. %), or % of yes/
no answer.
A. Teshager A. Nurses from two A. N/A A. Structured and pretested A. 40.7% of staff were N/A
et al., (2015) hospitals B. N/A questionnaire knowledgeable of SSI
B. Ethiopia B. 423 C. N/A B. Developed by the authors prevention measures.
C. 0.498 D. N/A C. NR B. No
D. Knowledge questions: 12 C. No
multiple choice questions with D. The mean score was 6.19 out
only one correct answer. of 12 on SSI prevention. Male
SSI prevention practices: 12 nurses, longer years of service
questions using a 3-point Likert and those with specific
scale. infection control training had
E. Given as mean score, higher knowledge scores.
stratified by independent
variables such as gender and
years of experience.
A.Tschelaut et al. A. Surgeons from A. N/A A. Questionnaire on line A. 65% of surgeons were aware 95% of surgeon’s believed
(2018) hospitals across Austria. B. N/A B. Developed by the authors to of preoperative decolonization that SSIs are an important
B. Austria B. 158 C. N/A gather details on the modalities in their respective hospitals. issue. 61.5% of surgeons
C. 0.916 D. N/A of preoperative decolonization B. No stated that their hospital’s
and personal views about the C. No infection prevention and
value of this measure to prevent D. No control department provided
SSI. advice on prevention or
C. Online surveillance. 21% did not do
D. Yes or no questions surveillance in their
E. Given as absolute number. hospital’s.
62% not convinced of benefits
of decolonisation
A. Woldegioris A. Nurses from 4 A. N/A A. Structured and pretested A. 74.5% of nurses, with a N/A
et al., (2019) hospitals B. N/A questionnaire mean
B. Ethiopia B. 204 C. N/A B. Developed by the authors survey score of 54.8% had a
C. 0.498 D. N/A C. NR good knowledge of SSI
D. Knowledge of SSI: 25 multiple prevention with 50% and
choice questions, 3 options only above considered good
1 correct. Correct answers got knowledge. Nurses who had
one point, incorrect got 0 points. undergone education in SSI
Practice: 25 statements with a 5- prevention were 5.3 times
point Likert scale more likely to be
E. knowledge: A higher score knowledgeable on SSI
indicated a greater degree of prevention (AOR 5.3; 95% CI
knowledge. The participants 2.11–13.7) and those with over
who scored 14 and above were 5 years’ experience were 8.9
categorized as ‘knowledgeable’’. times more likely to be
knowledgeable on SSI
prevention (AOR 8.9; 95%CI
3.2–2.4).
B. No
C. No
D. No
A.Zucco et al. A. Nurses who work in A. N/A A. Pilot tested questionnaire A. 73% of nurses were aware of Attitudes were assessed based
(2019) surgical care areas from B. N/A B. Developed in accordance with the appropriate time to bathe on the nurse’s belief of the
B. Italy across the 20 regions in C. N/A WHO guidelines for SSI before surgery, 53.8% knew effectiveness of prevention
C. 0.895 Italy in 36 hospitals. D. N/A intervention by the authors, the correct time for hair strategies. Results showed that
B. 1305 divided in to 5 sections to gather removal from the operative dressing change received the
information on demographic site. 28.9% did not know the highest score at 8.9 out of 10.
details, knowledge on risks and correct definition of "bundle". The lowest result was the
prevention of SSI, attitudes, 14.1% were aware of the belief that the use of a steam
practice and sources of discontinuation of surgical sterilization unit should be
information. antibiotic prophylaxis within minimised in the operating
C. NR 24 h of surgery. theatre at 4.7. 97.8% wanted
D. Knowledge: 5-point Likert B. No more education on SSI
scale, Attitude: nurses rated C. 90.7% identified obesity and prevention.
effectiveness of procedures on a 74.2% identified smoking as
scale of 1–- 10 risk factors for developing an
Sources: open ended questions. SSI.
E. n(%) or Mean score (SD), D. Overall knowledge
9
Index
bivariate and multivariate deficiency on evidence based

analysis also given of scores. prevention strategies.
A.Gillespie et al. A. Nurses from medical A. N/A A. Pilot tested, 42-item Survey A. 44.3% identified that N/A
(2014) and surgical areas B. N/A B. Developed by authors dressings should be left on in
B. Australia B. 120 C. N/A C. NR the postoperative period for
C. 0.951 D. N/A D. Two main sections, (1) 35 5–7 days. 80% identified the
knowledge based questions–- correct signs and symptoms of
yes/no questions (2) questions a wound infection.
on surgical dressing using a 5- 50.4%‘’unaware’ of national
point Likert scale. practice standard
E. (1) Scores presented on bar B. No
charts as n(%) (2) scores C. 97.5% correctly answered
stratified by Likert scale that poor hand washing,
category n(%). patient comorbidities and poor
aseptic technique can cause
SSIs.
D. No
A.Eskicioglu A. Surgeons and residents A. N/A A. Survey emailed and posted A. 90% identified that evidence Perceived barriers to receiving
et al. (2012) B. 76 B. N/A B. Developed by experts supported the use of surgical antibiotics in a timely manner
B. Toronto C. N/A including surgeons, residents antibiotic prophylaxis and was too busy, clarity on whose
C. 0.936 D. N/A and knowledge translation maintaining normothermia. role it was, changes
experts to assess beliefs, While 71% prescribe bowel intraoperatively and lack of
knowledge and practices cleansing agents communication. Published
relating to SSI prevention preoperatively only 50% guidelines were perceived as
procedures. 16 questions across believed that there was important. 75–90% of
5 domains. evidence to support its use. respondents believed that
C. Online and paper copy. While surgeons were aware of checklists, standardised orders
D. Some use of Likert scale, not the evidence in relation to no and surveillance programmes
fully reported hair removal (100%) and were key in ensuring
E. Respondent (n), % and perioperative hyperoxia (90%) antibiotics were delivered in a
no. (%) of respondents reporting it was not practiced. timely manner. yet only 50%
’’important’’ or very important’’ B. No had these in their place of
on Likert scale C. No work.
D. No
A.Kolade et al. A. Surgical ward and A. N/A A. Reliability tested A. Demonstrated good N/A
(2017) operating room Nurses B. N/A questionnaire knowledge of SSI prevention.
B. Nigeria B. 250 C. N/A B. NR 55% of the respondents
C. 0.535 D. N/A C. NR reported that
D. Knowledge: 10 questions, 2 shaving before surgery reduces
points awarded for correct the chance of surgical
answer, 0 for incorrect answer. site infections, 25.6% reported
Attitude: 10 questions with a 4- that they do not have an
point Likert scale using negative idea.
wording such that strongly B. No
disagree got 4 points, strongly C. No
agree got 1 point D. No
E. Given as % correct/ incorrect
or % of each category on Likert
scale.
A. Vu et al., A. Intensive A. N/A A. Interview with a A. 44% demonstrated N/A
(2021) ressuscitation nurses B. N/A questionnaire knowledge of SSI prevention.
B. Vietnam B. 93 C. N/A B. NR B. No
C. 0.703 D. N/A C. Face to face C. 80.6% had awareness of risk
D. Questions on knowledge, factors for SSI.
question types not reported. D. No
Scoring mechanism described as
higher score represents better
knowledge.
E. Given as no. of respondents
(%)
A. Patil et al., A. Interns A. N/A A. Questionnaire A. 64% overall found to have Reasons for non-compliance:
(2018) Junior Residents, B. N/A B. Not included, seems to be low knowledge of SSI 43.47% felt an "Inadequate
B. India Consultants & C. N/A designed by Authors derived prevention guidelines. 60.86% supply of surgical
C. 0.633 Staff nurses D. N/A from WHO and CDC guidelines had not attended any infection consumables (Cap, mask,
B. 138 to gather sociodemographic control training scrub, antiseptic solution)"
info, knowledge of participants B. N/A made adhering to guidelines a
on SSI prevention, and practices. C. N/A problem. 21.73% found
C. NR D. N/A "Inadequate knowledge about
D. Knowledge: 9 multiple choice disinfection and sterilizing
questions with 1 correct answer. techniques" to be a problem
correct answer gets 1 point, and 26.23% agreed that lack
incorrect gets 0. of training about infection
10
Index
E. Knowledge: Low or poor control methods was a

knowledge < 60%, moderate or causative factor.
good knowledge 60–80% and
> 80% means high knowledge,
given as n(%) and scores
stratified by faculty.
education, on collaborating with other disciplines and on individual lasting 90–120 min which incorporated role play, group discussion and
roles and responsibilities in SSI prevention. The cumulative results use of videos in addition to the PowerPoint presentation. A significant
showed an overall score of greater than 4.1/5 (Khan et al., 2021). improvement in knowledge scores was noted from 6.02/25 pre-test to
Eskicioglu et al. (2012) found that 56% believed that the use of check 22.82/25 post-test. This improvement was sustained for four weeks’
lists reduced the incidences of SSI, 55% believed that a local protocol post-test (23.06/25; p < 0.01).
should be in place, 51% believed that surveillance should be in place in a Of note, none of the included intervention studies focused on
hospital, and 43% believed that a dedicated SSI coordinator should be in knowledge or attitudes in relation to risk factors for developing an SSI
post. and aimed to enhance participants’ attitudes in relation to SSI and SSI
In relation to attitudes towards SSI prevention guidelines, Kolade surveillance. Moreover, none of the included studies reported on the
et al. (2017) reported poor attitudes among nurses, with 68% believing relationship between of knowledge and attitudes and incidence of SSIs.
that guidelines added to workload, 60% believing that there is no evi
dence of the effectiveness of guidelines, and 70% believing that guide 5. Discussion
lines are not required. In another study, the beliefs of healthcare
professionals in the operating room were measured on a five-point Likert Findings from this review indicate, overall, healthcare professionals’
scale. Low scores (mean±SD) were reported in relation to education knowledge of SSI was poor. Provision of education and training of all
available (2.66 ± 0.99), knowledge of guidelines and policies (2.74 disciplines involved in the care of a patient’s perioperative journey is
± 1.12), and culture in relation to the prevention of SSIs (2.80 ± 0.71), considered a critical strategy in reducing the incidence of SSIs (Anderson
with a moderate score in relation to surveillance (3.1 ± 1.09) (Khan et al., 2014). In a qualitative study on understanding the determinants of
et al., 2018). Mengesha et al. (2020) reported that 91% of nurses SSI prevention, Troughton et al. (2019) highlighted that having funda
believed that lack of time and education affected their ability to practice mental knowledge of what an SSI is and how SSIs are classified is
SSI prevention measures. In contrast, with a mean score of 9.1/10, Sessa essential for healthcare professionals caring for surgical patients. Three
et al., (2011) found that infection control nurses had a very positive of the studies incorporated educational interventions which proved
towards guidelines and protocols. effective in improving knowledge. This finding is echoed in two other
With an average score of 8.5/10, Zucco et al. (2019) reported posi systematic reviews where staff education helped reduce SSIs (Ariyo
tive attitudes toward preoperative checklists among surgical nurses. et al., 2019; Tomsic et al., 2020).
Checklists were seen as beneficial in identifying patients with infection The majority of the included studies focused on either doctors, nurses
at the time of surgery, in ensuring the use of clippers for removing hair at or both with very few studies including other healthcare personnel such
operative site, to prompt changing of wound dressings when stained and as managers and technicians ( Khan et al., 2018; Khan et al., 2021). None
in ensuring more advanced cleaning procedures in the operative envi of the reviewed studies included members of the wider multidisciplinary
ronment after contaminated surgeries (Zucco et al., 2019). Similarly, team such as pharmacists, physiotherapists, occupational therapists, or
surgeons and anaesthesiologists in Ahmed et al.’s (2019) study reported dietitians. Furthermore, the majority of studies involving multiple dis
a positive attitude towards the role of surgical antibiotic prophylaxis ciplines of healthcare professional were undertaken in countries with a
with 98% of participants believing in the need for a local guideline and low and medium HDI score whilst studies from countries with high and
100% in the need for a national guideline to enable the implementation very high HDI tending to concentrate on single disciplines only. It has
of evidence-based practices. been argued that prevention of SSI is the role of all disciplines
throughout a patient’s perioperative journey; however, nurses often
take ownership of prevention strategies and wound care (Gillespie et al.,
4.8. Effect of interventions to enhance knowledge of surgical site infection
2020). It is recognised that SSI prevention requires input and collabo
and surgical site infection surveillance
ration from many disciplines and therefore education on SSI prevention
(Burden and Thornton, 2018; Su, 2016). SSI prevention is complex and
Three studies assessed healthcare professionals’ levels of knowledge
is the responsibility of everyone in the surgical team (Troughton et al.,
of SSIs before and after an educational intervention (Elsharkawy et al.,
2019). Engagement of multiple disciplines in multicomponent quality
2019; Khan et al., 2021; Nagdeo et al., 2015) (Table 4). One focused
improvement interventions, including surveillance, have been shown to
solely on knowledge of surgical antibiotic prophylaxis and SSI preven
reduce the occurrence of SSIs and maintain patient safety (Allegranzi
tion (Nagdeo et al., 2015). All three studies found a significant
et al., 2018; Ban et al., 2017; Schreiber et al., 2018). In addition,
improvement in post-intervention knowledge scores using educational
inter-professional task-based education and continuous education with
interventions such as PowerPoint presentations (Elsharkawy et al.,
updates every two years to drive the collaborative approach to SSI
2019; Khan et al., 2021; Nagdeo et al., 2015), and the provision of
prevention.
educational material and discussion (Elsharkawy et al., 2019). Khan
This review found that certain prevention strategies were affiliated
et al. (2021) reported a statistically significant increase in mean
to different roles. The results extracted from the included studies can
knowledge of SSI prevention measures from 49.10/100 pre-test to
lead to tentatively suggest that nurses are the primary focus of research
86.46/100 post-test (p < 0.00) among nurses, doctors and technicians
in knowledge of SSI prevention specifically in relation to hair removal
following five sessions of task-based education using reflexive learning.
practices, identifying risk factors for developing and the awareness of
Similarly, Elsharkawy et al. (2019) undertook an education module
11
Table 4
Study characteristics and findings from interventional studies (n = 3).
A. Author/ Year A. Healthcare Intervention A. Title B. A. Instrument used B. Name of Findings on knowledge of A. SSI Findingsa
B. Country C. professional Components C. Facilitators D. tool C. Mode D. Question type B. Surveillance C. Risk factors D.
Human cohort B. Sample Duration and Scoring E. Summary scores Summative knowledge
development size
index
A.Khan et al. A. Nurses, doctors A. Educational intervention A. Questionnaire pre and post- A. No breakdown of individual O1. Showed a significant
(2021) and technologists B. World Health Organisation test for knowledge, a questions on SSIs such as time improvement in knowledge
B. Pakistan B. 145 guidelines for the prevention questionnaire for satisfaction classification, length of stay where the mean pre-test score
C. 0.544 of SSI, collaboration of levels with training and semi- attributed to SSI, mortality rate, was 49.10/100, and the mean
multiple disciplines and on structured interviews on antibiotic prophylaxis, post-test score was 86.46/100
reflexive learning. behaviour change in practice normothermia, hair removal (p < 0.00).
C. Three experienced and after 8 weeks. and time for implant O2. Not reported.
trained facilitators from B. Developed by the authors surveillance.
nursing and anaesthesia. C. Not reported B. Not in paper
D. 7.5 h - 5 × 1.5 h sessions D. Knowledge: 14 multiple C. No
choice questions D. The mean pre-test score was
Behavioural change: 10 items 49.10, and the mean post-test
on a 5-point Likert scale score was 86.46 (on a 1–100
E. Knowledge: difference in scale).
pre- and post-test scores show
min score, max score, range, n,
mean, SD, and p-value.
Behaviour: mean score on likert
scale (SD)
A. Nagdeo et al., A. Surgeons A. Educational intervention A. Questionnaire pre and post- A. Unclear insufficient data O1. States that a significant
(2015) B. 22 B. PowerPoint intervention. available- improvement in improvement in knowledge
B. India C. Not clear B. Developed by the authors to single dose SAP. Continues for from pre-intervention to post-
C. 0.633 D. Not reported. collect information regarding 3–5 days postoperatively in pre- intervention however no data
the use of prophylactic intervention and reduced to one reported.
antibiotic, its duration, time of day or one dose post- O2. Surgical site infection rate
administration, source of intervention for all 80 cases. of 2.5% pre-intervention and
information, B. No not reported post-
guidelines followed in hospital, C. No intervention.
prevention of SSI, rate of SSI, D. No
and about the Hospital
Infection Control
Committee
C. Not reported
D. Not reported E. Not reported
A.Elsharkawy A. Nurses working A. Educational intervention A. Questionnaire A. Pre intervention Mean (SD) O1. Knowledge at baseline
et al. (2019) in the Obstetrics B. Education session using B. Adopted from NICE 6.02 ± 0.56 to post intervention mean of 6.02 (standard
B Saudia and Gynaecology PowerPoint and including role guidelines and Sickder study of 23.06 ± 0.86 P < 0.01 deviation [SD]=0.56) to post
Arabia department play, group discussion, 2010. B. No teaching 22.82(SD =0.99)
C. 0.875 B. 44 demonstration and use of C. Not reported C. No then two weeks post teaching
videos. Provision of booklet D. Knowledge: 25 multiple D. No 23.16 (SD =0.59) and four
with all education material for choice questions with only 1 weeks post teaching 23.06
each attendee correct answer. 1 point for (SD=0.86) P < 0.01.
C. N/A correct, 0 for incorrect. O2. Not reported.
D. 90–120 min Practice: 25 questions on a
likert scale.
E. Knowledge: all scores
summed up and illustrated into
three categories; Poor: (0–8.3),
average: (8.4 − 16.7) good from
(16.8–25).
Practice: all scores summed up
and
illustrated ted into three
categories; Poor from
(25–58.3), average from
(58.4–91.7) and good from
(91.8–125).
Also shown as Mean score (SD)
pre and post teaching, and
stratified by years of
experience/ education level.
O1. Healthcare professionals’ knowledge and attitudes

O2. Incidence of surgical site infection
a
Findings presented according to the review objectives:
signs and symptoms of an SSI. Whilst the majority of the studies with group approach to prevention strategies but also to promote multidis
samples of medical practitioners were heavily focused on surgical ciplinary ownership of SSI prevention which was effective in one study
antibiotic prophylaxis. SSI prevention is the role of all disciplines and in the review (Khan et al., 2021). Wound contamination classification
therefore interdisciplinary education should be considered to promote was examined in only two studies within this review, yet a contaminated
12
or dirty surgery classification increases the risk of SSIs (Qasem et al., 7. Conclusion
2017). Equally, knowledge of the classification for wounds assist peri
operative healthcare professionals to identify patients who are higher The evidence in this review confirms that the level of knowledge of
risk of developing SSIs. Recording the level of wound contamination in surgical site infection and its prevention is poor amongst healthcare
the intraoperative period is recommended not only for surveillance of professionals. The attitudes of healthcare professionals towards SSI
SSIs and for risk stratification, but to make decisions on the need for prevention was positive in particular towards their role in prevention of
surgical antibiotic prophylaxis or the need for further antibiotics (ECDC, SSIs. This calls into account the extent to which healthcare professionals
2017; National Institute for Health and Care Excellence, 2019a, 2019b). are being educated to reduce the incidence of SSIs. There were limited
In this review identification of SSI risk factors was explored exclusively experimental studies addressing knowledge and attitudes in the context
among nurses. The ability of all healthcare professionals to identify risk of SSI. This limited the ability of authors to draw definitive conclusions
factors for SSIs enables the application of measures and facilitates the and highlights the need for further experimental research. Future
ability to address any modifiable risk factors to reduce the incidences of research should focus on the wider multidisciplinary team as opposed to
SSIs (Triantafyllopoulos et al., 2015). Modifiable risk factors to prevent nurses and doctors exclusively.
SSIs such as nutritional status, smoking, alcohol consumption, poor
glycaemic control and personnel hygiene can all be addressed in the Funding sources
preoperative period before the day of surgery (van Rooijen et al., 2017).
It is necessary to have the requisite knowledge to identify risk factors to No external funding.
engage in prevention strategies for reducing the risk of developing an SSI
(Kirchhoff et al., 2010). Declaration of Competing Interest
It was also highlighted in the studies reviewed that there is a need to
provide resources for SSI prevention strategies to assist with knowledge The authors declare that they have no known competing financial
translation from guidelines to practice such as facilitators, audit and interests or personal relationships that could have appeared to influence
feedback and education (Brisibe et al., 2014; Vu et al., 2021; Eskicioglu the work reported in this paper.
et al., 2012; Kolade et al., 2017). A third of the studies reviewed rec
ommended SSI surveillance with feedback with one study recommend
Acknowledgements
ing that surveillance is resourced to ensure that SSI prevention is
embedded in practice (Eskicioglu et al., 2012). This compounds the need
There were no further contributors.
to engage the multidisciplinary teams in education so as to undertake
active surveillance to successfully implement evidence based guidelines
Appendix A. Supporting information
and to reduce SSI rates (Sartelli et al., 2020; National Institute for Health
and Care Excellence, 2019a, 2019b; World Health Organization, 2018).
Supplementary data associated with this article can be found in the
Findings from this review also illustrated the challenge of operational
online version at doi:10.1016/j.nepr.2023.103637.
izing guidelines into practice. The majority of studies recommended
further education while Gillespie et al. (2014) concluded that organi
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Nurse Education in Practice 69 (2023) 103637

Contents lists available at ScienceDirect

Nurse Education in Practice

Healthcare professionals’ knowledge and attitudes of surgical site infection

Table 1 Table 1 (continued )

4.3. Characteristics of the reviewed studies

departments (74.5% vs 43.3%) protection devices and alcohol

prevention guidelines. Validated infection has resolved. 75%

three-point Likert scale and yes/ transmitting an infection to a

bivariate and multivariate deficiency on evidence based

E. Knowledge: Low or poor control methods was a

O1. Healthcare professionals’ knowledge and attitudes

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