Effect of focused nursing training on infection control measures on nurses’ practice for patients undergoing percutaneous nephrolithotomy

Abstract

BACKGROUND

Nursing care for patients undergoing percutaneous nephrolithotomy (PNL) is a crucial step in reducing complications and promoting recovery. Infection control procedures are vital tools for preventing most complications. Proper nursing education and training for managing these patients can provide sufficient protection against urinary tract infections and related issues, such as secondary hemorrhage and hospital readmission.

AIM

To evaluate nurses’ performance after receiving nursing instructions regarding the infection control measures for patients with PNL.

METHODS

A quasi-experimental research design (pretest-posttest) was employed. The study was conducted at Assiut University Urology Hospital, Assiut University, Egypt. The participant nurses worked in units providing healthcare for patients who underwent PNL and received focused nursing instructions on infection control measures. The tools used included a structured questionnaire assessing their knowledge of PNL healthcare and a nurses’ practice observation checklist. The researchers completed these tools before and after the nurses received focused education on infection control measures. The focused education was provided through an illustrated booklet. The local ethics committee approved this study.

RESULTS

This study comprised 30 nurses, including 19 females (63.3%). Of these, 46.7% were in the 20-25 age group, 90% had a high educational level, and 50% had less than 5 years of work experience. Significant differences were observed between pre- and post-test scores in overall performance (P = 0.001), total preoperative scores (P = 0.001), immediate postoperative scores (P = 0.006), infection control measures (P = 0.001), and respiratory hygiene practices (P = 0.001). In the pretest, 16.7% of the nurses demonstrated adequate practice levels of infection control measures for patients undergoing PNL, compared to 100% in the posttest (P = 0.001). No significant relationships were found between nurses’ practice levels and their demographic variables (P > 0.050).

CONCLUSION

The nurses’ performance improved significantly after receiving focused nursing instructions on infection control measures for patients with PNL. Nurses should participate in ongoing training programs on infection control procedures.

Key Words: Infection control measures; Nursing education; Nursing instructions; Percutaneous nephrolithotomy; Surgical nursing

Core Tip: Percutaneous nephrolithotomy (PNL) is currently the most widely used treatment for urolithiasis. It requires appropriate surgical and nursing-based healthcare measures. Nurses play a vital role in maintaining aseptic techniques and preventing hospital-acquired infections through infection control measures. Professional healthcare systems must ensure that nurses have up-to-date knowledge of appropriate and well-developed protocols. The present study demonstrated that implementing structured nursing instructions on infection control measures for patients undergoing PNL resulted in a significant improvement in nurses’ clinical performance and compliance with infection control standards. However, conducting further long-term randomized controlled trials is highly recommended.

INTRODUCTION

Percutaneous nephrolithotomy (PNL) is a minimally invasive surgical procedure used for the removal of large or complex renal stones larger than 2 cm when other techniques cannot effectively treat them[1,2]. Despite its advantages, PNL poses a significant risk of postoperative complications, including infection, hemorrhage, and injury to surrounding structures[1,3]. Infection control measures are therefore essential to prevent postoperative sepsis and enhance patient recovery[4,5].

Nurses play a crucial role in maintaining aseptic techniques and preventing hospital-acquired infections by properly implementing infection control protocols[6,7]. Ongoing education and structured nursing training programs have been shown to enhance nurses’ knowledge, compliance, and clinical performance in infection prevention[7,8]. Therefore, this study aimed to assess the impact of nursing instructions on nurses’ performance concerning infection control measures for patients undergoing PNL.

MATERIALS AND METHODS

Study design

A quasi-experimental (pretest-posttest) design was employed to achieve the study’s aim at Assiut University Urology Hospital, Egypt, between November 2023 and May 2024. The study included 30 nurses working in the Operating Room and in the Urology Department who provided direct care for patients undergoing PNL. Head nurses and those who refused to participate were excluded. The sample included all available staff nurses during the study period. Nurses’ performance was assessed before and three months after implementing the nursing instructions regarding the infection control measures.

Practical assessments

Data were collected using a structured questionnaire composed of two parts: (1) Demographic characteristics, including age, gender, qualification, years of experience, and previous infection control training; and (2) An observational checklist assessing nurses’ practice related to infection control measures during preoperative, intraoperative, and postoperative stages.

Focused nurse training: Nursing instructions were implemented through two educational sessions, comprising both theoretical and practical components. The focus was on hand hygiene, personal protective equipment, respiratory hygiene, handling sharps, maintaining asepsis, and safe injection techniques. These items were based on relevant literature[9,10]. The instructions were delivered orally and through an illustrated booklet. The effectiveness of the intervention was evaluated by comparing pre- and post-training performance scores using the same checklist.

Scoring system: Fifteen items on the observation checklist, each of which had sub-items. At practice, the nurse’s performance was classified as correct and incorrect. The marks were totaled and converted to a percentage. Nurses received two marks for correctly completing the step, one mark for performing it incorrectly, and zero for an incomplete step. Practice was deemed adequate if the total score was 70% or higher, and inadequate if the score was less than 70%.

Tool validity and reliability: This process was rigorous and passed through the following steps: (1) Design and development of the tools by the researchers was based on the practical knowledge and literature background; (2) Five experts from the Urology and Medical Surgical Nursing Departments assessed the study’s tools to ensure they met the required standards for face and content validity; (3) Reliability was assessed using the Cronbach’s alpha test, and the test’s score was 0.813; and (4) A pilot study was conducted on 10% of the sample (3 nurses) to evaluate the applicability and clarity of the developed tool. Minimal modifications were needed. Accordingly, the participants in the pilot study were included in the study’s total sample.

Study outcome

The primary outcome was the change in the practice scores of the educated and trained nurses.

Ethical approval and registration

The study protocol was approved by the Ethical Committee of the Faculty of Nursing, Assiut University (IRB No. 1120220520). Additionally, it was registered in ClinicalTrials under the number NCT06437379. Upon clarification of the study’s purpose and procedures, written informed consent was obtained from all participants.

Statistical analysis

The Statistical Package for Social Sciences version 20 was used to code, index, tabulate, and analyze the gathered data. Numbers, percentages, means, and standard deviation were used to display the data in tables and figures. The McNemar, Pearson, and χ² tests were used to determine whether a relationship existed between the variables. A P value of less than 0.05 was deemed statistically significant.

RESULTS

This study included 30 nurses working in the Urology Department and Operating Room at Assiut University Urology Hospital. All participants completed both the pre- and post-instruction assessments. The sociodemographic characteristics of the participating nurses are summarized in Table 1. The mean age of participants was 25.4 ± 3.8 years, and 63.3% were females. More than half of the nurses (56.7%) had 3-5 years of experience, and 33.3% had previously attended infection control training programs.

Table 1 Distribution of the studied nurses according to their demographic data (n = 30).

Demographic data	n	%
Gender
Male	11	36.7
Female	19	63.3
Age
20-25	14	46.7
25-30	12	40
30-35	4	13.3
Residence
Rural	15	50
Urban	15	50
Qualifications
Diploma	3	10
Institute	26	86.7
Bachelor degree	1	3.3
Years of experience
1-3 years	2	6.7
3-5 years	13	43.3
5-10 years	9	30
> 10 years	6	20
Training attendance
No	20	66.7
Yes	10	33.3
Type (n = 10)	10	100
Infection control
Duration (n = 10)	10	100
Duration (2 hours)

As shown in Table 2, there was a significant improvement in nurses’ total practice scores after the implementation of the nursing instructions. The total mean score increased from 225.7 ± 24.3 (pretest) to 283.6 ± 15.4 (posttest) (P < 0.001). Preoperative care (P < 0.001), immediate postoperative care (P = 0.006), respiratory hygiene (P < 0.001), and total infection control measures (P < 0.001) all showed highly significant differences.

Table 2 Nursing practice regarding care of patients undergoing percutaneous nephrolithotomy (n = 30).

Variables		Mean	SD	P value
Total preoperative	Pre	5.2333	5.40551	0.0001
	Post	16.9333	1.41259
Total intraoperative	Pre	30.4333	13.15343	0.080
	Post	37.4000	16.94128
Total immediate postoperative	Pre	11.4333	2.34423	0.006
	Post	14.3667	5.16275
Total post-operative wound dressing	Pre	13.5667	3.84782	0.571
	Post	14.3000	5.89652
Percutaneous nephrostomy care	Pre	11.6667	5.05373	0.234
	Post	13.5667	7.03039
Intravenous cannula care	Pre	7.4667	3.35007	0.174
	Post	8.9667	4.94440
Total urinary catheter care	Pre	12.0000	4.69042	0.501
	Post	12.9667	6.26145
Total infection control measures	Pre	55.5000	9.16797	0.0001
	Post	70.3333	2.84464
Total save injection	Pre	18.1333	8.86968	0.108
	Post	21.9667	9.30140
Respiratory hygiene and cough etiquette	Pre	60.3333	6.23855	0.0001
	Post	72.8000	2.64445
Total performance	Pre	225.7667	24.28237	0.0001
	Post	283.6000	15.37710

Figure 1 exhibited that 16.7% of nurses demonstrated adequate practice before the instructions, compared with 100% after the educational intervention.

Figure 1 Total practice score levels of the studied nurses for patients undergoing percutaneous nephrolithotomy in the pre- and posttest (n = 30; P = 0.001, χ²: 42.857). The McNemar test was used.

No statistically significant relationships were found between post-instruction practice scores and nurses’ demographic variables, including age, gender, residence, educational level, or years of experience (P > 0.05) (Table 3).

Table 3 Relationship between nurses’ practices and the demographic characteristics of the studied nurses (n = 30), n (%).

Demographic data	Nurses’ practices				P value
	Pre-intervention		Post-intervention
	Inadequate	Adequate	Inadequate	Adequate
Gender
Male	11 (36.7)	0 (0.0)	0 (0.0)	11 (36.7)	0.129
Female	14 (46.7)	5 (16.7)	0 (0.0)	19 (63.3)
Age
20-25	12 (40.0)	2 (6.7)	0 (0.0)	14 (46.7)	0.483
25-30	9 (30.0)	3 (10.0)	0 (0.0)	12 (40.0)
30-35	4 (13.3)	0 (0.0)	0 (0.0)	4 (13.3)
Address
Rural	11 (36.7)	4 (13.3)	0 (0.0)	15 (50.0)	0.330
Urban	14 (46.7)	1 (3.3)	0 (0.0)	15 (50.0)
Education level
Diploma	3 (10.0)	0 (0.0)	0 (0.0)	3 (10.0)	0.060
Institute	22 (73.3)	4 (13.3)	0 (0.0)	26 (86.7)
Bachelor	0 (0.0)	1 (3.3)	0 (0.0)	1 (3.3)
Years of experience
1-3 years	1 (3.3)	1 (3.3)	0 (0.0)	2 (6.7)	0.286
3-5 years	10 (33.3)	3 (10.0)	0 (0.0)	13 (43.3)
5-10 years	9 (30.0)	0 (0.0)	0 (0.0)	9 (30.0)
> 10 years	5 (16.7)	1 (3.3)	0 (0.0)	6 (20.0)

DISCUSSION

This study assessed the impact of a structured nursing instructions protocol on nurses’ practices related to infection control measures for patients undergoing PNL. The findings revealed a substantial improvement in nurses’ total practice scores following the educational interventions. This improvement indicated that continuous and well-organized educational programs can significantly enhance nurses’ adherence to infection prevention standards and patient safety guidelines[11,12].

Although nursing practice appears to be optimal across both genders, it has long been a predominantly female profession. This generalized trend poses concerns about gender disparity[13,14]. The current findings may be consistent with gender disparity. However, there is an observable trend of males joining the nursing profession in our hospitals.

Most nurses demonstrated inadequate practices before the intervention, but they showed improvement to adequate levels after the intervention. This outcome is consistent with previous studies that emphasized the positive impact of structured education on infection control performance among nurses[6,15]. Mohamed Helmy et al[15] reported that nurses were able to improve their aseptic techniques and reduce postoperative infection rates by implementing evidence-based guidelines.

The statistical analysis revealed a significant improvement in certain areas, such as preoperative preparation, immediate postoperative care, respiratory hygiene, and overall infection control compliance. These findings were consistent with the results of Hosny et al[7], who highlighted that ongoing training increases adherence to standard precautions and reduces nosocomial infections.

No significant association was found between nurses’ demographic variables and their postintervention practice levels, which aligns with Ahmed et al[16], who found that age, gender, and years of experience had minimal effect on nurses when they received equivalent training[16]. However, nurses with higher academic qualifications tended to exhibit slightly better improvement, supporting the notion that educational background enhances critical judgment and clinical performance[17].

This improvement can be attributed to the interactive and practical nature of the sessions, which combined theoretical teaching with real-life demonstrations. Ibrahim Abdeen Mhana et al[4] reported that participatory training methods improve long-term retention of infection control principles compared to lectures alone[4]. Continuous supervision and reinforcement also played a key role in maintaining proper infection control behaviors[18].

These findings underscore the importance of regular in-service education and supportive supervision in sustaining safe clinical practices. Specifically, it represents a crucial intervention in high-risk surgical units[19,20]. Mohammed et al[20] found similar outcomes, reporting that continuous educational interventions improved nurses’ adherence to infection control guidelines and reduced postoperative complications[20].

Nurses are considered responsible for implementing essential infection control measures[21]. They should promote the proper use of personal protective equipment, adherence to hand hygiene, and maintenance of sterile procedures. Heavy workload stressors, including fatigue, resource constraints, and compliance issues, decrease the effectiveness of infection control measures[21,22].

The institutional culture that prioritizes continuous education and training on infection control measures plays a crucial role in promoting nursing efforts to prevent hospital-acquired infections. Healthcare systems should maintain a culture that prioritizes safety, continuous training, and supportive leadership in the area of infection prevention[22-24]. The present study may promote this attitude by providing focused nurse training on specific procedures such as PNL.

Several initiatives have been introduced to improve patient outcomes, reduce rates of healthcare-related infections, and establish a safer workplace for staff[21,25,26]. The prevention and control of hospital-acquired infections relies heavily on the importance of patient safety. It has become a primary component of quality improvement initiatives in hospitals across various countries[21,22,25]. Future research should focus on the influence of nurse-led initiatives, the integration of modern artificial intelligence technologies for infection monitoring, and innovative training methods that can potentiate nurse compliance. Engaging nurses in hospital-based initiatives can help promote a sense of ownership and validation of their expertise[21,26].

In the literature, nurse education and training programs have been applied to various surgical settings[8,15,19,27,28]. However, the present study implemented a focused training program for nurses on infection control measures after PNL. This focused and structured training was provided to nurses in settings that serve patients with PNL, as PNL is currently the most common procedure performed for stones at our institution. The significant improvement in their knowledge and performance represented a short-term outcome. However, this constituted one of the study’s limitations, as assessing the long-term effects of this policy may require further long-term studies.

The sample size was limited to nurses who worked exclusively in settings that provided services to patients with PNL. Therefore, it was another limitation of the present study. The small sample size has a potential impact on statistical power, increasing variability, making it difficult to detect small effects, reducing confidence in the results, and increasing the likelihood of chance findings[29]. Additionally, it may influence the external validity of the results by making it difficult to generalize the study's findings to larger populations[30].

The quasi-experimental study design, lacking a control group, was another limitation of this study. Therefore, it is recommended to conduct future randomized controlled trials to verify whether these improvements are solely attributable to the focused nurse training intervention.

On the other hand, healthcare education programs for patients are another important strategy in the literature[31,32]. It should be implemented side-by-side with the education of nurses.

Overall, the present study highlights that structured nursing instruction is an effective strategy for bridging the gap between theoretical knowledge and clinical application, promoting standardized infection control practices and improving patient outcomes[15,18,19].

CONCLUSION

Nurses may have inadequate education and training on proper care for patients undergoing PNL. Based on the findings of the present study, nurses’ practice improved after receiving focused nursing instructions on infection control measures for patients with PNL.