DATA ACCESS OBJECTS

Aseptic technique, once a procedure undertaken by two clinicians working together is now mostly undertaken by a single clinician (Aziz 2009). Qualified nurses’ aseptic technique practices have been reported to be variable and confused for many years (Bree-Williams and Waterman 1996; Hallett 2000; Rowley 2001; Preston 2005; Aziz 2009; Rowley et al. 2010; Rowley and Clare 2011; Unsworth 2011; Gould et al. 2017a). Variable and confused practice is inevitable if there is lack of clarity in the meaning of aseptic technique. Differences in where and how health professionals have been trained and lack of educational updates since training have been blamed for disparate practices across the UK (Bree-Williams and Waterman 1996; Aziz 2009; Unsworth 2011; Unsworth and Collins 2011; Gould et al. 2017a). Literature reviews and continuous professional development papers criticise aseptic technique practice for being ritualistic in the absence of evidence (Hollinworth and Kingston 1998; Aziz 2009).

A literature review by Briggs et al. (1996) recognised a dearth of research into qualified nurses’ practice of aseptic technique compared to other infection

prevention practices such as hand-hygiene. Two studies have explored ward based nurses’ understanding and practice of aseptic technique (Bree-Williams and

31

qualified nurses’ practice of aseptic technique during wound care in the community (Hallett 2000; Unsworth and Collins 2011).

2.4.1 Ritualistic and complex practice

In Bree-Williams and Waterman’s (1996) mixed methods study, ward based nurses’ (n=21) aseptic technique during wound care was found to be complex and ritualistic. In sixteen out of seventeen observations of practice, nurses washed their hands more than twice. The transfer technique (clean forceps to transfer sterile material to the ‘dirty’ forceps) was maintained by three out of eight nurses. These findings may not be generalizable as the study was conducted in one hospital in the North of England, using a convenience sample of nurses. Selection bias may have affected the internal validity of the study as staff controlled researchers’ access to

observation of practice in the wards.

Earlier studies have found a simplified technique to be just as effective and

microbiologically safe as more complex techniques (Thomlinson 1987; Kelso 1989). In Thomlinson’s (1987) study, no difference was found in contamination rates between using forceps and gloved hands and ungloved hands washed in

chlorhexidine when cleaning abdominal wounds. Forceps were awkward to use and did not prevent the transfer of infection from the wound to hands. In Kelso’s (1989) study, a simplified aseptic technique (washing hands before and after the procedure and using one or two pairs of forceps without the transfer technique) was more cost effective, less time consuming, just as microbiologically safe than a more complex technique (using the transfer technique, five pairs of forceps and hand-washing three times). The simplified technique reduced the risk of airborne contamination by leaving the wound uncovered for a shorter period of time. More micro-organisms were isolated, the mean colony counts were higher on the finger streaks of both hands after loosening the dressing tape in lightly soiled dressings (70.7- 71.1) and moderately soiled (99.2-106.3) in the simplified technique than in the complex technique (15.2- 40.0) and (81.2- 87.9) respectively. Nevertheless, contamination of the forceps was reported to be similar in the simplified and complex technique. No data were presented to validate these findings.

The ‘clean’ hand, ‘dirty’ hand technique emerged following removal of forceps from wound dressing packs (Broome 1973; Alexander and O'Connor 1982). The ‘clean’ hand only comes into contact with the sterile field and the ‘dirty’ hand is used to clean the wound. Both hands should not come into contact with each other to avoid

32

contamination. Use of a ‘clean’ and ‘dirty’ hand has been criticised by Briggs et al. (1996) for lacking support from research evidence. Many other rituals have also been reported around the peripheral parts of aseptic procedures, such as cleaning the trolley (Briggs et al. 1996). In Thomson and Bullock’ study (1992) no benefit was found in cleaning the dressing trolley between patients unless visibly contaminated. The necessity for using a trolley in wound care has not been investigated (Briggs et al. 1996).

In conclusion, the complexity of aseptic procedures described in the literature varies (see Table 2). A simplified aseptic technique is not always promoted within the literature and practice guidelines. If nurses do not follow the available evidence, they may take unnecessary steps when performing aseptic technique.

2.4.2 Poor understanding of aseptic technique

The concept and principles of aseptic technique are not well understood by qualified nurses (Hallett 2000; Unsworth and Collins 2011; Gould et al. 2017a). A qualitative study by Hallett (2000) explored community nurses’ (n=7) perceptions of quality in nursing care using in-depth interviews. Community nurses did not fully explain the concept of aseptic technique and were uncertain about their ability to achieve aseptic technique in the domiciliary setting. These findings suggest a lack of understanding of how the principles of aseptic technique might be applied in the domiciliary setting. Hallett (2000) recommends the need to explore what is taught about aseptic technique in undergraduate education.

A qualitative study by Unsworth and Collins’ (2011) examined district nurses’ (n=10) adaptation of aseptic technique and adherence to the principles of asepsis using non-participant observation of aseptic procedures (n=30) and semi-structured interviews. In contrast to Hallett’s study (2000) district nurses believed they were able to perform aseptic technique in the community. In Unsworth and Collin’s (2011) study, nurses during interviews demonstrated understanding of the principles of aseptic technique and described adapting their practice to overcome challenges in the home environment. Despite this, nurses were observed contaminating the sterile field in twenty-one aseptic procedures. A lack of training and confusion over a clean technique and aseptic technique was identified.

A survey was undertaken to explore ward-based nurses’ (n=180) understanding of aseptic technique, confidence to perform aseptic technique and opportunities for educational updates and competency assessment (Gould et al. 2017a). Qualitative

33

content analysis of qualified nurses’ responses revealed a lack of clarity about the meaning of aseptic technique. Aseptic technique was identified as a method or procedure by 65% (n=91) nurses. Confusion over the terms ‘sterility’ and

‘cleanliness’ was evident. Forty-six percent of nurses showed some understanding of aseptic technique in minimising or preventing infection. Only six respondents gave a more accurate description of the underlying principle of aseptic technique, based on Lister’s work. The majority of nurses 92% (n=168) were very confident or confident in their ability to apply an aseptic technique, despite 72% (n=130)

reporting not receiving any training in the last five years and 90% (n=164) no competency assessment since training. Eighty-nine percent (n=161) of nurses agreed that it was important or very important to standardise aseptic technique. Similar to Clare and Rowley’s (2018) findings, 76% (37/49) of nurses strongly agreed that standardising practice improved patient care.

Studies into qualified nurses’ understanding and practice of aseptic technique have emerged over a long period of time. In that time general opinion about HCAIs and the extent to which they are avoidable has changed immensely. Healthcare has changed, with increasing admissions and turnover of patients and use of more invasive procedures and devices. While the practice of aseptic procedures may change, the underlying principles remain the same. Only one study has

comprehensively explored nurses’ understanding of aseptic technique (Gould et al. 2017a). Most studies have been conducted using small samples of qualified nurses from one NHS Trust in the North of England (Bree-Williams and Waterman 1996; Hallett 2000; Unsworth and Collins 2011). Geographical variations in aseptic technique practices may exist.

2.5 Summary

It is challenging for anyone wanting to inform their aseptic technique practice using the literature. There have been many different contributors to the literature upon aseptic technique who have perpetuated rather than demystified the confusion around aseptic technique. No universal definition of aseptic technique exists. It is therefore difficult for health professionals to determine what they should aspire to achieve in terms of aseptic technique. Furthermore, how can aseptic technique be measured in a healthcare system where audit and measuring cost effectiveness is important. Nursing students may be faced with learning a concept which lacks clarity and being taught by qualified nurses who have sub-optimal understanding and practices. Confusion around aseptic technique might impact on the teaching

34

and assessment of students’ competency in aseptic technique. The next chapter will present an overview of competency-based education and discuss how nursing students learn aseptic technique and are taught and assessed.

35

Chapter 3 - Aseptic technique in pre-registration