Level of Knowledge and Wound Care Practice at a Tertiary Referral Hospital in Ethiopia: A Survey in 180 Nurses

Wound infections are a global public health challenge, a major cause of morbidity and mortality in low- and middle-income countries. Poor wound care results delayed wound healing process and wound infections. Improving the knowledge and practice of wound care is paramount to reduce wound infection. However, there is no study done in Ethiopia. This study was aimed to assess the knowledge and practices of nurses who worked at Felege Hiwot Specialized Hospital towards wound healing and care. Methods A survey was conducted among 180 nurses worked in Felegehiwot specialized hospital during January 1 to 30, 2018. The study participants were selected through simple random sampling technique. Descriptive statistics were used to describe the study participants. Both Bivariable and multivariable ordinal logistic regression was done and proportional odds ratio (POR) with a 95% condence interval (CI) was reported to show the strength of association. A p-value < 0.05 was used to declare statistically signicant.


Abstract Background
Wound infections are a global public health challenge, a major cause of morbidity and mortality in low-and middle-income countries. Poor wound care results delayed wound healing process and wound infections. Improving the knowledge and practice of wound care is paramount to reduce wound infection. However, there is no study done in Ethiopia. This study was aimed to assess the knowledge and practices of nurses who worked at Felege Hiwot Specialized Hospital towards wound healing and care.

Methods
A survey was conducted among 180 nurses worked in Felegehiwot specialized hospital during January 1 to 30, 2018. The study participants were selected through simple random sampling technique. Descriptive statistics were used to describe the study participants. Both Bivariable and multivariable ordinal logistic regression was done and proportional odds ratio (POR) with a 95% con dence interval (CI) was reported to show the strength of association. A p-value < 0.05 was used to declare statistically signi cant.

Conclusions
The knowledge and practice of wound care of nurses were found to be poor. Above two-fth of nurses doesn't provide predischarge education on wound care. For this, provision of a structured preservice and in-service training and education program on wound healing and care, improve nurses educational level or experience sharing, establish and put in place wound healing and care guideline and assessment tools in hospitals and conduct the further qualitative study the level of wound care practice was recommended.

Background
Wound infections acquired during health care delivery are a global public health challenge, the commonest causes of nosocomial infections accounted to 20% to 25% [1] and leads to sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection [2]. It is a major cause of the increasing cost due to extended hospitalization [3,4], morbidity [5] and mortality particularly in low-and middle-income countries [6,7].
Wound infection resulted due to the disturbance of the wound healing process that must occur in the proper order, at a speci c time, and continue for a speci c duration at an optimal intensity [1]. Wounds are physical injuries that cause a disturbance in the normal skin anatomy and function and many factors can affect wound healing, [4,[8][9][10][11] causing impaired tissue repair.
Proper wound care is one the major preventive majors of wound infections [20-23], the world health organization (WHO) calls to prevent healthcare-associated sepsis with a simple cost effective practice such as hand hygiene [24,25]. The nurses' knowledge regarding wound care and the interventions provided at an early stage is important for wound healing and all surgical wounds require special nursing care both at the hospital or at home [26][27][28][29][30][31].
Assessing the knowledge and practice of wound care is paramount to reduce wound infection. Better knowledge of wound care decreases surgical complications, repeated admissions, hospitalization duration, and improves the quality of life [32]. The incidence rate of wound infection is still higher in Ethiopia, 10.9 to 75% [15,33,34] and in this hospital [34]. However, there is no study done on the knowledge and practice of wound healing and care at the national and regional level. Therefore, this study was conducted to assess the knowledge and practices of nurse professionals working at Felege Hiwot tertiary referral hospital, regarding wound healing.

Methods
Study Area, design and period A survey was conducted from January 1 to 30, 2018 in Felege Hiwot tertiary referral hospital found in Bahir Dar city. Bahir Dar is a capital city in the Amhara region in the Northwest of Ethiopia about 578 km from Addis Ababa and is one of the leading tourist destinations in Ethiopia, nearby Lake Tana and Blue Nile River [35]. In the city, there are 12 public health facilities, 10 health centres and 2 hospitals. The hospital is a tertiary hospital, serving over 7 million people as the referral centre and has around 400 beds and 9 operating tables and 750 members of staff and among those 292 are nurses. The hospital provides obstetrics, paediatrics, internal medicine, ophthalmology, ENT and surgery services [36].

Population and sampling
Source populations were all nurses who work in Felege Hiwot hospital. All sampled nurses of Felege Hiwot hospital who selected in a simple randomly technique will be included and nurse managers were excluded. The total number of representative sample was selected using a single population formula as follows: Where n= minimum sample size required for the study, (Z=1.96) with con dence interval of 95% and α =0.05, P=prevalence (p=0.5), w=is a tolerable margin of error (w=0.05). Using the correction formula with a 10% nonresponse rate, 182 was the nal sample size. Strati ed with Simple random sampling method was used by using the sampling frame which found from the head of nurses/ matron.

Variables and measurements
The dependent variables were knowledge and practice of wound care and the independent variables included were sociodemographic factors (age, occupation, educational background, marital status and facility-related factors (working area, and training on wound care).
Good Knowledge: participants who answer more than 80% of the knowledge questions correctly.
Moderate knowledge: those study participants who answer 60-79% of the knowledge question correctly.
Poor knowledge: those study participants who answer less than 60% of the knowledge questions correctly.
Good Practice: those study participants who correctly respond to practice questions and score above 80% Moderate practice: those study participants who correctly respond to practice questions score 60-79%.
Poor Practice: study participants who correctly respond to practice questions score below 60% [37]. Data collection procedure and quality control The data was collected using self-administered structured questionnaires adopted from different related kinds of literature [38][39][40] and modi ed in our context. A questionnaire was prepared in English and translated into the local language, and back to English for consistency. Two nursing staffs were collecting the data and one senior staff was recruited as supervisors and pretest was conducted in Finote Selam hospital on 5% of sample size. The data were checked daily basis for completeness and consistency.

Data processing and analysis
Data were entered and analyzed using SPSS version 23 and descriptive analysis such as percentages, frequency distribution was used. The bi-variable and multi-variable proportional odds model (POM), was tted to assess factors associated with knowledge and practice of wound healing and care. Chi-square parallel line tests were checked (p-value = 0.46), indicating that the assumption was not violated. Model tness using the chi-square goodness-of-t test (p = 0.152) was checked. All variables with a p-value ≤ 0.25 in the bivariable analysis were entered into the multivariable analysis to control the confounding effect. Adjusted proportional odds ratio (POR) with a 95% CI was used to assess the association between explanatory and outcome variables. Variables with p-values < 0.05 in the multivariable analysis were considered to be statistically signi cant. The analysis was done by reporting of STROBE statement checklist [41].

Ethical consideration
Ethical clearance was obtained from Bahir Dar University, department of nursing. A formal letter was written to Bahir Dar specialized Hospital and permission was secured from the medical director. All study participants were informed that they have the right not to participate in the study or stop the interview at any time they want if that was their choice. Written consent was obtained from all participants before the interview. All information obtained in the study was stored con dential and secured.

Results
Socio-demographic characteristics of the participants A total of 182 nurses worked in Felegehiwot comprehensive specialized hospital were participated in the study making a response rate of 100 %. Ninety-six, (52.7%) were females and two-third, (67.6%) of the participants was found within the age range of 20-30. Almost half, (47.8%) of nurse professionals were served from one to ve years and 138(75.8%) had a bachelor degree in nursing. Most of the respondents, 132(72.5%) does not get training about wound healing and care ( Table 1).

Level of knowledge of nurses regarding wound care
The study had found that 34 (18.7%) of the respondents have a good knowledge and two-fth, (41.8%) of the nurses had poor knowledge of wound healing and care. The majority172 (94.5%) knows as immobility, impaired nutrition, and location of the wound are risk factors for wound infection. Similarly, 118(64.8%) knows as wet therapy is the "gold standard" for treating chronic wounds and 127(69.8%) of the respondents know the pain in the wound must be evaluated by the patient than the healthcare providers. One hundred and thirty (71.4%) know the selection of the coverage of the wound should be based on a characteristic of the deathbed. Only half of 100(54.9%) of the respondents have known as the rst stage of pressure ulcer is cannot easily identify in people of dark skin and 135 (74.2%) respondents know as irrigation removes debris from wound better than swabbing ( Table 2).

Level of the practice of nurses on wound care
This study found, 109 (59.9%) of the respondents had poor and 17(9.3%) of nurses have a good level of practice on wound healing and care ( Figure 2). Forty-one (22.5%) of the participants were using the same dressing type for the entire wound healing time usually and almost half (48.9%) nurses change the treatment plan always when the wound lls with granulation tissue and epithelization.
Regarding the wound cleansing, more than half (57.8%) used normal saline always, 79 (43.4%) of nurses used hydrogen peroxide for sometimes and a large proportion (74.2%) were never used water for wound cleansing.
The majority, 62.6% and 61 % of the participants positioning the wound and observing the wound on daily ow, rush, and temperature respectively and above two-thirds (68.1%) of nurses provide suggestions about nutrition for the patient always (Table3). Regarding the predischarge education, 144(79.1%) of the participants informing about wound care always, mainly about the food groups for faster wound healing (67.0%) and119 (65.4%) of them provide education on hygiene to prevent infection on the incision area (Table 4).
Associated factors of the level of knowledge and practice of wound care In a bivariate proportional ordinal regression sex, working experience in this hospital, the clinical setting in this center and training on wound care was associated with knowledge of the wound care. But in multivariable regression, only working experience and clinical setting in this center was signi cantly associated with the level of knowledge of nurses on wound care.
Those nurses who have working experience of fewer than 5 years in this hospital has 58% times less likely to have a good knowledge (aPOR 0.42, 95% CI: 1.11, 2.72) than those working years 10 years and above. On the other hand, those working in the surgical setting or ward were ve and a half times greater chance of to have a good level of knowledge level (aPOR 5.45, 95 % CI: 1.61, 2.21) and those working in the emergency ward were 74 times less likely (aPOR, 0.26, 95%CI: 0.03,0.18) to have better knowledge than their counterparts.
Age, clinical experience, working experience in this center, clinical setting, training on wound care and level of knowledge in wound care were included in the multivariable ordinal logistic regression. But training and the level of knowledge of wound care were the only remaining signi cant factors of the practice of wound care. Those nurses who have to get training on wound care were 2 times higher odds of performing the good level of practice of wound healing and care than those who haven't get training ( aPOR 1.9, 95% CI: 0.59, 0.87). On the other hand, those women who have a good level of knowledge on wound care were ve and a half times greater chance of attaining a good level of practice than their counterparts (aPOR 5.56, 95% CI: 1.08, 2.26).

Discussion
Wound infection the commonest cause of nosocomial infection in healthcare and prevention with proper wound care is important. This study investigated the knowledge and practice of nurses towards wound healing and cares. About the level of nurse's knowledge on wound healing and care, the result of this study showed that 18.7% of the participants had good knowledge but a large proportion (41%) of participants have a poor level of knowledge. This was much lower than the studies conducted in Australia, 34.7% [42] Brazil, 69.4% [38], United Kingdom, 44.1% [43] and France, 28% [44] have good knowledge of wound care in respectively. The possible difference might be due to socio-demographic, clinical the setting, sample size and methodological difference and also the poor quality of care in our setting due to limited resources. Despite, this nding is better than a study done in Nigeria [45], only 6% had good knowledge.
The majority 172(94.5%) of the respondents have good knowledge of the immobility; impaired nutrition, and location of the wound are risk factors for wound infection. This study revealed that wound healing and care practice of nurses was very poor, 9.3%. The result of this study is similar a study done in Nigeria [45]. However, this is lower than the United Kingdom's nding [43], 40% and Turkey's [39], 50% of nurses have better practice on wound healing and care practice. This discrepancy might be because of socio-demographic, training and knowledge difference on wound care. In this study, it was found that 40.6% of the nurses did not provide predischarge education about wound healing regularly on the discharge of the patient, similar to a Turkish study [39]. Hence, patients discharged to home without the required knowledge and skill for care at home leads to physical and psychological stress.
This study revealed that the length of working experience was associated with knowledge of wound care. It showed the lower the year of experience, the lower the level of knowledge. This is supported by another study [43,46] . This might be since those who have lower years of working experience have lower chance to work with different experienced professionals not learn from their coworker's experience and prevents to gain acquired knowledge of wound care. The clinical setting difference is one of the factors of knowledge of wound healing and care, showed that those working at the surgical ward were more knowledgeable and those working in the emergency department were less knowledgeable. This is supported by a study done in Denmark [47] and the United Kingdom [48], knowledge varies as the role of nurses varies. This might be wound care would be expected to be performed routinely in everyday practice in the surgical ward than others which will increase their knowledge and lack of training for all staff providers and source on another ward might be explained for lower knowledge.
Furthermore, this nding showed that those nurses who have training on wound care have a higher level of practice than their counterparts. This is in line with other studies [43,49,50]. The possible explanation for this might be that those who have taken training would be more likely to be knowledgeable with the updated information, leads to the practice of the acquired evidence. Knowledge of wound care was the most predictor of wound healing and care practice, in which those professionals have good knowledge, were more likely to practice based on the recommendations. This is supported by different studies [43,48,51,52]. This might be explained due to hat the level of knowledge in the care of patients with wounds can re ect on their practice and in uence of the other members of the nursing team, their self-assessment of competence on the wound will be higher when they had increased their wound care knowledge, enhanced their practice of the evidence-based practice of wound care.
Even several extensive have been made to reduce the limitations; the study subjects in this study only included government hospitals and unable to a representative for private hospitals. The cross-sectional nature of this study will make it unable to form a temporal relationship between the outcome and predictor variables. The study is also prone to social desirability bias which could lead to over/underestimation of the study found hence it was self-reporting by the participants.

Conclusions
The knowledge and practice of wound care of nurses were found to be poor. Above two-fth of nurses doesn't provide predischarge education on wound care. For this, provision of a structured preservice and in-service training and education programs on wound healing and care, improve nurses educational level or experience sharing, establish and put in place wound healing and care guideline and assessment tools in hospitals and conduct further qualitative study the level of wound care practice was recommended.

Ethics approval and consent to participate
The study protocol was reviewed and approved by Bahir Dar University Research Ethics Review Committee. The o cial letter of cooperation was obtained from the College of Medicine and Health Science in Bahir Dar specialized Hospital and permission was secured from the medical director. All study participants were informed that they have a right not to participate in the study or stop the interview at any time they want if that was their choice. Written consent was obtained from all participants before the interview. All information obtained in the study was stored con dential and secured. Consent to publication: Not applicable.

Availability of data and materials
The data sets used and analyzed during the current study are available from the corresponding author on reasonable request.
Competing interest: the authors declare that they have no competing interests  Yr, year of experience    Others-Obs/gyn, Urology, Neurology, Geriatrics, Nephrology, Hematology and Pediatrics