Nurses Practice Regarding Post-operative Wound Care And Its Associated Factors Of Hospitalised Patients In Public Hospitals Of Mekelle City, Tigray, Ethiopia, 2018/19.

Background: Post-operative wound care is a care that applied sterile gauze or bandage to wound to promote healing and protect the wound from further harm after surgical operation is done internally or externally to the involved organs. Post-operative Wound care is a nursing duty that requires excellent skills and knowledge to prevent massive complications such as infection, gangrene and amputation or, in severe cases, even death. Methods: Hospital based cross sectional study design was implemented and the total sample size was 375 nurses working in Ayder Comprehensive Specialized Hospital, Mekelle Hospital and Quiha hospital. Pre-test was done on 10 % of the sample size. Data was collected by observation and face to face interviewing using pre tested checklist and structured questionnaire respectively from March 20, 2019 to May 20, 2019. Simple random sampling was used. Data was coded, entered and analyzed using SPSS version 22.0 for statistical analysis. Binary logistic regression analysis was used to determine the predictor variables to the outcome variables with 95% condence level at p-value of < 0.25 and nally p-value < 0.05 was described as statically signicant. Result: A total of 375 respondents were participated in the study. Among them, 234(62.4%) were women. The overall nursing post-operative wound care practices were poor 258(68.8%). Work experience (AOR=0.47, 95%CI; 0.26-0.86), level of education (AOR=0.03, 95%CI; 0.004-0.25) and lack of materials (AOR=0.29, 95%CI; 0.09-0.89) was found to be associated with nurses post-operative wound care practice. Conclusion and recommendation: Factors such as work experience, educational level and lack of materials were statically signicant association with nurses post-operative wound care practice. Highly qualied in other staff in the tenderized dressing techniques of postoperative wounds.


Background
Wound care is de ned as the application of uid to a wound to remove exudates, slough, necrotic debris, bacterial contaminants and dressing residue without adversely impacting cellular activity vital to the wound healing process (1). The custom of post-operative wound care practice is as old as the history of surgery (2). It was started by washing the wounds by beer, making the plasters and bandaging the wound(3).
Approximately10% of the hospitalized surgical patients suffers from surgical site infection in the world due to insu cient nursing postoperative wound care practice. Adequate level of skill and positive attitude are essential components in the delivery of post-operative wound care (4).
Effective wound care promotes wound healing and leads to early discharge and saving costs. The dressing protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing (5).Even to prevent such post-operative complications, it is necessary to study existing wound care practices and measure the difference between these and, ideally, to lean more towards evidence-based practices for wound care (6).
A surgical site infection is one of the most common causes of health care associated infection. It is also one of the most important complications of a surgical intervention. Certain factors are known to be responsible for surgical site infections. including application of skin antiseptics, inadequate sterilization of instruments, surgical hand's scrubs, and post-operative dressing techniques (7).
Postoperative wound infection is the leading infection in the general patient population in countries with limited resources, affecting up to two third of operated patients and with a frequency up to nine times higher than in developed countries. Postoperative wound infection accounts for about 15% of all healthcare-associated infections and about 37% of the hospital-acquired infections of surgical patients. In western countries, the frequency of such infections is 15-20% of all cases, with an incidence of 2-15% in general surgery. In Africa an incidence of surgical site infection ranging from 2.5-30.9% following various types of surgical procedures and up to 21% of operated patients develop wound infection in Ethiopia (9, 10).

Study area and period
The study was conducted in public Hospitals of Mekelle city, Tigray, Ethiopia The study was conducted March 20, 2019 to April 20, 2019.

Study design
Institutional based cross -sectional study was employed.

Source population
All nurses working in post-operative Hospitalized Patients at the public hospitals of Mekelle city.

Study population
All selected nurses who are working in post-operative hospitalized Patients of the public hospitals of Mekelle city in the study period.

Inclusion and exclusion criteria
Inclusion criteria All nurses working in post-operative hospitalized Patients at the public hospitals.

Exclusion criteria
Nurses who were not directly involved in the bedside patient care such as head nurse and facilitator.

Sample size determination and sampling technique
The actual sample size for the study was determined by using the formula for single population proportion by assuming 5% marginal error (d), 95% con dence interval and the proportion of poor nurses practice on post-operative wound care was taken 57.7% from previous study in Tanzania among nurses working in surgical wards. Based on the above information, the total initial sample size was calculated by using the formula.
Where;n = require initial sample size, Z = critical value for normal distribution at 95% con dence interval which equals to 1.96 P = 57.7%, estimated proportion of nurses who had poor Practice on postoperative wound care. Since the source of population is few and to increase the representativeness, correction formula was not used and the study participants nal sample size was 375 nurses.
Sampling technique and Sampling procedure Simple random sampling method was employed to allocate the 375 study participants who are working in the wards during data collection period. Sampling process was based on lottery method Operational De nitions Practice -The application of standards and knowledge in to action (12).
Good practice -those who scored above the mean on practice items (9 and 14).
Poor practice -those who scored below the mean on practice items (9 and 14).
Post-operative -a period from patient is admitted to ward after having surgery till discharge home (28) Wound care -dressing of wound using standard way (8).

Data collection tool and technique
Standard checklist and set of structured questionnaires by reviewing different literatures and modi ed by the researcher was used to collect the data after getting ethical clearance from IRB of Mekelle University. It was prepared in English then, the data were collected using observation and face to face interview from the study subjects. In this study BSc Nurses was collected data using a pretested checklist and questionnaire from the sample population according to the inclusion criteria. Four data collectors (BSc Nurses) from Mekelle Health Center and two supervisors (MScN) from Ayder comprehensive specialized Hospital was selected and they were participated throughout the data collection period.

Data quality control
Prior to data collection a two days training was given by the principal investigator. The training was supported by clearly prepared training manual and incorporated that; objectives of the study, introduction of checklist and questionnaire format, Procedure of observing and interviewing. To ensure quality of data, properly designed standardized data collection tool was used. Pre-test was conducted using 10% of the sample on nurse working in surgical ward in Wukro hospital before 2 weeks of the actual data collection period to assess instrument validity, simplicity, ow and consistency and questionnaire modi cation was made after the pretest accordingly Data processing and analysis The collected data was edit, check visually for its completeness and the response was coded, enter and analyzed using SPSS version 22.0.Descriptive statistics such as frequency, percentage mean and standard deviation was computed and the results was summarized and present by tables, charts and texts.

Socio-demographic characteristics of respondents
A total of 375 nurses were involved in the study with the response rate of 100%. Among the participants 234(62.4%) of them were females, the mean age and standard deviation of the participants was 33.98 ± 6.12 with majority of 207(55.2%) of the nurses age was 25-34 years, educational level of the study participants282 (75.2%) of them had BSc degree in nursing. Regarding, work experience in the wards of the study participants majority 182(48.5%) of them had from 2-5 years (As shown in Table 1). Nurse's practice on postoperative wound care More than half 201(53.6%) of nurses were able to review physician order for dressing change procedures. Regards to documentation and teaching phase, documenting after dressing any signs of in ammation, infection or wound progress were done only by 3.7% of the participants followed by record of date and time 8.5% after the procedure (As shown in Table 2).   Note AOR = adjusted odds ratio, COR = crude odds ratio, 95% CI = 95% con dence interval

Discussion
In this study, nurses' post-operative wound care practice of 375 nurses working in admitted patients of Mekelle public hospitals were analyzed. Among the total Nurse, majority 258(68.8%) of them had poor post-operative wound care practice. This result was higher than a study done in Tanzania Muhimbili National Hospital were 57.7% (9) and Khartoum State Alamal hospital 23.4% (13). This could be due to the difference in study population and staff commitment.
In the Preparation phase More than half (53.6%) of nurses were able to review physician order for dressing change procedures. this is less than a Study done in Khartoum State Alamal hospital66.7% (13). prepare necessary equipment's was done by 69.5%, and there is a relatively similar result in TanzaniaMuhimbili National hospital64.8% (9). Explain the procedure to patient or patient family was done by 46.1%which is lower than a study in Tanzania Muhimbili National hospital81.7% (20) and Khartoum State Alamal hospital59%(25). Provide privacy 9.1%. its lower than a Study in Nigeria 83.3% (15).Nurses hand washing before the procedures start was 27.7%. Lower than Study in Tanzania Muhimbili National Hospital 49.3% (9) and A study done in Kenya Mariakani cottage hospital 57.1% (17).
This could be due to the difference in staff experience.
In the Applying of dressing technique phase, wear disposable glove to remove old dress was observed by 68.3% this is lower than a Study done in Tanzania Muhimbili National Hospitals 99% (20). Put on sterile glove was done by 81.9%,this is higher than a Study done in Tanzania Muhimbili National Hospital 63% (9).clean wound with antiseptic solution using gauze swab from least contaminated area to most contaminated 51.7%,its higher than a Study done in Tanzania Muhimbili National Hospital 34%, (9).Use separate gauze swab for each stroke 42.7%,lower than a Study done in Khartoum State Alamal hospital 55% (26).Cover the wound with sterile gauze 96.5%. its higher than a study done in Sudan Bahry Hospital 58.3% (16). This could be due to difference in material availability.
Regards to documentation and teaching phase, documenting after dressing any signs of in ammation, infection or wound progress were done only by 3.7% of the participants followed by record of date and time 8.5% after the procedure. This is better than a Study done in Tanzania Muhimbili National Hospital 0% (9)and lower than study done in Rwanda Butare Hospital 13% (8). This may be due to the different in nurse's habit towards documentation and hospital regulation.
Post-operative counseling and instructing the patient/relatives not to temper with the wound and nutrition was 13.6% of nurses. This result is Relatively similar with a Study done in Tanzania Muhimbili National Hospital 15% (9).This may be due to the similarity in study design and study participants. And its lower than a Study done in Khartoum State Alamal hospital 33.3% (13). This may be due to different study setting. Among the participants 14.4% of the answered that there is lack of familiarity with antiseptics. This result is lower than a study done in Mekelle public hospitals pediatric ward 26.6%(15). The possible difference may be due to the present study is wider in scope than the previous one as well as due to the instrument variation.
Work experience was signi cantly associated with poor nurses practice of post-operative wound care.
This result is supported by the studies conducted in Nigeria (15) and Iraq (9).Educational level was also signi cantly associated with poor nurses practice of post-operative wound care. This result is supported by the ndings conducted in Jaban Baghadad (19).Lack of materials is also signi cantly associated with poor nurses practice of post-operative wound care. This result is supported with the studies conducted in kenyataMarakani (17). The possible reason might be due to the similarity of study design.

Conclusion
Nurses' practice was observed good in covering of the wound with sterile gauze, however regards to recording of in ammation and infection was the lowest practice observed by nurses. Over all nurses' practice towards post-operative wound care was poor performance. Nurses Practice of post-operative wound care depends on work experience, educational level and lack of materials.
Based on the above nding of the study the following recommendations were made: -

Abbreviations
Declarations Ethics approval and consent to participate Ethical clearance and approval was obtained from the institutional review board of Mekelle University CHS. Letters of permission was obtained from each hospitals Moreover, prior to conducting the study, the purpose and objective of the study was described to the study participants and written informed consent was obtained. The study participants were informed as they had full right to discontinue during the interview. Participants' con dentiality and any special data security requirements was maintained and assured by not exposing patients name and information. According the university ethical clearance rule and regulation, ethical clearance was obtained from institutional review board of Mekelle University (Reference number, MU/ 1266 /2019).

Consent for publication
Not applicable as there is no image or other con dentiality related issues.

Availability of data and materials
The datasets used during the current study is available from the corresponding author on reasonable request.

Competing interests
The author declares that they have no competing interests.

Funding
Mekelle University was the source of funding (refence No. 1266/2019).The University covers all payment issues related to the study (data collection-nal).
Author's contribution YT, KB and KB make interpretation of the data and helping during analysis. GL prepares and submits the manuscript. All author have read and approved the manuscript.

Figure 1
Institutional related associated factors