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International Journal of Nursing Practice 2014; 20: 187–193
RESEARCH PAPER
Malaysian nurses’ skin care practices of preterm infants: Experience vs. knowledge Zainah Mohamed Master in Nursing Neonatal Cert RN PhD Candidate, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia Lecturer, Nursing Department, Faculty of Medicine, Universiti Kebangsaan, Malaysia
Jennifer Margaret Newton PhD Ed.D Grad Cert Sci RN RM Associate Professor Research, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
Rosalind Lau PhD MPH MEdStuds BAppSci RN RM Research Fellow, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
Accepted for publication December 2012 Mohamed Z, Newton JM, Lau R. International Journal of Nursing Practice 2014; 20: 187–193 Malaysian nurses’ skin care practices of preterm infants: Experience vs. knowledge This study sought to explore the impact of Malaysian nurses’ perceptions, knowledge and experiences in preterm infant skin care practices using a descriptive approach. Questionnaires were distributed to Neonatal Intensive Care Unit (NICU) nurses in one teaching hospital in Malaysia. A knowledge gap was revealed among nurses in both theoretical and practical knowledge of preterm infant skin. Nurses working for more than 5 years in NICU or having a Neonatal Nursing Certificate (NNC) were not predictors of having adequate knowledge of preterm infants’ skin care. The results highlight the complex issue of providing effective skin care to preterm infants. However, a specific finding related to nurses’ confidence provides some direction for future practice and research initiatives. Clear clinical evidence-based guidelines and Continuing Nursing Education on relevant topics of preterm infants’ care may provide the required knowledge for the nurses. Key words: neonatal nursing, nursing knowledge, preterm infant, quantitative, skin care.
INTRODUCTION Preterm infants are exposed to numerous medical and nursing procedures during hospitalization. During this period, the infants’ skin plays an important role as a protective and regulatory barrier between the body and the external environment.1 Infants born at 26 weeks gestation have a thinner epidermis layer than infants born at 34
Correspondence: Zainah Mohamed, School of Nursing & Midwifery, Faculty of Medicine, Nursing and Health Sciences, P.O. Box 527, Building E, Peninsula Campus, McMahons Road, Frankston, Vic. 3199, Australia. Email: [email protected] doi:10.1111/ijn.12125
weeks gestation.2 Fat and zinc which are essential to maintain an intact, healthy skin surface are also insufficient at this time.3 Therefore, the lower the preterm infants’ gestational age is, the higher their risk of developing skin damage and injury. A thin epidermis layer may lead to problems such as transepidermal water loss (TEWL), ineffective thermoregulation, skin injury and infection.3 Despite these potential risks, the management of the preterm infants’ skin is considered to be a lesser priority than cardiovascular or respiratory stability.4 Although nurses may not have control over many of the factors that place preterm infants at risk for skin breakdown, nurses have the ability to positively influence the outcomes © 2013 Wiley Publishing Asia Pty Ltd
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through knowledgeable assessment, prevention, treatment and evaluation of infants’ skin integrity.5 While several studies have found that level of education is a better predictor of improved patient outcomes;6,7 others argue that nursing education provides limited information on the basic knowledge and nursing care of preterm infants’ skin.8,9 This is disconcerting as nurses need to understand their actions and incorporate this understanding10 into their daily professional practice by being able to combine knowledge, reasoning and skills.11 The two key components of nursing knowledge are theoretical knowledge and practical knowledge. Theoretical knowledge or ‘knowing that’ is acquired through the formal setting of nursing schools, books, scientific journals or lectures.12 Practical knowledge or ‘knowing how’ is acquired through the practice of nursing. The latter entails both knowing what we do and understanding what we are doing; it is not just premised on habits, routines or guidelines.13 Practical knowledge is gained over time through clinical experience, and this experience is essential for expertise to develop.10 Most models of expertise suggest that about 5 to 10 years of practical experience is necessary for expertise to develop.10,14 Repeated clinical experience with similar situations results in better performance15 and acquisition of a motor skill normally follows a smooth curve with increased years in clinical experience.16 However, clinical experience alone has been reported to have no significant influence on improving the outcomes of patients.6,7,17,18 A longitudinal study on clinical skill development found that nurses with more experience tended to make as many mistakes as less experienced nurses.17 To ensure that their knowledge is developed, nurses must be aware of and reflect on a learning experience to enable the synthesis of old knowledge with new knowledge.10
PURPOSE OF THE STUDY This study sought to explore Malaysian neonatal nurses’ skin care practices based on their knowledge, measured by possession of a Neonatal Nursing Certificate (NNC), with nurses who rely on their knowledge base derived through experience alone. Nurses’ perceptions on their level of knowledge of preterm infants’ skin care were also examined. The practices of preterm infants’ skin care were examined in five specific areas: general knowledge, TEWL, adhesive application and removal, skin disinfectant and skin injury related to medical devices. The relationship between nurses’ level of knowledge, length of © 2013 Wiley Publishing Asia Pty Ltd
work experience in Neonatal Intensive Care Unit (NICU) and holding the NNC was also explored. The NNC is a full time 6-month specialized course with a focus on advanced neonatal care knowledge and practice.
METHODS—SETTING AND SAMPLE A quantitative descriptive approach, using a survey design was conducted in a NICU in a university hospital in Malaysia. Participants were qualified nurses working in the NICU. No exclusion criteria were applied in this study. During the study period, the NICU had 54 female Registered Staff Nurses (RSN). Forty-one (75.9%) neonatal nurses voluntarily participated in this study. Approval to conduct the study was granted by the ethics committee of the study site (FF-248-2008) and the researchers’ university (Number: CF08/2409– 2008001232). The questionnaire consisted of three sections: (i) demographic data and (ii) nurses’ perceptions of their level of knowledge measured on a 4-point Likert scale, along with open-ended questions on sources of knowledge used in managing preterm infants’ skin. The third section comprised 20 multiple choice questions on knowledge of adhesive application and removal, skin disinfectant and tissue injury due to medical devices. The correct answers were totalled. The nurses were also given an opportunity to provide suggestions on how to improve preterm infants’ skin care in their workplace. This questionnaire was adapted from a questionnaire designed by Lund et al.9 Some questions were not relevant to the area of this current study and therefore were omitted. Alternative questions were developed based on a literature review of previous studies on preterm infants’ skin care. Content validity of the questionnaire was then tested and reviewed by a panel of experienced neonatal care practitioners that consisted of three neonatal specialists and two neonatal nursing experts from two different hospitals (n = 5, average years of experience = 15). Nursing staff were introduced to the study during a staff meeting by one of the researchers. Posters of the study were displayed in the staff tea room along with explanatory statements and questionnaires. Nurses who chose to participate were given 1 week to complete the questionnaire at a time convenient to them. Completed questionnaires were placed in an envelope, sealed and placed in a locked box for confidentiality purposes. The box was subsequently collected by one of the researchers.
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Data were analyzed using SPSS version 15.0 (Statistical Package for the Social Sciences; Chicago, IL, USA). Descriptive analyses were performed on the demographic data and level of knowledge of preterm infants’ skin. The level of knowledge of preterm infants’ skin was scored based on the respondents’ correct answer to each question. Fisher’s Exact tests was used to determine if there was a relationship between nurses’ knowledge of preterm infants’ skin with length of work experience in NICU and holding the NNC. Fisher’s Exact tests were used due to the small sample size.
RESULTS The mean age of the 41 participating NICU nurses was 28.8 years. Details of the general characteristics of the participants are shown in Table 1. All participants held a Diploma in nursing which in Malaysia is a 3-year education programme. Although most of the respondents had been working in NICU for more than 5 years, 33 (80.5%) of the respondents did not have an NNC and, interestingly, 36 (87.8%) respondents had only ever worked in NICU, starting there as new graduates. Table 2 provides details of respondents’ years of NICU experience and holding a NNC. The results revealed a diversity of knowledge and care practices among this group of NICU nurses. Nearly all of the respondents (80.5%) somewhat disagreed they had a Table 1 General characteristics of the respondents (n = 41) Characteristics Age (years)
Marital status Ethnicity Entry when commenced working in NICU Experience in NICU (years)
Neonatal nursing certificate
36 Married Single Malay New graduate Experienced RSN 5 years and having no NNC Experience in NICU > 5 years and having a NNC Total
13 20 8 41
31.7 48.8 19.5 100
NICU, Neonatal Intensive Care Unit.
© 2013 Wiley Publishing Asia Pty Ltd
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Table 3 Respondents’ scores of correct answer of preterm infants’ skin care knowledge (n = 41) Variables
General knowledge of preterm infants’ skin 1) Evaporation is the greatest source of heat loss for a preterm infant. 2) Maintenance of skin integrity in the preterm infants is most important to limit insensible water loss. 3) The risk of skin breakdown is increased in preterm infants’ skin. 4) Skin maturation is influenced by the gestational age of the neonate. 5) Incomplete developed stratum corneum limits the function of preterm infants’ skin. 6) Trace minerals is important in maintaining skin integrity and promoting wound healing. 7) Appropriate caloric intake is necessary for maintaining skin integrity and healing skin breakdown. 8) Oedema often exhibit in newly born preterm infants. Knowledge of TEWL 1) Increased humidity in the incubator will also increase the ambient temperature in the incubator. 2) Setting of appropriate ambient humidity will contribute to ‘rain out’ in an incubator. 3) Measurement of TEWL reflects the maturation of the stratum corneum. 4) TEWL can be reduced by specific interventions. Knowledge of adhesive application and removal 1) The immaturity of preterm infants’ skin will create problems upon application and removal of adhesive tapes. 2) In spite of improving skin dryness, emollients containing petroleum will also lead to risk of sepsis. 3) Skin breakdown pertaining to adhesive application and removal can be prevented through specific procedures Knowledge of skin disinfectant 1) Solutions contained povidone iodine can be absorbed through the skin and could lead to hypothyroidism. 2) Povidone iodine should be removed immediately from the preterm infants’ skin using saline or sterile water. Knowledge of skin injury 1) Skin injury related to pulse oximeter probe can be reduced by routinely change the probe sites. 2) Adjusting the height and level of the bed will prevent pressure on the nares due to Nasal Continuous Positive Airway Pressure (NCPAP) driver. 3) IV infiltration and extravasations can be prevented by specific nursing care. NICU, Neonatal Intensive Care Unit; NNC, Neonatal Nursing Certificate.
© 2013 Wiley Publishing Asia Pty Ltd
Years of experience in NICU
NNC
< 5 (n = 13) n (%)
> 5 (n = 28) n (%)
No (n = 33) n (%)
Yes (n = 8) n (%)
2 (15.4) 2 (15.4)
12 (42.9) 8 (28.6)
9 (27.3) 6 (18.2)
5 (62.5) 4 (50)
10 (76.9) 4 (30.8) 13 (100)
26 (92.9) 8 (28.6) 28 (100)
28 (84.8) 9 (27.3) 33 (100)
8 (100) 3 (37.5) 8 (100)
5 (38.5)
15 (53.6)
13 (39.4)
7 (87.5)
3 (23.1)
14 (50)
12 (36.4)
5 (62.5)
1 (7.7)
3 (10.7)
3 (9.1)
1 (12.5)
8 (61.5)
24 (85.7)
24 (72.7)
8 (100)
3 (23.1)
17 (60.7)
12 (36.4)
8 (100)
2 (15.4) 9 (69.2)
2 (7.1) 23 (82.1)
4 (12.1) 24 (72.7)
0 (0) 8 (100)
8 (61.5)
25 (89.3)
26 (78.8)
7 (87.5)
0 (0)
2 (7.1)
2 (6.1)
0 (0)
1 (7.7)
0 (0)
1 (3)
0 (0)
1 (7.7)
5 (17.9)
4 (12.1)
2 (25)
4 (30.8)
14 (50)
15 (45.5)
3 (37.5)
13 (100)
27 (96.4)
32 (97.0)
8 (100)
2 (15.4)
22 (78.6)
16 (48.5)
8 (100)
13 (100)
26 (92.9)
31 (93.9)
8 (100)
Nurses’ knowledge and preterm infants’ skin care
respondents with NNC (29.2%) and non-NNC holders (29.3%). It was evident that respondents in both groups knew that the immaturity of skin will create problems upon application and removal of adhesive tape but did not know exactly how to prevent skin break down. All respondents with less than 5 years experience correctly answered questions on pulse oximetry and IV cannulation, though only 15.4% of nurses knew how to care for the skin of preterm infants on nasal continuous positive airway pressure (NCPAP). This implies that respondents with less than 5 years experience lacked knowledge of potential skin injury of preterm infants on NCPAP. However, all NNC holders answered the questions correctly, as compared to 79.8% of non-NNC holders suggesting that nurses with NNC had a very good knowledge of skin injury of preterm infants on NCPAP.
NURSES’ ACTUAL KNOWLEDGE VS. PERCEPTIONS OF PRETERM INFANTS’ SKIN CARE The overall percentage of correct answers across the 20 knowledge questions (section 3 of the questionnaire) for respondents with more than 5 years working experience in NICU was 53.8% compared to 35.5% for nurses with less than 5 years working experience in NICU. This suggests that length of work experience has some influence on nurses’ knowledge of preterm infants’ skin. However, there was no significant relationship between length of work experience in NICU with the overall total score on knowledge of preterm infants’ skin, (P = 0.176). A similar finding emerged for respondents with an NNC. Their total percentage of correct answers was 63.1% compared to 46.1% for respondents without NNC (P = 0.201). The results of the Fisher’s Exact Test (exact P) of the relationship between nurses’ knowledge of preterm infants’ skin with length of work experience in NICU and holding the NNC are shown in Table 4. The total percentage of correct answers was found to be inconsistent with the nurses’ choice of answer (agreed or disagreed) about having a strong knowledge of preterm infants’ skin. Three respondents who disagreed they had a strong knowledge scored the highest marks, 14 out of a possible 20 scores. These respondents scoring the highest marks were NNC holders who had more than 5 years experience working in NICU. This is interesting and suggests that these three nurses, despite their experience and qualifications, lacked self-confidence with regard to their own level of knowledge of preterm infants’ skin care.
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Table 4 Relationship of respondents’ knowledge of preterm infants’ skin care with NICU experience and holding a NNC (n = 41) Variables
Fisher’s exact test (exact P)
General knowledge of preterm infants’ skin Knowledge of TEWL Knowledge of adhesive application and removal Knowledge of skin disinfectant Knowledge of skin injury Overall total score of knowledge of preterm infants’ skin
Experience
NNC
0.564
0.265
0.144 0.131
0.016* 1.000
0.354 0.002* 0.176
0.444 0.193 0.201
* P < 0.05 (2-tailed). NNC, Neonatal Nursing Certificate; TEWL, transepidermal water loss.
DISCUSSION The findings of this study highlight two areas of concern: (i) the translation of learning into practice or lack of it; and (ii) low self-confidence of the nurses with regard to their knowledge base. Due to the acuity of NICU, Malaysian student nurses (during their basic nursing course) are usually provided with an opportunity to work in a Level 1 nursery, although they are only allowed to provide limited care to the infants. Without appropriate clinical experience opportunities, nurses may find it difficult to translate what they learn in the classroom19 into practice. Novices who are placed in an NICU may not have a good knowledge of the range of infants’ conditions, further impeding the transfer of their knowledge into practice. NNC holders are expected to show a deeper understanding of neonatal knowledge, be up-to-date with current evidence-based practice and competent in neonatal care practices. Despite the theoretical knowledge provided in the 6-month Neonatal Care Course, the difference in percentage of correct answers between NNC holders and non-NNC holders was only 17%. This suggests that either the physiological content of preterm infant skin taught in the Neonatal Care Course is limited or that this group of nurses had difficulty in translating theory into practice. Given that the difference for correct answers was only 17% between nurses with or without © 2013 Wiley Publishing Asia Pty Ltd
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an NNC, it would seem that experience in managing preterm infants’ skin care may play a role even though the analysis showed no significant association. The result, however, should be treated with caution, given the small sample size. Although not statistically significant, there could however be a clinical significance. For this group of nurses, their practice might be based on experience alone suggesting that they might ‘know how’ but do not understand the ‘know that’ that underpins their practice. If knowledge is not fully articulated, then nurses may not understand the theoretical bases of what they are doing,13 and this may affect the patient’s outcomes. If existing staff practices are inappropriate, it might influence the practice of new nurses.20 In clinical areas, the preferred method of learning is through observation and emulating a role model who is ‘the expert’ of the ward.10 Thus, it is disconcerting that novice nurses may follow inappropriate practices of ward staff rather than the theory taught in college.21 To assist in the translation of learning, topics on neonatal skin care should receive equal attention with other neonatal topics in the NICU’s weekly Continuing Nursing Education activities. This would be an effective pedagogical strategy to assist in reducing new staff nurses’ knowledge gaps, as suggested by the majority of respondents in this study. A dichotomy existed with some of the nurses’ perceptions of their own level of knowledge and their overall total score on knowledge of preterm infants’ skin. The respondents who scored the highest total correct answers perceived themselves as not having a strong knowledge of preterm infants’ skin care despite their NICU experience greater than 5 years and holding an NNC. These nurses could be considered as ‘silent knowers’.22 Silent knowers are individuals who remain silent for most of the time because they lack confidence to speak their minds; they accept authority as their legitimate source of knowledge while their knowledge base remains unarticulated and embedded in silent practice.22 It would appear that some nurses currently working in this NICU lacked confidence in their own knowledge and practice pertaining to preterm infants’ skin care. If nurses who have just finished their Neonatal Care Course lack confidence, then it is unlikely they would suggest changes, and consequently new knowledge will remain unrevealed and later diminish.23 Confidence was not originally defined nor examined in this study—only knowledge and experience. Further work explicitly examining confidence and the influence it has on practice is required to ascertain if this is a cultural © 2013 Wiley Publishing Asia Pty Ltd
Z Mohamed et al.
issue pertaining to this particular NICU or more widespread. Moreover, it would be useful to determine if there is any association between nurses’ perceived confidence and competence. The NNC holders’ expectations on what they can change in terms of neonatal practices in the ward and the obstacles they are facing in the clinical area warrants further research. Although the level of nurses’ confidence seems low, sources of practical knowledge about preterm infants’ skin were typically influenced by years of working experience: nurses with less than 5 years experience were found to rely mainly on information obtained from senior nurses. This group of nurses usually value and acknowledge expert opinion as an important source of knowledge24 and consider their colleagues to have relevant experience.25 Therefore, it can be questioned to what extent this group of nurses sourced evidence-based information, given that the findings of this study identified a knowledge gap in certain aspects of preterm infants’ skin care from ‘the expert’ nurses as measured in total percentage of correct answers. This study was based on a small sample of neonatal nurses working in one Malaysian NICU only; therefore, this limits the generalizability of the results to other NICU settings. In this study, nurses were requested to complete the questionnaire individually at a time convenient to themselves and in not more than 30 min. However, independence could not be ensured as the questionnaires were not completed in the presence of a researcher. The survey tool included questions on preterm infants’ skin care with multiple correct answers which, while facilitating an exploration of degrees of knowledge and understanding, might have hinted towards the correct answers. The differences between knowledge and nursing practice were not explored in depth due to timeframe constraints in which the researchers had to complete the study. Although the study was concerned with nurses’ knowledge of preterm infants’ skin and the relationship between education and experiences, interactions between education and experience were not examined. Finally, the low percentage of respondents with an NNC made the relationship between nurses’ knowledge and preterm infants’ skin care practice difficult to accurately assess.
RECOMMENDATIONS AND CONCLUSION Prior research has indicated that knowledge and experience has a significant impact on nursing practice.
Nurses’ knowledge and preterm infants’ skin care
However, the findings of this study suggest that this may not always be the case. Replication of similar types of studies across other NICUs may provide a wider perspective on whether the knowledge gaps in preterm infants’ skin care exist among neonatal nurses. Critical in the management of preterm infant skin care is the adequacy and availability of education and training for nursing staff regarding specific topics in this area. Clinical evidencebased guidelines on preterm infant skin care guidelines need to be developed to promote consistency in practice within the individual contexts of NICUs.
ACKNOWLEDGEMENTS The authors are grateful to the hospital that allowed the study to be conducted and the nurses who completed the questionnaires.
REFERENCES 1 Brandon DH, Coe K, Hudson-Barr D, Oliver T, Landerman LR. Effectiveness of no-sting skin protection and aquaphor on water loss and skin integrity in premature infant. Journal of Perinatology 2010; 30: 414–419. 2 Houska-Lund C, Durand DJ. Skin and skin care. In: Merenstein GB, Gardner SL (eds). Handbook of Neonatal Intensive Care. St. Louis, MO, USA: Mosby Elsevier, 2006; 447–466. 3 Hoath SB, Rutter N. Prematurity. In: Hoath SB, Maibach HI (eds). Neonatal Skin: Structure and Function. Madison Avenue, New York, NY: Marcel Dekker, 2003; 136–162. 4 Butler CT. Pediatric skin care: Guidelines for assessment, prevention and treatment. Pediatric Nursing 2006; 32: 443– 450. 5 Hockenberry MJ, Wilson D. Wong’s Nursing Care of Infants and Children. St. Louis, MO, USA: Mosby, 2010. 6 Aiken LH, Clarke SP, Cheung RB. Educational levels of hospital nurses and surgical patient mortality. Journal of American Medical Association 2003; 290: 1617–1623. 7 Considine J, Botti M, Thomas S. Do knowledge and experience have specific roles in triage decision making? Academic Emergency Medicine 2007; 14: 722–726. 8 Lott JW. Skin blood flow responses to thermal stimuli in healthy term newborns. Newborn and Infant Nursing Reviews 2003; s3: 179–183. 9 Lund CH, Osborne JW, Kuller JM, Lane AT, Lott JW, Raines DA. Neonatal skin care: Clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Journal of Obstetric, Gynecologic and Neonatal Nursing 2001; 30: 41–51. 10 Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA, USA: AddisonWesley, 1984.
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11 Higgs J, Andresen L, Fish D. Practice knowledge—Its nature, sources and contexts. In: Higgs J, Richardson B, Dahlgren MA (eds). Developing Practice Knowledge for Health Professionals. Sydney, Australia: Butterworth-Heinemann, 2004; 51–70. 12 Mantzoukas S, Jasper M. Types of nursing knowledge used to guide care of hospitalized patients. Journal of Advanced Nursing 2008; 62: 318–326. 13 Gustavsson B. Revisiting the philosophical roots of practical knowledge. In: Higgs J, Richardson B, Dahlgren MA (eds). Developing Practice Knowledge for Health Professional. Sydney: Butterworth Heinemann, 2004; 35–50. 14 Bereiter C, Scardamalia M. Surpassing Ourselves: An Inquiry into the Nature and Implications of Expertise. Chicago, IL, USA: Open Court, 1993. 15 Kolb DA. Experiential Learning: Experience as a Source of Learning and Development. Englewood Cliffs, NJ, USA: Prentice Hall, 1984. 16 Quinn FM. Principles and Practice of Nurse Education. Cheltenham, UK: Stanley Thornes, 2000. 17 Bjork IT, Kirkevold M. Issues in nurses’ practical skill development in the clinical setting. Journal of Nursing Care Quality 1999; 14: 72–84. 18 Kovner CT, Schore J. Differentiated levels of nursing work force demand. Journal of Professional Nursing 1998; 14: 242– 253. 19 Newton JM, McKenna L. Uncovering knowing in practice during the graduate year: An exploratory study. Contemporary Nurse 2009; 31: 153–162. 20 Cheraghi MA, Salasli M, Ahmadi F. Factors influencing the clinical preparation of BS nursing students in Iran. International Journal of Nursing Practice 2008; 14: 26– 33. 21 Tsai MT, Tsai LL. The critical success factors and impact of prior knowledge to nursing students when transferring nursing knowledge during nursing clinical practice. Journal of Nursing Management 2005; 13: 459–466. 22 Usher K, Fitzgerald M. Introduction to nursing research. In: Borbasi S, Jackson D, Langford R (eds). Navigating the Maze of Nursing Research: An Interactive Learning Adventure. Marrickville, Australia: Elsevier Mosby, 2008; 3–28. 23 Harvey G, Loftus-Hill A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B. Getting evidence into practice: The role and function of facilitation. Journal of Advanced Nursing 2002; 37: 577–588. 24 O’Connell B. Ways of knowing in nursing. In: Greenwood J (ed.). Nursing Theory in Australia Development & Application. Frenchs Forest, New South Wales, Australia: Prentice Hall, 2000; 55–76. 25 Estabrooks CA, Rutakumwa W, O’Leary KA, ProfettoMcGrath J, Milner M, Levers MJ. Source of practice knowledge among nurses. Qualitative Health Research 2005; 15: 460–476.
© 2013 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2014; 20: 187–193
RESEARCH PAPER
Malaysian nurses’ skin care practices of preterm infants: Experience vs. knowledge Zainah Mohamed Master in Nursing Neonatal Cert RN PhD Candidate, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia Lecturer, Nursing Department, Faculty of Medicine, Universiti Kebangsaan, Malaysia
Jennifer Margaret Newton PhD Ed.D Grad Cert Sci RN RM Associate Professor Research, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
Rosalind Lau PhD MPH MEdStuds BAppSci RN RM Research Fellow, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
Accepted for publication December 2012 Mohamed Z, Newton JM, Lau R. International Journal of Nursing Practice 2014; 20: 187–193 Malaysian nurses’ skin care practices of preterm infants: Experience vs. knowledge This study sought to explore the impact of Malaysian nurses’ perceptions, knowledge and experiences in preterm infant skin care practices using a descriptive approach. Questionnaires were distributed to Neonatal Intensive Care Unit (NICU) nurses in one teaching hospital in Malaysia. A knowledge gap was revealed among nurses in both theoretical and practical knowledge of preterm infant skin. Nurses working for more than 5 years in NICU or having a Neonatal Nursing Certificate (NNC) were not predictors of having adequate knowledge of preterm infants’ skin care. The results highlight the complex issue of providing effective skin care to preterm infants. However, a specific finding related to nurses’ confidence provides some direction for future practice and research initiatives. Clear clinical evidence-based guidelines and Continuing Nursing Education on relevant topics of preterm infants’ care may provide the required knowledge for the nurses. Key words: neonatal nursing, nursing knowledge, preterm infant, quantitative, skin care.
INTRODUCTION Preterm infants are exposed to numerous medical and nursing procedures during hospitalization. During this period, the infants’ skin plays an important role as a protective and regulatory barrier between the body and the external environment.1 Infants born at 26 weeks gestation have a thinner epidermis layer than infants born at 34
Correspondence: Zainah Mohamed, School of Nursing & Midwifery, Faculty of Medicine, Nursing and Health Sciences, P.O. Box 527, Building E, Peninsula Campus, McMahons Road, Frankston, Vic. 3199, Australia. Email: [email protected] doi:10.1111/ijn.12125
weeks gestation.2 Fat and zinc which are essential to maintain an intact, healthy skin surface are also insufficient at this time.3 Therefore, the lower the preterm infants’ gestational age is, the higher their risk of developing skin damage and injury. A thin epidermis layer may lead to problems such as transepidermal water loss (TEWL), ineffective thermoregulation, skin injury and infection.3 Despite these potential risks, the management of the preterm infants’ skin is considered to be a lesser priority than cardiovascular or respiratory stability.4 Although nurses may not have control over many of the factors that place preterm infants at risk for skin breakdown, nurses have the ability to positively influence the outcomes © 2013 Wiley Publishing Asia Pty Ltd
188
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through knowledgeable assessment, prevention, treatment and evaluation of infants’ skin integrity.5 While several studies have found that level of education is a better predictor of improved patient outcomes;6,7 others argue that nursing education provides limited information on the basic knowledge and nursing care of preterm infants’ skin.8,9 This is disconcerting as nurses need to understand their actions and incorporate this understanding10 into their daily professional practice by being able to combine knowledge, reasoning and skills.11 The two key components of nursing knowledge are theoretical knowledge and practical knowledge. Theoretical knowledge or ‘knowing that’ is acquired through the formal setting of nursing schools, books, scientific journals or lectures.12 Practical knowledge or ‘knowing how’ is acquired through the practice of nursing. The latter entails both knowing what we do and understanding what we are doing; it is not just premised on habits, routines or guidelines.13 Practical knowledge is gained over time through clinical experience, and this experience is essential for expertise to develop.10 Most models of expertise suggest that about 5 to 10 years of practical experience is necessary for expertise to develop.10,14 Repeated clinical experience with similar situations results in better performance15 and acquisition of a motor skill normally follows a smooth curve with increased years in clinical experience.16 However, clinical experience alone has been reported to have no significant influence on improving the outcomes of patients.6,7,17,18 A longitudinal study on clinical skill development found that nurses with more experience tended to make as many mistakes as less experienced nurses.17 To ensure that their knowledge is developed, nurses must be aware of and reflect on a learning experience to enable the synthesis of old knowledge with new knowledge.10
PURPOSE OF THE STUDY This study sought to explore Malaysian neonatal nurses’ skin care practices based on their knowledge, measured by possession of a Neonatal Nursing Certificate (NNC), with nurses who rely on their knowledge base derived through experience alone. Nurses’ perceptions on their level of knowledge of preterm infants’ skin care were also examined. The practices of preterm infants’ skin care were examined in five specific areas: general knowledge, TEWL, adhesive application and removal, skin disinfectant and skin injury related to medical devices. The relationship between nurses’ level of knowledge, length of © 2013 Wiley Publishing Asia Pty Ltd
work experience in Neonatal Intensive Care Unit (NICU) and holding the NNC was also explored. The NNC is a full time 6-month specialized course with a focus on advanced neonatal care knowledge and practice.
METHODS—SETTING AND SAMPLE A quantitative descriptive approach, using a survey design was conducted in a NICU in a university hospital in Malaysia. Participants were qualified nurses working in the NICU. No exclusion criteria were applied in this study. During the study period, the NICU had 54 female Registered Staff Nurses (RSN). Forty-one (75.9%) neonatal nurses voluntarily participated in this study. Approval to conduct the study was granted by the ethics committee of the study site (FF-248-2008) and the researchers’ university (Number: CF08/2409– 2008001232). The questionnaire consisted of three sections: (i) demographic data and (ii) nurses’ perceptions of their level of knowledge measured on a 4-point Likert scale, along with open-ended questions on sources of knowledge used in managing preterm infants’ skin. The third section comprised 20 multiple choice questions on knowledge of adhesive application and removal, skin disinfectant and tissue injury due to medical devices. The correct answers were totalled. The nurses were also given an opportunity to provide suggestions on how to improve preterm infants’ skin care in their workplace. This questionnaire was adapted from a questionnaire designed by Lund et al.9 Some questions were not relevant to the area of this current study and therefore were omitted. Alternative questions were developed based on a literature review of previous studies on preterm infants’ skin care. Content validity of the questionnaire was then tested and reviewed by a panel of experienced neonatal care practitioners that consisted of three neonatal specialists and two neonatal nursing experts from two different hospitals (n = 5, average years of experience = 15). Nursing staff were introduced to the study during a staff meeting by one of the researchers. Posters of the study were displayed in the staff tea room along with explanatory statements and questionnaires. Nurses who chose to participate were given 1 week to complete the questionnaire at a time convenient to them. Completed questionnaires were placed in an envelope, sealed and placed in a locked box for confidentiality purposes. The box was subsequently collected by one of the researchers.
Nurses’ knowledge and preterm infants’ skin care
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Data were analyzed using SPSS version 15.0 (Statistical Package for the Social Sciences; Chicago, IL, USA). Descriptive analyses were performed on the demographic data and level of knowledge of preterm infants’ skin. The level of knowledge of preterm infants’ skin was scored based on the respondents’ correct answer to each question. Fisher’s Exact tests was used to determine if there was a relationship between nurses’ knowledge of preterm infants’ skin with length of work experience in NICU and holding the NNC. Fisher’s Exact tests were used due to the small sample size.
RESULTS The mean age of the 41 participating NICU nurses was 28.8 years. Details of the general characteristics of the participants are shown in Table 1. All participants held a Diploma in nursing which in Malaysia is a 3-year education programme. Although most of the respondents had been working in NICU for more than 5 years, 33 (80.5%) of the respondents did not have an NNC and, interestingly, 36 (87.8%) respondents had only ever worked in NICU, starting there as new graduates. Table 2 provides details of respondents’ years of NICU experience and holding a NNC. The results revealed a diversity of knowledge and care practices among this group of NICU nurses. Nearly all of the respondents (80.5%) somewhat disagreed they had a Table 1 General characteristics of the respondents (n = 41) Characteristics Age (years)
Marital status Ethnicity Entry when commenced working in NICU Experience in NICU (years)
Neonatal nursing certificate
36 Married Single Malay New graduate Experienced RSN 5 years and having no NNC Experience in NICU > 5 years and having a NNC Total
13 20 8 41
31.7 48.8 19.5 100
NICU, Neonatal Intensive Care Unit.
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Table 3 Respondents’ scores of correct answer of preterm infants’ skin care knowledge (n = 41) Variables
General knowledge of preterm infants’ skin 1) Evaporation is the greatest source of heat loss for a preterm infant. 2) Maintenance of skin integrity in the preterm infants is most important to limit insensible water loss. 3) The risk of skin breakdown is increased in preterm infants’ skin. 4) Skin maturation is influenced by the gestational age of the neonate. 5) Incomplete developed stratum corneum limits the function of preterm infants’ skin. 6) Trace minerals is important in maintaining skin integrity and promoting wound healing. 7) Appropriate caloric intake is necessary for maintaining skin integrity and healing skin breakdown. 8) Oedema often exhibit in newly born preterm infants. Knowledge of TEWL 1) Increased humidity in the incubator will also increase the ambient temperature in the incubator. 2) Setting of appropriate ambient humidity will contribute to ‘rain out’ in an incubator. 3) Measurement of TEWL reflects the maturation of the stratum corneum. 4) TEWL can be reduced by specific interventions. Knowledge of adhesive application and removal 1) The immaturity of preterm infants’ skin will create problems upon application and removal of adhesive tapes. 2) In spite of improving skin dryness, emollients containing petroleum will also lead to risk of sepsis. 3) Skin breakdown pertaining to adhesive application and removal can be prevented through specific procedures Knowledge of skin disinfectant 1) Solutions contained povidone iodine can be absorbed through the skin and could lead to hypothyroidism. 2) Povidone iodine should be removed immediately from the preterm infants’ skin using saline or sterile water. Knowledge of skin injury 1) Skin injury related to pulse oximeter probe can be reduced by routinely change the probe sites. 2) Adjusting the height and level of the bed will prevent pressure on the nares due to Nasal Continuous Positive Airway Pressure (NCPAP) driver. 3) IV infiltration and extravasations can be prevented by specific nursing care. NICU, Neonatal Intensive Care Unit; NNC, Neonatal Nursing Certificate.
© 2013 Wiley Publishing Asia Pty Ltd
Years of experience in NICU
NNC
< 5 (n = 13) n (%)
> 5 (n = 28) n (%)
No (n = 33) n (%)
Yes (n = 8) n (%)
2 (15.4) 2 (15.4)
12 (42.9) 8 (28.6)
9 (27.3) 6 (18.2)
5 (62.5) 4 (50)
10 (76.9) 4 (30.8) 13 (100)
26 (92.9) 8 (28.6) 28 (100)
28 (84.8) 9 (27.3) 33 (100)
8 (100) 3 (37.5) 8 (100)
5 (38.5)
15 (53.6)
13 (39.4)
7 (87.5)
3 (23.1)
14 (50)
12 (36.4)
5 (62.5)
1 (7.7)
3 (10.7)
3 (9.1)
1 (12.5)
8 (61.5)
24 (85.7)
24 (72.7)
8 (100)
3 (23.1)
17 (60.7)
12 (36.4)
8 (100)
2 (15.4) 9 (69.2)
2 (7.1) 23 (82.1)
4 (12.1) 24 (72.7)
0 (0) 8 (100)
8 (61.5)
25 (89.3)
26 (78.8)
7 (87.5)
0 (0)
2 (7.1)
2 (6.1)
0 (0)
1 (7.7)
0 (0)
1 (3)
0 (0)
1 (7.7)
5 (17.9)
4 (12.1)
2 (25)
4 (30.8)
14 (50)
15 (45.5)
3 (37.5)
13 (100)
27 (96.4)
32 (97.0)
8 (100)
2 (15.4)
22 (78.6)
16 (48.5)
8 (100)
13 (100)
26 (92.9)
31 (93.9)
8 (100)
Nurses’ knowledge and preterm infants’ skin care
respondents with NNC (29.2%) and non-NNC holders (29.3%). It was evident that respondents in both groups knew that the immaturity of skin will create problems upon application and removal of adhesive tape but did not know exactly how to prevent skin break down. All respondents with less than 5 years experience correctly answered questions on pulse oximetry and IV cannulation, though only 15.4% of nurses knew how to care for the skin of preterm infants on nasal continuous positive airway pressure (NCPAP). This implies that respondents with less than 5 years experience lacked knowledge of potential skin injury of preterm infants on NCPAP. However, all NNC holders answered the questions correctly, as compared to 79.8% of non-NNC holders suggesting that nurses with NNC had a very good knowledge of skin injury of preterm infants on NCPAP.
NURSES’ ACTUAL KNOWLEDGE VS. PERCEPTIONS OF PRETERM INFANTS’ SKIN CARE The overall percentage of correct answers across the 20 knowledge questions (section 3 of the questionnaire) for respondents with more than 5 years working experience in NICU was 53.8% compared to 35.5% for nurses with less than 5 years working experience in NICU. This suggests that length of work experience has some influence on nurses’ knowledge of preterm infants’ skin. However, there was no significant relationship between length of work experience in NICU with the overall total score on knowledge of preterm infants’ skin, (P = 0.176). A similar finding emerged for respondents with an NNC. Their total percentage of correct answers was 63.1% compared to 46.1% for respondents without NNC (P = 0.201). The results of the Fisher’s Exact Test (exact P) of the relationship between nurses’ knowledge of preterm infants’ skin with length of work experience in NICU and holding the NNC are shown in Table 4. The total percentage of correct answers was found to be inconsistent with the nurses’ choice of answer (agreed or disagreed) about having a strong knowledge of preterm infants’ skin. Three respondents who disagreed they had a strong knowledge scored the highest marks, 14 out of a possible 20 scores. These respondents scoring the highest marks were NNC holders who had more than 5 years experience working in NICU. This is interesting and suggests that these three nurses, despite their experience and qualifications, lacked self-confidence with regard to their own level of knowledge of preterm infants’ skin care.
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Table 4 Relationship of respondents’ knowledge of preterm infants’ skin care with NICU experience and holding a NNC (n = 41) Variables
Fisher’s exact test (exact P)
General knowledge of preterm infants’ skin Knowledge of TEWL Knowledge of adhesive application and removal Knowledge of skin disinfectant Knowledge of skin injury Overall total score of knowledge of preterm infants’ skin
Experience
NNC
0.564
0.265
0.144 0.131
0.016* 1.000
0.354 0.002* 0.176
0.444 0.193 0.201
* P < 0.05 (2-tailed). NNC, Neonatal Nursing Certificate; TEWL, transepidermal water loss.
DISCUSSION The findings of this study highlight two areas of concern: (i) the translation of learning into practice or lack of it; and (ii) low self-confidence of the nurses with regard to their knowledge base. Due to the acuity of NICU, Malaysian student nurses (during their basic nursing course) are usually provided with an opportunity to work in a Level 1 nursery, although they are only allowed to provide limited care to the infants. Without appropriate clinical experience opportunities, nurses may find it difficult to translate what they learn in the classroom19 into practice. Novices who are placed in an NICU may not have a good knowledge of the range of infants’ conditions, further impeding the transfer of their knowledge into practice. NNC holders are expected to show a deeper understanding of neonatal knowledge, be up-to-date with current evidence-based practice and competent in neonatal care practices. Despite the theoretical knowledge provided in the 6-month Neonatal Care Course, the difference in percentage of correct answers between NNC holders and non-NNC holders was only 17%. This suggests that either the physiological content of preterm infant skin taught in the Neonatal Care Course is limited or that this group of nurses had difficulty in translating theory into practice. Given that the difference for correct answers was only 17% between nurses with or without © 2013 Wiley Publishing Asia Pty Ltd
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an NNC, it would seem that experience in managing preterm infants’ skin care may play a role even though the analysis showed no significant association. The result, however, should be treated with caution, given the small sample size. Although not statistically significant, there could however be a clinical significance. For this group of nurses, their practice might be based on experience alone suggesting that they might ‘know how’ but do not understand the ‘know that’ that underpins their practice. If knowledge is not fully articulated, then nurses may not understand the theoretical bases of what they are doing,13 and this may affect the patient’s outcomes. If existing staff practices are inappropriate, it might influence the practice of new nurses.20 In clinical areas, the preferred method of learning is through observation and emulating a role model who is ‘the expert’ of the ward.10 Thus, it is disconcerting that novice nurses may follow inappropriate practices of ward staff rather than the theory taught in college.21 To assist in the translation of learning, topics on neonatal skin care should receive equal attention with other neonatal topics in the NICU’s weekly Continuing Nursing Education activities. This would be an effective pedagogical strategy to assist in reducing new staff nurses’ knowledge gaps, as suggested by the majority of respondents in this study. A dichotomy existed with some of the nurses’ perceptions of their own level of knowledge and their overall total score on knowledge of preterm infants’ skin. The respondents who scored the highest total correct answers perceived themselves as not having a strong knowledge of preterm infants’ skin care despite their NICU experience greater than 5 years and holding an NNC. These nurses could be considered as ‘silent knowers’.22 Silent knowers are individuals who remain silent for most of the time because they lack confidence to speak their minds; they accept authority as their legitimate source of knowledge while their knowledge base remains unarticulated and embedded in silent practice.22 It would appear that some nurses currently working in this NICU lacked confidence in their own knowledge and practice pertaining to preterm infants’ skin care. If nurses who have just finished their Neonatal Care Course lack confidence, then it is unlikely they would suggest changes, and consequently new knowledge will remain unrevealed and later diminish.23 Confidence was not originally defined nor examined in this study—only knowledge and experience. Further work explicitly examining confidence and the influence it has on practice is required to ascertain if this is a cultural © 2013 Wiley Publishing Asia Pty Ltd
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issue pertaining to this particular NICU or more widespread. Moreover, it would be useful to determine if there is any association between nurses’ perceived confidence and competence. The NNC holders’ expectations on what they can change in terms of neonatal practices in the ward and the obstacles they are facing in the clinical area warrants further research. Although the level of nurses’ confidence seems low, sources of practical knowledge about preterm infants’ skin were typically influenced by years of working experience: nurses with less than 5 years experience were found to rely mainly on information obtained from senior nurses. This group of nurses usually value and acknowledge expert opinion as an important source of knowledge24 and consider their colleagues to have relevant experience.25 Therefore, it can be questioned to what extent this group of nurses sourced evidence-based information, given that the findings of this study identified a knowledge gap in certain aspects of preterm infants’ skin care from ‘the expert’ nurses as measured in total percentage of correct answers. This study was based on a small sample of neonatal nurses working in one Malaysian NICU only; therefore, this limits the generalizability of the results to other NICU settings. In this study, nurses were requested to complete the questionnaire individually at a time convenient to themselves and in not more than 30 min. However, independence could not be ensured as the questionnaires were not completed in the presence of a researcher. The survey tool included questions on preterm infants’ skin care with multiple correct answers which, while facilitating an exploration of degrees of knowledge and understanding, might have hinted towards the correct answers. The differences between knowledge and nursing practice were not explored in depth due to timeframe constraints in which the researchers had to complete the study. Although the study was concerned with nurses’ knowledge of preterm infants’ skin and the relationship between education and experiences, interactions between education and experience were not examined. Finally, the low percentage of respondents with an NNC made the relationship between nurses’ knowledge and preterm infants’ skin care practice difficult to accurately assess.
RECOMMENDATIONS AND CONCLUSION Prior research has indicated that knowledge and experience has a significant impact on nursing practice.
Nurses’ knowledge and preterm infants’ skin care
However, the findings of this study suggest that this may not always be the case. Replication of similar types of studies across other NICUs may provide a wider perspective on whether the knowledge gaps in preterm infants’ skin care exist among neonatal nurses. Critical in the management of preterm infant skin care is the adequacy and availability of education and training for nursing staff regarding specific topics in this area. Clinical evidencebased guidelines on preterm infant skin care guidelines need to be developed to promote consistency in practice within the individual contexts of NICUs.
ACKNOWLEDGEMENTS The authors are grateful to the hospital that allowed the study to be conducted and the nurses who completed the questionnaires.
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