Surgical and wound site infections (SWSIs) are the second most common type of healthcare-associated infection (HAI) in Europe (European Centre for Disease Prevention and Control (ECDC), Zarb et al, 2012). The global impact of SWSIs on individuals and the economy puts major epidemiological burdens on both developing and high-income countries (Allegranzi et al, 2016). Based on data from 48 studies, a study published by Leaper et al (2004) estimated the financial cost of SWSIs in Europe to be €1.47-€19.1 billion, and the average patient stay in hospital increases by 6.5 days, which means it costs three times as much to treat an infected patient (Leaper et al, 2004). Data collected by NHS hospitals in England from April 2010 to March 2012 estimated the length of hospital stay attributed to SWSIs to increase by 7–13 days, with a total of 4694 bed-days lost over this period (Jenks et al, 2014). In 2017–2018, the incidence of SWSI was higher than it was 10 years ago (Public Health England, 2018).
The World Health Organization estimates that HAIs can be reduced by at least 30% with effective infection prevention and control (IPC) measures (WHO, 2019). However, prevention involves a complex process of integrating a range of measures (Allegranzi et al, 2016). According to the Department of Health (DH, 2001), one of the fundamental processes of preventing HAIs when performing wound care is adherence to the principles of asepsis. Asepsis is a process of using sterile procedures to eliminate microorganisms from an area (Lówbúrý et al, 2013). Aseptic non-touch technique (ANTT) involves using a sterile procedure to prevent contamination of wounds and other susceptible sites (Northamptonshire Healthcare NHS Foundation Trust, 2018). The Health and Social Care Act 2008 makes it a requirement for all healthcare providers to use ANTT as a standardised aseptic technique, and to demonstrate education and audit across the board.
According to the literature, nurses have found it challenging to attain asepsis, with few successfully adhering to the principles of ANTT during wound-care procedures (Ding et al, 2017). In addition, those who adhere to the principles often do not understand the rationale for this practice (Bree-Williams and Waterman, 1996; Gould et al, 2018). Notably, a theory-practice gap has been identified regarding microbiology and infection control knowledge among undergraduate nurses and transfer of this to practice (Cox et al, 2014). Overall, there is a gap between nurses' understanding of ANTT and its application in practice (Bree-Williams and Waterman, 1996; Ding et al, 2017). Although there are a variety of reasons why nurses adhere to the standardised technique (Teija-Kaisa and Eija, 2016), little research has been done on exploring nurses' awareness of the rationale for it, their responsiveness to the principles of ANTT or their perception of applying these principles in practice.
The purpose of this review is to identify the challenges that nurses face in applying the principles of ANTT during wound-care practice.
A literature review was carried out to identify and summarise common challenges encountered by nurses when using ANTT during wound-care procedures.
Inclusion and exclusion criteria
The review covered primary research papers published in English between January 1993 and December 2018. Articles focusing on nurses and their experiences on the application of ANTT during wound management were included. Studies published before 1993, including reports concerning nurses, were excluded since the aseptic technique became standardised internationally in 1993. Only papers written in English were included and literature reviews were excluded from this study.
Four databases (CINAHL, British Nursing Database, PubMed and PsycINFO) were searched using keywords. Boolean operators were used in the search process, with ‘AND’ and ‘OR’ used to combine keywords and their synonyms. Articles were obtained using the keywords ‘registered nurse’ OR ‘nurse’ OR ‘staff nurse’ OR ‘graduate nurse’ OR ‘qualified nurse’ AND ‘aseptic non touch technique’ OR ‘aseptic technique’ OR ‘non touch technique’ OR ‘sterile technique’ OR ‘asepsis’ OR ‘infection prevention and control’ OR aseptic AND ‘wound care’ OR ‘wound healing’ OR ‘wound management’ OR ‘wound treatment’ OR ‘wound assessment’ OR ‘wound dressing’ OR ‘wound’ AND ‘challenges’ OR ‘barriers’ OR ‘limitations’ OR ‘understanding’ OR ‘experience’ OR ‘awareness’ OR ‘perception’ OR ‘insight’ OR ‘knowledge’ OR ‘clinical competence’ OR ‘professional compliance’ OR ‘adherence’.
From this search using the keywords on all four databases, 528 records were identified. Once duplicates had been eliminated, 270 articles were left. A total of 257 papers were excluded for not meeting the inclusion criteria after the titles and abstracts were reviewed. Overall, 13 articles met the inclusion criteria. Of the 13 articles, only seven were relevant and were therefore included in the review (Figure 1).
To ascertain the trustworthiness and value of the chosen papers, the criteria from the Critical Appraisal Skills Programme (CASP, 2018) tool for qualitative research were used. The critical appraisal tool for the quantitative study used Coughlan et al's (2007) step-by-step guide to critiquing research, and the CASP 2018 tool was employed for the cross-sectional study. All articles in this review were deemed to be of high quality and the researchers had no ethical concerns.
Data extraction helps researchers to obtain relevant information from the papers reviewed in preparation for data analysis (Aveyard et al, 2018). Braun and Clarke's (2006) thematic analysis process of identifying and analysing patterns of meaning in a data set was used to develop themes in the study. Each paper was examined to develop codes (Table 1). These were then grouped into potential subthemes according to their homogeneity and attributes. Further examination of all subthemes led to the development of three main themes (Table 2).
|Author and date, country
|Aim of study
|Bree-Williams and Waterman (1996) England
|An examination of nurses' practices when performing aseptic technique for wound dressings
|To establish if nurses' actions in aseptic technique using the glove technique are simple and based on up-to-date knowledge, and do not incur unnecessary waste
|Observation and formal interviews
|Aholaakko (2011) Finland
|Reducing surgical nurses' aseptic practice-related stress
|To explore aseptic practice-related stress in surgery. The objectives are to define stress-related factors and how to reduce them
|Interviews and videotaped stimulation interviews
|Teija-Kaisa and Eija (2016) Finland
|Reasoning for adherence to aseptic practices in the operating room
|To explore reasoning for self-reported adherence to surgical aseptic practice recommendations
|Self-administered questionnaire Principal component analysis used to identify main reasons for aseptic practice adherence
|Ding et al (2017) Australia
|Nurses' practice in preventing postoperative wound infections: an observational study
|To prospectively describe surgical nurses' postoperative wound-care practices and the extent to which observed surgical wound practice aligned with evidence-based guideline recommendations
|Cross-sectional, prospective, observational study
|In observed episodes of wound care (n=60)
|Gould et al (2018) England
|Survey to explore understanding of the principles of aseptic technique: qualitative content analysis with descriptive analysis of confidence and training
|To determine nurses' understanding of the term ‘aseptic technique’, their confidence in undertaking it and their opportunities to update their knowledge and undergo periodic assessment
|Survey with purpose-designed, self-reported questionnaire
|Response rate was 72%
|Timmins et al (2018) Haiti
|Nursing wound care practices in Haiti: facilitators and barriers to quality care
|To describe the facilitators and barriers to high-quality wound care in surgical wards
|Qualitative descriptive, with observation and interviews
|Four themes related to barriers and facilitators were identified: materials and resources; nurse:patient ratios, workload and support; nurses' roles and responsibilities; nurses knowledge and training
|Unsworth and Collins (2011) England
|Performing an aseptic technique in a community setting: fact or fiction?
|To examine how experienced practitioners have adapted the aseptic technique in a community setting and to what extent the changed procedure still adheres to the principles of asepsis
|Non-participant observation and individual semistructured interviews
|Material and resources
|Equipment and environment-related stress
|Work experience and sensitivity
Three overarching themes emerged following interrogation of the data. These were:
Material and resources
The review found that an unfamiliar environment or inadequate equipment was a significant stress factor experienced by nurses during procedures involving ANTT (Aholaakko, 2011), with some nurses admitting they felt stressed when they had received little or no training on how to use new equipment. Some nurses commented on how procedure packs had kept evolving over the years, which made it more difficult for those who had their aseptic technique education years ago to keep up (Unsworth and Collins, 2011).
There was also a consensus that time restrictions may be a contributing factor to the limited adherence to the principles of ANTT by nurses (Ding et al, 2017). This could be exacerbated by a high workload, since nurses may need to rush through tasks, particularly where nurse:patient ratios are low (Timmins et al, 2018).
Findings from this study further revealed a hierarchical dynamic and lack of interdisciplinary collaboration or shared agreement between professionals, leading to negative skill discretion in ANTT performance among nurses as a result of healthcare workers shifting responsibilities (Aholaakko, 2011; Timmins et al, 2018). A study by Unsworth and Collins (2011) highlighted that nurses in the community are accustomed to working alone, which raises concern about the practice of ANTT becoming ritualistic.
There was a general acknowledgement across the literature that nurses' education may affect their ability to maintain aseptic practice (Unsworth and Collins, 2011; Gould et al, 2018; Timmins et al, 2018). One nurse participant said the principles of asepsis taught in their initial training were embedded in them (Unsworth and Collins, 2011). However, the study by Timmins et al (2018) found there were significant differences between ANTT training across schools because nursing programmes lacked standard curricula, and highlighted that competency in ANTT was no longer routinely assessed during nurse training in UK universities (Gould et al, 2018).
Bree-Williams and Waterman (1996) found that nurses experienced difficulties while trying to adapt to changes in ANTT such as adopting the ‘clean hand, dirty hand’ approach, which made the procedure more complicated and led to a lack of uniformity across nursing practice. Unsworth and Collins (2010) reported on how ANTT had gone through several changes over the years, including the introduction of pre-sterile packs that did not include forceps and contained sterile gloves in one size only, which made it difficult to ensure asepsis. Some of the nurses admitted to having received no refresher training for almost 5 years and were often oblivious to developments that had taken place in the hospital (Gould et al, 2018).
Furthermore, Bree-Williams Waterman (1996) found that not all nurses understood the reasoning for applying ANTT, and their practices were not often based on evidence in the literature. Although some nurses were able to identify important principles relating to reducing bacteria contamination and transfer, with one study participant stating the importance of a sterile environment (Unsworth and Collins, 2011), a study by Gould et al (2018) revealed that nurses' knowledge of the concept of sterility and cleanliness was not very thorough, which may further contribute to the difference in the way these techniques are practised.
Studies reported breaches in aseptic practice owing to human behaviour, including a lack of compliance with recommendations or adherence to infection control (Aholaakko, 2011; Teija-kaisa and Eija, 2016).
An evident stress factor was differences between work experiences of team members. A senior nurse acknowledged there nurses' aseptic practice varied depending on their experience, adding that competence in ANTT practice comes with experience. Junior nurses admitted to feeling uncertain during procedures involving aseptic practice, with the sense that every step was flawed and the belief that they had to imitate the actions of more experienced nurses (Aholaakko, 2011). This study also revealed cases of experienced nurses feeling the pressure to work more, making them stressed and anxious in the moments leading up to the performance of their tasks.
A study by Teija-Kaisa and Eija (2016) suggested that the morals of individual practitioners and shared morals of members in a team are challenged by internal and external issues. There was a statistically significant difference (P=0.002) in ethical-sensitive reasoning, with nurses appearing to be more ethically sensitive than physicians, while some nurses stated their reasons for adhering to aseptic practice as believing it is the right thing to do and the patient having the right to good care (Teija-Kaisa and Eija, 2016).
There were reports of nurses feeling guilty when they made mistakes in their aseptic procedures, and subsequently blaming themselves for surgical site infections. This was indicated when a nurse became worried about harming a patient's thin skin during a preoperative procedure, leading to feelings of frustration. It was evident that nurses felt a deep-rooted accountability to their patients, seeing them as their moral responsibility (Aholaakko, 2011).
Three of the studies informing this review were conducted in England, two in Finland, one in Australia and the other in Haiti. All revealed exogenous variables that influenced nurses' application of ANTT principles during wound-care procedures, which may affect the accomplishment of IPC priorities (Allegranzi et al, 2016). Some of the variability observed in nurses' ANTT practice stems from education and training (Takahashi, 2002), while the review further revealed that nurses' behaviour directly affects compliance with IPC practice (Aholaakko, 2011; Teija-Kaisa and Eija, 2016).
The overarching theme of nurse education is a significant factor in ANTT practice. The initial training in practice that nurses receive might help sustain what they have been taught at university, since nurses said the concept of asepsis was instilled in them (Unsworth and Collins, 2011). However, the quality and extent of training received might affect how this technique is practised. Timmins et al (2018) reported incongruencies between what was learnt at university and clinical procedures observed in practice, attributing these to differences between the training received by nurses and a lack of standard curricula across universities. The WHO (2016) recommended that IPC education and training should be part of a complete healthcare strategy and embedded within clinical practice and training, rather than delivered in isolation, as this integrated approach would help build nurses' knowledge of IPC and its associated principles, which is essential in reducing cases of SWSIs (Beers and Bowden, 2005; Walker et al, 2007).
Nurses may simply not understand the rationale for infection-control practices and are therefore unable to link theory to practice (Cox et al, 2014). If nurses do not understand why it is necessary to maintain asepsis, this could impact on their resolve to apply its principles in practice (Gould et al, 2018), inevitably increasing the chance of patients acquiring infections from clinical procedures. Although ANTT has been set as the standard technique to be used in the UK (DH, 2008), its application remains a challenge for nurses who must determine what counts as acceptable practice (Ford and Koehler, 2001). The National Institute for Health and Care Excellence (NICE) developed clinical guidelines for healthcare-associated infections: prevention and control in primary and community care. These guidelines were updated in 2017; however, they do not include the guiding principles of ANTT or its application during wound management procedures (NICE, 2017). Instead, it implied that practitioners ought to be trained on the standard principles of IPC.
Furthermore, the WHO (2016) says it should be mandatory for healthcare providers to maintain good performance by providing regular training and education based on IPC principles and best practice. Competency in aseptic practice is also required to be monitored regularly by local trust's IPC policies and guidelines under the Health and Social Care Act 2012. However, although applying a structured training process in practice may be helpful in reducing episodes of SWSIs and consequently control HAIs, healthcare organisations continually strive to reinforce ANTT training in a way that learning is facilitated (Ford and Koehler, 2001).
A major subtheme within the ‘nurses’ behaviour’ theme is that nurses' decision-making skills when applying the principles of ANTT can be positively or negatively affected, depending on whether the system is in a state of wellness or experiencing some stress (Neuman and Fawcett, 2011). Some internal factors perceived by nurses in this study that may influence their mental processes include stress associated with work experience or work sensitivity (including ethical sensitivity, situation sensitivity or infection sensitivity within the clinical environment), stress induced by the absence of interdisciplinary collaboration and equipment or environment-related stress (Aholaakko, 2011; Teija-kaisa and Eija, 2016). Although some nurses may correlate being in the profession for several years with improved competency and confidence in their role, others might feel anxious as a result of the pressure to ‘know’ more or to perform to a higher standard, which may ensue from the struggle to keep up with changes in ANTT procedure without adequate refresher training (Bree-Williams and Waterman, 1996; Unsworth and Collins, 2011; Gould et al, 2018). Nonetheless, the revalidation process introduced by the Nursing and Midwifery Council in 2016 is intended help ensure that all registered nurses and midwives in England promote and maintain good practice, as well as build overall confidence in areas where there is a recognised need for this (NMC, 2019). This may also help to mitigate the idea of ANTT practice becoming ritualistic, as is found among nurses working alone in the community (Unsworth and Collins, 2011). However, although nurses have a responsibility to recognise these limitations and address them accordingly, there is a possibility that ANTT competency may be overlooked in the process.
Also arising from the ‘material and resources’ and ‘nurses' education’ themes, some community nurses are uncertain about how to work with the standard packs provided for ANTT procedures, since these frequently change. However, the NICE guideline on developing and updating local formularies recommends that systems ought to be in place to ensure healthcare organisations develop and update local formularies effectively and in accordance with statutory requirements (NICE, 2019). An aseptic environment is critical to practising ANTT and community nurses strive to replicate the procedure as practised in the acute setting, ensuring effective hand decontamination, using the appropriate wound care pack according to local formulary guidelines and performing standardised ANTT procedures underpinned by its key principles, guidance may help nurses become more confident. This will further boost their confidence that they are practising as aseptically as possible while working in a non-sterile or unfamiliar environment (Hart, 2007; Rowley and Clare, 2011).
According to the WHO (2019), measures put in place to prevent HAIs may be ineffective without staff accountability and behavioural change. In this review, nurses' moral sensitivity seems to be the central value and guides practice; the actions nurses take in adhering to the principles of ANTT will largely depend on their values and beliefs (Aholaakko, 2011; Teija-Kaisa and Eija, 2016). As such, when nurses are morally motivated, this may be reflected in their efforts to ensure their patients are protected from harm (NMC, 2018). The implication is that nurses will be practising within the codes of conduct and behaviour set out by the NMC, signifying the values that translate to good practice. This concept of valued-based practice resonates that all clinical decisions should be informed by both values and evidence (Fulford et al, 2006; Radden, 2007). However, in modern health, the universal attention on values is diminishing and leaning more towards an evidence-based approach (Fulford et al, 2002).
Limitations of the review
A major limitation of this study was that only two studies were drawn from the UK, which limits the transferability of the findings. However, the findings are not insignificant.
This study included only articles written in English and, had other languages been included, the findings may have been different.
Additionally, the study used thematic analysis, which is prone to interpretation and is therefore also a limitation.
Ultimately, practising within the stipulated principle of ANTT remains nurses' responsibility. However, promoting IPC compliance and adherence to ANTT require a more integrated approach, involving local and national organisations, including higher education institutions that teach nursing. It might be helpful if trusts are mandated to incorporate a more structured approach to training and this should be addressed under the new standards for education to allow for routine, practical and contextual learning. This might make nurses feel less overwhelmed by the frequency and schedule of training (Bree-Williams and Waterman, 1996). It may also be beneficial to arrange training whenever changes are made to the standard packs used in ANTT procedures, including measures such as introducing content labels on the pre-packs.
Furthermore, it is recommended that the recently reviewed NICE (2017) guideline is revised to accommodate the standard principles of ANTT, in view of guiding standard procedures for wound-care management. This will support adherence to the principles of ANTT during wound-care procedures, since NICE is recognised as the professional source of protocols and guidelines for nurses, and is based on high-quality evidence (De Brún, 2013).
Although policies and procedures guide the performance of aseptic practice, nurses' educational background can leave them feeling unsure about how ANTT should be carried out (Hallett, 2000). If nurses are to understand the rationale for the principles and practices around infection control, it is not enough for universities to teach the practical aspects alone. This review proposes that higher institutions teaching nursing design their curriculum so it equips future nurses with in-depth knowledge of infection control and the microbiological principles that inform these practices.
Finally, this review was informed by seven research studies conducted in different countries and, although several themes were uncovered from the literature, time limitations did not allow for all factors to be addressed. Therefore, further research is needed to highlight challenges faced in a UK context when applying the principles of ANTT. This will ascertain whether the issues identified in this study are country specific and allow for effective mitigation strategies to be targeted at a national level.