Title Page                                                                                                                                i

Certification                                                                                                                            ii

Dedication                                                                                                                              iii

Acknowledgement                                                                                                                  iv

Table of Content                                                                                                                     v

List of Table                                                                                                                            viii

List of Figures                                                                                                                         ix

Abstract                                                                                                                                  x


Background to the Study                                                                                                       1

Statement of Problem                                                                                                             3

Purpose of the Study                                                                                                              4

Objectives of the Study                                                                                                           4

Hypotheses                                                                                                                             4

Significance of the Study                                                                                                       5

Scope of the Study                                                                                                                 5

Operational Definitions                                                                                                          6


Conceptual Review:                                                                                                                8

Asepsis                                                                                                                                   8

Aseptic Technique                                                                                                                  10

Sterile Technique                                                                                                                    11

Surgical Aseptic Technique                                                                                                    12

Surgical Hand Scrub                                                                                                               14

Use of Personal Protective Device                                                                                         15

Maintaining a Sterile Field During Surgery                                                                            17

Control and Design for Safer Surgical Procedure                                                                  18

Layout of the Operating Theatre                                                                                            19

Concept of Attitude of Theatre Users Towards Surgical Aseptic Standard                          21

Factor that Influence Attitude of Theatre Workers                                                                22

Concept of Compliance to Surgical Aseptic Standard                                                           22

Theoretical Framework Related to the Study                                                                         25

Health Belief Model (HBM)                                                                                                  27

Model of the Study                                                                                                                31

Empirical Review                                                                                                                    33

Summary of literature review                                                                                                 38


Research Design                                                                                                                     39

Area of the Study                                                                                                                   39

Target Population                                                                                                                    41

Sample                                                                                                                                                41

Instrument for Data Collection                                                                                               43

Validity of Instrument                                                                                                                        45

Ethical Considerations                                                                                                            46

Procedure for Data Collection                                                                                                46

Method of Data Analysis                                                                                                       48


Demographic Characteristics of the Respondents                                                                  49

Research Objective 1: Theatre Workers’ Attitude Towards Various Aspects of Surgical     51

Aseptic Standard Practice

Research Objective 2: Theatre  Practice of Surgical Aseptic Standard.                                 55

Research Objective 3: Test of Hypotheses                                                                             61

Ho1- There is no Significant Relationship Between Theatre Users’ Attitude to

Wards Standard Aseptic Technique and their Compliance to Surgical Aseptic Standard.    61

Ho2- There is no Significant Variations in the Practice of Surgical Aseptic              62

Standards Across Tertiary Health Institutions in Enugu State.

Ho3: There are no Significant Variations in the Compliance of Theatre Workers to Surgical

Aseptic Standard Practices.                                                                                                    63


Discussion of major findings                                                                                                  66

Respondents’ Characteristics                                                                                                  67

Theatre Workers’ Attitude Towards Various Aspects of Surgical Aseptic

Standard Practice                                                                                                                                68

Theatre Workers’ Compliance with Surgical Aseptic Standard Practice.                              69

Practice of Surgical Hand Scrub                                                                                             69

Compliance with the Use of Personal Protective Device.                                                      70

Maintenance of Surgical Field During Surgery                                                                      70

Relationship Between Theatre Workers’ Attitude Towards Standard Aseptic Technique

And Compares of the Practice of Surgical Aseptic Standard Across Tertiary Health

Institutions in Enugu State.                                                                                                    71

Summary                                                                                                                                 73

Recommendations                                                                                                                  74

Limitations                                                                                                                              75

Suggestion for Further Study                                                                                                 76

References                                                                                                                              77

Appendix                                                                                                                                82





Table1:   Population Distribution of Theatre Staff and Sampling Size Proportions               43

Table 2:  Demographic Characteristics of the Respondents                                                   50

Table 3: Theatre workers’ attitude towards the practice of surgical hand scrub                    52

Table 4: Attitude towards the use of personal; protective device.                                         53

Table 5: Attitude towards maintaining a sterile field during surgery                                     54

Table 6: Theatre workers practice of surgical Hand Scrub.                                                    55

Table 7: To assess theatre workers practice of under listed aspects of surgical aseptic

standard in the practice of the use of personal protective device                             57

Table 8: To assess theatre workers practice of under listed aspects of surgical aseptic

standard in the practice of the use of personal protective device.                            58

Table 9: Maintaining a Sterile field during Surgery                                                                60

Table 10: Summary of the tables on surgical aseptic standard practices                                61

Table 11: Relationship between theatre workers’ attitude towards standard aseptic

techniques and their compliance to surgical aseptic standard                                62

Table 12: Comparison of surgical aseptic standard practices across tertiary institutions in

Enugu State.                                                                                                                                                     63

Table 13: Mean comparison of compliance with surgical aseptic standard practices

by theatre worker.                                                                                                  64



Figure 1:1    The health belief model                                                                          27

Figure 2:2    Conceptual model of the study of attitude and compliance to

Surgical Aseptic Standard.                                                                     31



Surgical aseptic technique is the application of those strict principles and procedures aimed at preventing the invasion of surgical sites by micro organisms. Prevention of surgical site infection (SSI) has become a priority worldwide. Approximately 50,000 deaths are estimated to occur annually across Europe, as a consequence of surgical site infection. In some university teaching hospitals in Nigeria, the rate of SSI ranges from 10 to 20%. This was linked to non compliance with standard practice due to poor theatre workers’ attitude to work. Compliance to surgical aseptic standard in this study entails theatre workers’ readiness and obedience to carry out the correct procedure in the area of surgical hand scrub, proper use of personal protective device and maintenance of sterile field during surgery. The purpose of this study is to determine the attitude and compliance of theatre workers towards the practice of surgical aseptic standard in tertiary health institutions in Enugu state. The specific objectives were to: (i) elicit theatre workers’ attitude towards various aspects of surgical aseptic standard, (ii) determine theatre workers’ practice of surgical aseptic standard, (iii) determine the relation between attitude and compliance in the practice of surgical aseptic standard and (iv)compare the practice of standard aseptic technique across tertiary health institution in Enugu State. The study adopted a descriptive cross sectional survey design. It was conducted at the three tertiary health institutions in Enugu State, Nigeria. Using purposive sampling technique and observing the following inclusion criteria: (a) participants must be doctors and nurses working in the operating theatre, (b) must be certified, registered, and licensed to practice in the operating theatre, (c) must be physically fit to operate or assist during surgery and (d) willingness to participate in the study. A total of 272 theatre workers were recruited from the population of 660 theatre worker. Instruments for data collection were the pre tested, 20 item researcher developed questionnaire on attitude of theatre workers and 40 item observational checklist. The instruments were validated by the researcher’s supervisor and two experts in the Department of Nursing in University of Nigeria Enugu Campus. Reliability of the questionnaire was established using test retest method at two weeks interval that yielded Cronbach’s alpha correlation coefficient of 0.88. The observational checklist, inter rater scores showed high degree of agreement. Data collected were subjected to descriptive statistics and analysed using Pearson’s Product Moment Correlation and analysis of variance (ANOVA) at p < 0.05 significant level. The significant means decision point for attitudinal item is >2.5 and >2 for observational checklist. The perceived attitude of theatre workers to surgical aseptic technique was positive with overall mean of  3.40 ± 0.81, while SHS had 3.79 ± 0.18, use of PPD 3.1 ± 0.18, and MSF had 3.43 ± 0.81.Theatre workers’ compliance to surgical standard practices were as follows: surgeons and peri operative nurses consistently had higher mean score, for SHS (2.89 ± 0.19, 2.78 ± 0.18), use of PPD (2.84 ± 0.12, 2.81 ± 0.22) and MSF(2.75 ± 0.20, 2.84 ± 0.19) respectively, than physician and nurse anesthetists score SHS (2.34 ± 0.45, 2.39 ± 0.40), use of PPD (2.43 ± 0.35, 2.71 ± 0.31) and MSF (2.29 ± 0.42, 2.61 ± 0.41) respectively. There were significant relationship (r= 0.86, r= 0.81, r= 083) between attitude and compliance. There were no significant variations (p> 0.05) in the practices across the three health institutions. Surgeon and physician anesthetists showed less compliance to the practice of wearing theatre outfit within the restricted area, with mean score of 1.67 and 1.56 respectively.





Background to the Study

Surgical aseptic technique is the application of those strict principles, practices, and procedures aimed at preventing the invasion of surgical sites by microorganisms during intra and post-operative period (Briggs, 2013). This according to Albany, (2010) is achieved by ensuring that only uncontaminated equipment, fluid, and items come in contact with the sterile field during clinical procedures. Albany, (2010) refers to this procedure as Aseptic Non Touch Technique (ANTT). However, ineffective application of these clinical procedures and protocols according to Briggs, (2013) usually result to surgical site infection which in turn gives rise to long periods of hospitalization and high cost of hospital bill to both patient and hospital

The prevention of surgical site infection has become a priority worldwide. Approximately 50,000 deaths are estimated to occur annually across Europe as a consequence of surgical site infection (Jones, 2012). In New York, the national infection average per 1000 is 2.7% (National Infection Control, 2010). Albany (2010) in a study in a New York hospital recorded 3.7% infection rate per 1000 in the surgical intensive care unit. If the infection rate is that high in developed economies, the situation may be expected to be worse in developing countries like Nigeria, where challenges to compliance to surgical aseptic standards are definitely more.(Infection Control Policy (2010) A descriptive study carried out in the University Hospital Lagos by Afolabi, (2012) showed about 15% to 20% infection rate in male surgical ward. This was linked to non- compliance due to poor attitude of theatre workers to surgical aseptic standard in the area of surgical hand scrub, use of personal protective device and maintenance of sterile field during surgery observed by Berkeley (20012).

Compliance in this regard implies the readiness of theatre workers to practice various aspects of surgical aseptic standard in the area of surgical hand scrub, use of personal protective device and maintenance of surgical field during surgery. In other word, it involves willingness of theatre workers to stick firmly in practice to the rules and principles of standard aseptic technique. Previous studies according to Ginasekara (2010) have shown that compliance to the surgical aseptic standard among theatre workers has been generally unstable and increase in compliance has been difficult to sustain. Nevertheless, He noted that poor attitude is responsible for substandard practice as far as compliance to the surgical aseptic practice is concerned. Several reasons for noncompliance have been identified, including staff attitude and lack of interest to work. Relationship among theatre users has also been identified as an important factor in improving compliance (WHO, 2013). Sidon (2011) also stated that the designing and establishment of a practicable evidence-based surgical aseptic standard coupled with a positive attitude to work has been known to improve compliance to surgical aseptic standard practice.

Macleod, (2010) defines attitude as a predisposition, a tendency or a propensity to respond positively or negatively to a certain idea, object, person or situation.   Attitude is therefore a serious variable in compliance (Leon, 2011).This is precisely because attitude influences individual’s choice of action either positively or negatively. A positive attitude is sure to affect compliance positively with a low rate of surgical site infection as collateral, while poor attitude is associated with noncompliance to the protocol and corresponding increase of rate of surgical site infection.