RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCESKARNATAKA, BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS (IN BLOCK LETTERS) / Mr. ARUN S.GANI,
M.Sc. NURSING 1ST YEAR,
SHRI B. M. PATIL INSTITUTE OF NURSING SCIENCES,
BIJAPUR -586103
2. / NAME OF THE INSTITUTION / SHRI B. M. PATIL INSTITUTE OF NURSING SCIENCES,
BIJAPUR -586103
3. / COURSE OF THE STUDY AND SUBJECT / M.Sc. NURSING 1ST YEAR,
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION TO THE COURSE / 4/6/2011
5. / TITLE OF THE STUDY
“A STUDY TO ASSESS THE KNOWLEDGE AND ITS PREVENTIVE PRACTICES REGARDING MRSA (METHICILLIN -RESISTANT STAPHYLOCOCCUS AUREUS) AMONG GENERAL NURSING AND MIDWIFERY INTERNSHIP STUDENTS AT SELECTED SCHOOLS OF NURSING IN BIJAPUR WITH A VIEW TO PROVIDE AN INFORMATION BOOKLET.”
6.
7. / BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
“Infectious diseases will last as long as humanity itself”
Good health is bedrock on which social progress is built. A nation of healthy people can do those things which make life worthwhile and, as the level of health increases, so does the potential for happiness. We have been talking about health as it pertains to the individuals and to a certain extent, the family. Nursing students at all levels, however, as well as students in the other health disciplines, need to be aware of the health status and the major health problems of people in the society in which they intend to practice.1
Staphylococcus aureus is a bacterium that is carried on the skin of about 30 percent of healthy individuals. However, when the skin is damaged such as a scratch staphylococcus aureus can cause a wide range of problems, from a mild skin infection to a severe, life-threatening illness.2 MRSA infection is caused by a strain of staphylococcus aureus bacteria that become resistant to the antibiotics commonly used to treat ordinary staphylococcus infections.3
Transmission of MRSA is through personal contact or contact with contaminated objects. Nurses can transmit MRSA from one patient to another not only by not washing their hands between patients but also by using the same equipment, such as glucometer, blood pressure cuffs, etc. on different patients.4
However, in 1959, methicillin, an antibiotic closely related to penicillin, was introduced to treat staphylococcus and other bacterial infections. Within one to two years, staphylococcus aureus bacteria started to be isolated that were resistant to methicillin. These staphylococcus aureus bacteria were then termed methicillin resistant staphylococcus aureus.5 MRSA usually show resistance to many antibiotics, hence it is also called Multidrug-resistant staphylococcus aureus.6
MRSA were first reported in the early 1960's and are now regarded as a major hospital acquired pathogen worldwide.7 The incidence of hospital acquired MRSA continues to rise globally.8
The Royal College of Nursing reports, Although nasal colonization with MRSA occurs frequently in nurses, the bacteria usually remain on the skin only a short time. Nurses with chronic skins lesions are most likely to become permanently colonized with MRSA. MRSA usually responds quickly to treatment in healthy individuals, and the treatment should be carried out as soon as colonization is diagnosed, to prevent infection of patients and other healthcare personnel.4
What’s more, anyone can become either a MRSA carrier or host……………

6.1 NEED FOR THE STUDY

Methicillin resistant staphylococcus aureus is making news as a dangerous, sometimes fatal disease for hospital patients and recently seen in students also. MRSA is also a major source of illness acquired in nursing homes, yet few new studies have looked at how to prevent its spread among elderly residents.9
News reports have alerted the general public about this infection and its potentially dire complications. MRSA infections are linked to high costs and poor outcomes. Fear of exposure to MRSA and other infections has even led some people to cancel or postpone elective surgery. About 1/3rdof the general population carries staphylococcal microbes. Estimates of healthcare workers’ carrier status range from 50% to 90%. The most common carriage site is the anterior nares. MRSA is highly resilient and can live without a host for an indeterminate time. The bacterium can live for weeks on inanimate objects, such as light switches, side rails, uniforms and other clothing, medical equipment, etc.10
MRSA infected 1.5% of the population of our country in 2004, the Centers for Disease Control and Prevention (CDC) reported. And also hospital-acquired MRSA accounted for around 86% of serious infections in 2005, the CDC and Prevention adds.4According to a 2009 report by the CDC, more than 90,000 life-threatening illnesses and nearly 19,000 deaths associated with MRSA occur yearly in USA. The CDC found nearly 85% of MRSA cases were linked to healthcare settings.10
As per report of Yale University School of Medicine 53% of health care workers’ hands were shown presence of MRSA after touching bedside rails and tables. Even 24% of staffs’ hands shown presence of MRSA, who had cleaned rooms after patient discharge. It also explains that cross-contamination can be prevented by thorough cleaning of patient’s room and equipments.4
A study was conducted on “Prevalence and characteristics of Staphylococcus aureus (S. aureus) colonization among healthcare professionals (HCPs) in an urban teaching hospital” inNew Jersey. A cross-sectional study enrolled 256 staff from the ICUs, emergency department (ED), and prehospital services. S. aureus was isolated from 112 of 256 (43.8%) HCPs, including 30 of 52 (57.7%) paramedics, 51 of 124 (41.1%) nurses, 11 of 28 (39.3%) clerical workers, and 20 of 52 (38.5%) physicians. MRSA was isolated from 17 (6.6%) HCPs, including 1 (1.9%) paramedic, 13 (10.5%) nurses, 1 (3.6%) clerical worker, and 2 (3.8%) physicians. Among S. aureus isolates, 15.2% were MRSA. MRSA prevalence was 9.6% (12/125) in emergency department workers, 5.1% (4/79) in ICU workers, and 1.9% (1/52) in emergency medical services workers. Compared with paramedics, who had the lowest prevalence of methicillin resistance among S. aureus isolates (1 of 30 [3.3%] isolates), nurses, who had the highest prevalence (13 of 51 [25.4%] isolates), had an odds ratio of 9.92 (95% confidence interval, 1.32-435.86; P = .02) for methicillin resistance. The observed prevalence of S. aureus and MRSA colonization among HCPs exceeds previously reported prevalence in the general population. The proportion of community-associated MRSA among all MRSA in this colonized HCP cohort reflects the distribution of the USA 300 community-associated strain observed increasingly among US hospitalized patients.11
MRSA is becoming more prevalent in healthcareand community settings. A MRSA survey was conducted to nursing students to gauge their general knowledge about MRSA. The score shown that the nursing students had a knowledge deficit regarding MRSA. Nursing students need specific MRSA content in the nursing curriculum and need role models in healthcare settings who are following infection control guidelines. A variety of teaching strategies may be used to effectively teach this topic to nursing students. The goal of this education is to prevent the spread of MRSA organisms and decrease the related costs of treating MRSA infections.12
MRSA is notorious for having serious physical and economical implications for patients, healthcare managers and practitioners. So, it is important that healthcare professionals and managers are given adequate information to enhance their knowledge and understanding of the condition in order to minimize and control it.13
A study was conducted on “The perceptions and understanding of MRSA infections among adults' and children's nurses”. The study result shows that the overall level of knowledge of infection control was relatively inadequate. Educational interventions and training should be implemented with nurses of different disciplines in order to improve their knowledge scores and practice proficiency. Repeating the study in other settings and in a larger sample size would be worthwhile to see if these conclusions can be generalized.13
Preventive measures for HA-MRSA are; people who are infected or colonized with MRSA often are placed in isolation as a precaution to prevent the spread of MRSA. Visitors and health care workers caring for people in isolation may be required to wear protective garments and must follow strict hand hygiene procedures. Contaminated surfaces and laundry items should be properly disinfected. For CA-MRSA careful hand washing, scrub hands briskly for at least 15 seconds, carry a small bottle of hand sanitizer, keep wounds covered, avoid sharing personal items such as towels, sheets, razors, clothing and athletic equipment, shower after athletic games or practices.3
Today’s GNM internship students are tomorrow’s professionalstaff nurses. This category of people may be exposed to MRSA during their working period if they don’t take any preventive measures. Hence studies are needed to address nurses' knowledge, attitudes and self-reported practices, and hence a gap in human knowledge is identified, which provides a good rationale to get control over the MRSA.

6.2 REVIEW OF LITERATURE

A study was conducted on “Deficient knowledge of multidrug-resistant bacteria and preventive hygiene measures among primary healthcare personnel” inSweden. Total, 5 urban and rural primary healthcare centers were included. 10 physicians, 38 district nurses and 10 nursing assistants participated. Physicians showed significantly better results than district nurses and nursing assistants did. Awareness of proper hand-washing as an effective preventive method and use of aprons in nursing care was high among all participants. Staff who knew they had cared for these patients had significantly better results than the others did. The result suggests that evidence-based education of multidrug-resistant and hygiene preventive measures, in primary health with subsequent follow-up should become a prioritized clinician and management concern. Research is needed that focus implementation of evidence-based educations, staff attitudes and responsibilities related to the work with patients at risk of multidrug-resistant bacteria.14
A study was conducted on “Nursing staff perceptions of methicillin-resistant Staphylococcus aureus and infection control (IC) in a long-term care facility (LTCF)” inAtlanta, USA. The study result shows that only 59% of participants perceived that MRSA posed a risk to patients. Consistency of self reported IC practices varied by specific behavior. Lack of supplies (26%) and lack of information (24%) were reported as primary barriers to IC. All participants perceived patient behavior as a barrier, and all were interested in additional education about MRSA and IC. Comparing nurses with nursing assistants, nurses more frequently reported the IC professional as the most trusted information source (60% versus 0%, P < .005); nursing assistants (NAs) were more likely to trust the charge nurse (77% versus 4%, P < .001). These results suggest that the perceptions regarding the real threat of MRSA and infection transmission that would drive IC prevention behaviors in this high-risk population vary among nursing staff, as do nursing staff IC practices. This study provides insight into the complex educational and other strategies needed to implement multilevel, multidimensional IC in LTCFs.15
A study was conducted on “Infection control and management of MRSA: assessing the knowledge of staff in an acute hospital setting” in Dundee, UK. A questionnaire survey was carried out through group administration during a study day and by face-to-face interviews. Subjects included in the questionnaire were infection and colonization, treatment, and the availability of local support and advice. There were 174 responses, divided equally between doctors and nurses. Knowledge on many aspects of MRSA and its management was deficient, although the majority of participants who felt that they required additional information about MRSA acknowledged this. The survey confirmed that assumptions should not be made about adequate knowledge and expertise of staff in relation to MRSA. Gaps in awareness of aspects of care and management were highlighted and information and educational needs identified.16
A study was conducted on “Does isolation prevent the spread of methicillin-resistant Staphylococcus aureus?” in Toronto. In this study 886 patients were included. The study examined rates of MRSA colonization or infection in 2 intensive care units (ICUs) and compared a strategy of isolating infected or colonized patients (“move phase”) with not isolating them (“non-move phase”) and hand hygiene compliance was measured by observation. The cumulative risk of a patient acquiring MRSA was 2% per ICU day. There was no difference in time to MRSA acquisition between the non-move phase and the move phases (adjusted hazard ratio 0.79, 95% confidence interval 0.51–1.22). This finding was unchanged after adjustment for potential confounders, and in a variety of sensitivity analyses.17
A study was conducted on “Awareness of bacterial resistance among physicians, pharmacists and nurses” in Jordan. In this study questionnaire was administered to 352 participants. The results indicate that most of the responding physicians and pharmacists considered Pseudomonas aeruginosa and MRSA the most frequently encountered resistant bacterial species. However, nurses recognized both MRSA and vancomycin-resistant Enterococci (VRE) as the most prevalent resistant species. Physicians and nurses (50.0% and 61.6%, respectively) reported prolonged hospitalization as a factor likely to contribute to the increased incidence of bacterial resistance. About 58% of pharmacists indicated the use of antibiotics without prescription as a significant reason for the development of bacterial resistance. Most of physicians (61.2%) reported that appropriate infection control is the most important measure to reduce bacterial resistance. Pharmacists (58.1%) recognized better adherence to the infection control guidelines as the most important factor that could reduce the risk of bacterial resistance. The findings of this study indicate a varying level of awareness of bacterial resistance among the health care professionals. Thus, serious efforts are still needed to develop and implement strategies to decrease the future risk of bacterial resistance to antibiotics.18
A study was conducted on “UK healthcare workers' knowledge of methicillin -resistant Staphylococcus aureus practice guidelines” in UK. In the result the mean score for knowledge levels obtained from doctors was 6.6 (1.68), for non-clinical control population was 4.7 (1.8) and for infection control nurses 8.4 (1.12). There were significant differences in knowledge levels between different population groups (P<0.001), UK employment region of the participant (P=0.01) and the doctors' medical specialty (P=0.02). Career seniority and gender of the participant were not significantly associated with differences in levels of knowledge. This questionnaire study evaluates a novel discriminatory questionnaire tool which differentiates knowledge levels of MRSA practice guidelines among a non-clinical population, HCWs and specialist infection control staff, thus providing a means for the rapid assessment of MRSA educational interventions. The study identifies demographics within HCW target populations which are associated with low levels of such knowledge. The result of the study revealed that consideration towards revising current HCW educational programs to improve knowledge and best practice in MRSA prevention is required.19
A study was conducted on “senior staff nurses' perceptions about MRSA”.The study was to examine the perceptions, attitudes and beliefs of 10 senior staff nurses. In the study, 60% of participants believe that MRSA is out of control and state 'why should they bother worrying about it'. Furthermore, 80% of participants commented that prescribed courses of nasal mupirocin were frequently missed. The perception is that IV treatments were more important and effective than topical agents. The study has established that a small section of experienced staff nurses perceive MRSA to be out of control and they are not overly concerned about its management.20
6.3STATEMENT OF THE PROBLEM
“A study to assess the knowledge and its preventive practices regarding MRSA (Methicillin- Resistant Staphylococcus Aureus) among general nursing and midwifery internship students at selected schools of nursing in Bijapur with a view to provide an information booklet.”
6.4OBJECTIVES
  1. To determine the level of knowledge regarding MRSA among GNM internship students as measured by structured knowledge questionnaire.
  2. To determine the level of preventive practices regarding MRSA among GNM internship students as measured by practice questionnaires.
  3. To find out the association between knowledge scores and preventive practice scores of GNM internship students with selected demographic variable.
  4. To develop and to distribute an information booklet regarding MRSA among GNM internship students.
6.5OPERATIONAL DEFINITIONS
a)Knowledge: In this study knowledge refers to correct responses given by the GNM internship students regarding MRSA.
b)MRSA:In this study MRSA refers to a specific strain of the Staphylococcus aureus bacterium, a common pathogen normally present in the body flora and commonly found on the skin or in the mucous membranes of healthy people.
c)Preventive Practices: In this study preventive practice refers to actions which are required to break the chain of MRSA transmission.
d)General Nursing and Midwifery internship student: In this study GNM internship student refers to those who have completed their III year GNM and training as intern at selected schools of nursing in Bijapur.
e)Information booklet: In this study information booklet is a tool which contains complete information of MRSA and its preventive measures.
6.6 ASSUMPTIONS
The study assumes that:
a)Most of the GNM internship students may have inadequate knowledge regarding Methicillin resistant staphylococcus aureus infection.
b)The information booklet will enhance the knowledge of the GNM internship students regarding Methicillin-resistant staphylococcus aureus infection.
6.7 HYPOTHESES
The following hypotheses will be tested at 0.05 level of significance.
H1 There will be significant association between knowledge scores with selected demographic variables.
H2 Therewill be significant association between preventive practice scores with selected demographic variables.
6.8DELIMITATIONS
The study is limited to only GNM internship students.
The study is limited to 100 samples.
The study is limited to selected nursing schools at Bijapur.
MATERIALS AND METHODS
7.1) SOURCE OF DATA
The data will be collected from 100 GNM internship students from selected nursing schools at Bijapur.
7.1.1) RESEARCH DESIGN
Descriptive research design.
7.1.2) RESEARCH APPROACH
Descriptive exploratory approach.
7.1.3) SETTING
The study will be conducted in the selected nursing schools at Bijapur.
7.1.4) POPULATION
The population under study includes GNM internship students of selected nursing schools at Bijapur.
7.1.5) VARIABLES
  • Research variable:Knowledge and preventive practices.
  • Demographic variable:Age, sex, previous information regarding MRSA infection.
7.2) METHOD OF DATA COLLECTION
7.2.1) SAMPLING PROCEDURE
The sample for the study will be selected by convenient sampling technique.
7.2.2) SAMPLE SIZE
In this study the sample size will be 100 GNM internship students from selected nursing schools at Bijapur.
7.2.3) INCLUSION CRITERIA FOR SAMPLING
GNM students who are working as intern in selected nursing schools at Bijapur.
Students who are available at the time of study.
Students who are willing to participate at the time of study.
7.2.4) EXCLUSION CRITERIA FOR SAMPLING
Students who are absent at the time of the study.
Students who have not passed in III year GNM.
7.2.5) INSTRUMENTS TO BE USED
  • Structured knowledge questionnaire
  • Preventive practice questionnaire
7.2.6) DATA COLLECTION METHOD
Permission will be obtained from the concerned authority.
Purpose of conducting the study will be explained to the subjects.
Informed consent will be obtained from the subjects.
Data will be collected by using structured knowledge questionnaire and practice questionnaire.
7.2.7) DATA ANALYSIS PLAN
Data will be analyzed according to the objectives and hypotheses of the study using descriptive statistics like mean, median, frequency, percentage, standard deviation and inferential statistics like chi-square, Karl Pearson coefficient co-rrelation. And will be presented in the form of tables, graphs and diagrams.
7.2.8) DURATION OF STUDY
4-6 weeks
7.3) DOES THE STUDY REQUIRE ANY INVESTIGATION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?IF SO, PLEASE DESCRIBE BRIEFLY.
No, only verbal response, no intervention is carried out.
7.4) HAS ETHICAL CLEARNCE BEEN OBTAINED FROM YOUR INSTITUTIONS IN CASE OF 7.3?
Not applicable.
8. / LIST OF REFERENCES:
  1. Gas D. Introduction to patient care.4th ed. New Delhi, Elsevier publishers; 2006.
  1. Methicillin-resistant Staphylococcus aureus (MRSA). Available from: URL:
  1. MRSA infection Prevention. Available from: URL:
  1. Robin S. A Fact Sheet On Mrsa In Nursing. 2010 sep; Available from: URL:
  1. Davis CP, Stoppler MC. MRSA Infection (Methicillin-Resistant Staphylococcus aureus) Infection. Available from: URL:
  1. Methicillin-resistant Staphylococcus aureus. Available from: URL:
  1. Methicillin-Resistant Staphylococcus aureus (MRSA) Detection and Identification Methods. Available from: URL:
  1. Cooper BS, Stone SP, Kibbler CC, Cookson BD, Roberts JA, Medley GF, Et al. Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA). British medical journal. 2004; 329:1.
  1. Few Strategies Exist to Prevent MRSA Spread in Nursing Homes. Available from: URL:
  1. Jarnagin TE. MRSA: A growing threat in both community and healthcare settings.American Nurse Today [serial online] 2010 June 5(6). Available from: URL:
  1. Elie-Turenne MC, Fernandes H, Mediavilla JR, Rosenthal M, Mathema B, Singh A et al. Prevalence and characteristics of Staphylococcus aureus colonization among healthcare professionals in an urban teaching hospital. Infect Control Hosp Epidemiol [serial online] 2010 Jun; 31(6):574-80.
  1. Jennings-Sanders A, Jury L. Assessing methicillin-resistant Staphylococcusaureus knowledge among nursing students.Nurse Educ Today [serial online] 2010 Nov; 30(8):789-93.
  1. Lugg GR, Ahmed HA. Nurses' perceptions of methicillin-resistant Staphylococcus aureus: Impacts on practice. Available from: URL:
  1. Mamhidir AG, Lindberg M, Larsson R, Fläckman B, Engström M. Deficient knowledge of multidrug-resistant bacteria and preventive hygiene measures among primary healthcare personnel.J Adv Nurs 2011 Apr; 67(4):756-62.
  1. Wolf R, Lewis D, Cochran R, Richards C. Nursing staff perceptions of methicillin-resistant Staphylococcus aureus and infection control in a long-term care facility.J Am Med Dir Assoc [serial online] 2008 Jun; 9(5):342-6.
  1. Easton PM, Sarma A, Williams FL, Marwick CA, Phillips G, Nathwani D et al. Infection control and management of MRSA: assessing the knowledge of staff in an acute hospital setting.J Hosp Infect [serial online] 2007 May; 66(1):29-33.
  1. Dhaliwal J,McGeer A. Does isolation prevent the spread of methicillin-resistant Staphylococcus aureus? CMAJ [serial online] 2005 March 29; 172(7): 875.
  1. Alzoubi K, Ayoub N, Al-Sakaji S, Al-Azzam S, Mhaidat N, Masadeh M. Awareness of bacterial resistance among physicians, pharmacists and nurses.Int J Occup Med Environ Health [serial online] 2009;22(4):363-72.
  1. Brady RR, McDermott C, Cameron F, Graham C, Gibb AP. UK healthcare workers' knowledge of methicillin-resistant Staphylococcus aureus practice guidelines; a questionnaire study. J Hosp Infect [serial online] 2009 Nov; 73(3):264-70.
  1. Lines L. A study of senior staff nurses' perceptions about MRSA.Nurs Times [serial online] 2006;Apr 11-17;102(15):32-5.

9. / SIGNATURE OF THE CANDIDATE:
10. / REMARKS OF THE GUIDE:
11. / NAME AND DESIGNATION:
11.1 GUIDE: / MR. SHALMON CHOPADE
PROFESSOR AND HOD OF MEDICAL SURGICAL NURSING,
SHRI B.M.PATIL INSTITUTE OF NURSING SCIENCES, BIJAPUR-586103
11.2 SIGNATURE:
11.3 CO-GUIDE: / MR. SHASHIKUMAR JAWADAGI
ASSOCIATE PROFESSOR,
SHRI B.M.PATIL INSTITUTE OF NURSING SCIENCES, BIJAPUR- 586103
11.4SIGNATURE:
12. / 12.1HEAD OF THE DEPARTMENT: / MR. SHALMON CHOPADE
PROFESSOR AND HOD OF MEDICAL SURGICAL NURSING
SHRI B.M.PATIL INSTITUTE OF NURSING SCIENCES, BIJAPUR- 586103
12.2 SIGNATURE:
13. / 13.1REMARKS OF THE CHAIRMAN AND PRINCIPAL:
13.2SIGNATURE: