KNOWLEDGE OF NEPHROLOGY NURSES ON EVIDENCE 

BASED GUIDELINES FOR PREVENTION OF HAEMODIALYSIS 

CATHETER RELATED INFECTIONS 

 

 

 

 

 

 

 

 

 

Mphanye Joseph Ntlhokoe 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A research report submitted to the 

Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 

in partial fulfilment of the requirements for the degree 

of 

Master of Science in Nursing 

 

 

 

Johannesburg, 2016



ii 
 

DECLARATION 
 

I, Mphanye Joseph Ntlhokoe, declare that this research report is my own work. It is being 

submitted for the degree of Master of Science (in Nursing) at the University of the 

Witwatersrand, Johannesburg. It has not previously been submitted for any degree or 

examination at this or any other university. 

 

Signature ……………………………………………. 

………………………………day of ………………… 2016 

 

Protocol Number M130921 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 



iii 
 

DEDICATION 
 

Special dedication to my family for their inspiration, love and support throughout my 

studies at the University of the Witwatersrand, Johannesburg. 

Many thanks to all the Nephrology nurses who participated in my study and the 

expertpanel who agreed on and validated my research tool. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 



iv 
 

ACKNOWLEDGEMENTS 
 

 

I thank God for provision and protection throughout my study; I owe nothing to myself.  

 

My gratitude goes to the following people and institutions: 

To my wife, Mpho Ntlhokoe and my family for their tireless support throughout my 

study. 

To my supervisor Shelley Schmollgruber for her guidance, total support and 

motivation. Sincerely you were not only a supervisor to me but also a mentor. A 

big thank you to you. 

  

To the Wits biostatistician for their statistical analysis and interpretation of the data. 

 

To all the Nephrology nurse experts for their input into the validation of the 

instrument used in the study. 

 

To the institution where the research was carried out and the relevant personnel of 

this institution. 

 

To the Nephrology nurses who participated in this study and their families, thank 

you for making this study possible. 

 

 

 

 

 

 

 

 

 

 

 

 

 



v 
 

ABSTRACT 

 

The purpose of the study was to determine knowledge of nephrology nurses’ on evidence 

based guidelines for the prevention of haemodialysis catheter related infections. The study 

was done in 5 haemodialysis units from two university-affiliated, public sector and tertiary 

level hospitals in Gauteng which are: “Baragwanath Hospital and Charlotte Maxeke 

Academic Hospital”.  

 

Face and content validation of the research instrument “Evaluation questionnaire 

concerning nurses’ knowledge of interventions for prevention of haemodialysis catheter-

related bloodstream infections” was done by a panel of experts to ensure applicability of 

the instrument to the South African context.  Prior to commencement of the study, ethical 

clearance and permission to conduct the study was obtained from the relevant authorities 

and the university committee. A non-experimental, descriptive, prospective study design 

was utilised in order to meet the objectives of the study. Descriptive and comparative 

statistics were used to analyse the data which was done in consultation with a statistician. 

 

Knowledge was reorganised as poor (0-50%), average (50-70%) and good (71% and 

above). Overall, participants performed well in the second part of the questionnaire where 

their knowledge was tested regarding evidence based guidelines in prevention of vascular 

access infection; the majority 72.50% (n=58) scored more than 71%, indicating they have 

knowledge of evidence based guidelines on prevention of vascular access infection, 20% 

of participants scored between 51 and 70%, whilst only 2% scored below 50%. 

 

A positive correlation (with moderate strength) between age and experience (r=0.563) was 

established indicating that as age increases the experience will also increase moderately. A 

slight negative correlation, which was very weak (null correlation) was also established 

between years of experience and performance as most respondents were above and below 

the regression line. Therefore years of experience has no influence over performance. 

 

 



vi 
 

TABLE OF CONTENTS 
 

 Page 

DECLARATION  ii 

DEDICATION  iii 

ACKNOWLEDGEMENTS  iv 

ABSTRACT  v 

TABLE OF CONTENTS  vi 

LIST OF FIGURES xii 

LIST OF TABLES xiii 

LIST OF ABBREVIATIONS  xiv 

 

 

CHAPTER ONE: OVERVIEW OF THE RESEARCH STUDY  

1.0 INTRODUCTION  1 

1.1 BACKGROUND  OF THE STUDY 1 

1.2 PROBLEM STATEMENT 4 

1.3 PURPOSE OF THE STUDY 4 

1.4 RESEARCH OBJECTIVES  4 

1.5 SIGNIFICANCE OF THE STUDY 5 

1.6 RESEARCHER’S ASSUMPTIONS 5 

1.6.1 Meta-theoretical Assumptions  6 

1.6.1.1 Person 6 

1.6.1.2 Environment  6 

1.6.1.3 Health and wellness  6 

1.6.1.4 Nephrology nursing  6 

1.6.2 Theoretical Assumptions 7 



vii 
 

1.6.2 Methodological Assumptions 10 

1.7 OVERVIEW OF THE RESEARCH METHODOLOGY 11 

1.8 RELIABILITY AND VALIDITY  11 

1.9 ETHICAL CONSIDERATIONS 12 

1.10 SUMMARY 12 

 

CHAPTER TWO: LITERATURE REVIEW 

 

2.1 INTRODUCTION 14 

2.2 OVERVIEW OF HAEMODIALYSIS  14 

2.3 END-STAGE KIDNEY DISEASE  15 

2.3.1 Prevalence  15 

2.4 OVERVIEW OF CATHETER RELATED INFECTION 15 

2.4.1 Definition of Catheter-related Infection  16 

2.4.2 Incidences of Infection  16 

2.4.3 Pathophysiology  17 

2.4.4 Risk Factors  17 

2.5 TYPES OF VASCULAR ACCESS  18 

2.6 EVIDENCE BASED GUIDELINES TO PREVENT HAEMODIALYSIS 

CATHETER RELATED INFECTIONS  

23 

2.6.1 Education, Training and Staffing  25 

2.6.2 Site of Insertion  26 

2.6.3 Patient factors  27 

2.6.4 Skin Preparation  28 

2.6.6 Dressings 29 

2.6.6 Antibiotic and Antiseptic Ointment  29 



viii 
 

2.6.7 Anticoagulation  29 

2.6.8 Full Barrier Precautions  29 

2.6.9 Hand Hygiene 30 

2.7 NURSES KNOWLEDGE RELATED TO EVIDENCE-BASED 

GUIDELINES FOR CATHETER RELATED BLOODSTREAM 

INFECTIONS  

30 

2.8 BARRIERS AND FACILITATORS TO EVIDENCE BASED PRACTICE 

GUIDELINES  

32 

2.9 SUMMARY  34 

 

 

CHAPTER THREE: RESEARCH METHODOLOGY 

 

3.1 INTRODUCTION  36 

3.2 OBJECTIVES OF THE STUDY 36 

3.3 RESEARCH DESIGN 36 

3.3.1 Non Experimental 37 

3.3.2 Descriptive 37 

3.3.3 Prospective 37 

3.3.4 Contextual design 37 

3.4 RESEARCH METHOD 38 

3.4.1 Population 38 

3.5 SAMPLE AND SAMPLING 39 

3.6 DATA COLLECTION 39 

3.6.1 Instrument 40 

3.6.2 Validity and Reliability of Instrument 40 



ix 
 

3.6.3 Procedure 41 

3.6.4 Data Analysis 42 

3.7 VALIDITY AND RELIABILITY 43 

3.7.1  Validity 43 

3.7.2  Reliability 43 

3.8 PRE-TESTING THE INSTRUMENT  44 

3.9 ETHICAL CONSIDERATIONS 44 

3.10 SUMMARY 45 

 

 

CHAPTER FOUR: DATA ANALYSIS AND RESULTS 

 

4.1 INTRODUCTION   46 

4.2 APPROACH TO DATA ANALYSIS 46 

4.3 VALIDATION OF THE INSTRUMENT 47 

4.3.1 Demographic Data 47 

4.3.2 Content validity of the instrument 48 

4.4 RESULTS AND FINDINGS OF MAIN STUDY 49 

4.4.1 Section A: Demographic Data  49 

4.4.1.1 Age distribution  50 

4.4.1.2 Gender distribution  51 

4.4.1.3 Qualifications  52 

4.4.1.4 Years of working experience  53 

4.4.2 Section B: Knowledge of evidence based practice  54 

4.4.2.1 Hand washing during accessing vascular access. 55 

4.4.2.2 Skin cleansing during accessing vascular access. 56 



x 
 

4.4.2.3 Type of vascular access for vascular access exit site. 57 

4.4.2.4 Removal of vascular access exit site dressing. 58 

4.4.2.5 Use of antibiotic/antiseptic ointment for vascular access exit sites 59 

4.4.2.6 Use of anticoagulant locks for vascular access catheter lumens 60 

4.4.2.7 Checking vascular catheter exit sites 61 

4.4.2.8 Checking fistulas and graft vascular access sites 62 

4.4.2.9 Changing vascular access catheter dressing 63 

4.4.2.10 Use of protective clothing by nursing staff 64 

4.4.2.11 Avoidance of cross contamination for haemodialysis patients 65 

4.4.2.12 Level of knowledge about haemodialysis related catheter infections 66 

4.4.3 Correlations between Experience Levels and Knowledge  67 

4.4.4 Correlations between Age and Levels of Experience  69 

4.5 DISCUSSION OF RESULTS  70 

4.6 SUMMARY  75 

 

 

CHAPTER 5: SUMMARY, DISCUSSION OF RESULTS, 

CONCLUSIONS, AND RECOMMENDATIONS 

 

5.1 INTRODUCTION 76 

5.2 SUMMARY OF THE STUDY 76 

5.2.1 Purpose of the study 76 

5.2.2 Objectives of the study 77 

5.2.3 Methodology 77 

5.3 SUMMARY OF MAIN RESEARCH FINDINGS 78 

5.4 CONCLUSION 79 

5.5 LIMITATIONS OF THE STUDY  80 



xi 
 

5.6 RECOMMENDATIONS OF THE STUDY 80 

5.6.1 Clinical Nursing Practice 81 

5.6.2 Nursing Education 82 

5.6.3 Nursing Research 82 

 

LIST OF REFERENCES  83 

 

APPENDICES  

APPENDIX A Panel of experts information letter  93 

APPENDIX B Panel of experts consent form 94 

APPENDIX C Panel of experts checklist 95 

APPENDIX D Data collection instrument 98 

APPENDIX E Consent form for participants 100 

APPENDIX F Participants Information letter 101 

APPENDIX H Ethics clearance certificate 102 

APPENDIX I Approval letter from  Charlotte Maxeke Academic Hospital 103 

APPENDIX J Language proofing and editing  104 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



xii 
 

LIST OF FIGURES 

 
Figures  Page 

4.1 Expert panel rating of the questionnaire item content validity  47 

4.2 Distribution of age of nurse respondents  49 

4.3 Distribution of gender of all participants 50 

4.4 Distribution of education in nephrology (n=80) 51 

4.5 Distribution of years of working experience in renal unit 52 

4.6 Frequencies obtained on hand washing 55 

4.7 Frequencies obtained on skin cleaning 56 

4.8 Frequencies obtained on dressing used on vascular catheter exit site 57 

4.9 Frequencies obtained on dressing removal 58 

4.10 Frequencies obtained on the type of antibiotic/antiseptic ointment to 

be used on exit site 

59 

4.11 Frequencies obtained on anticoagulation lock 60 

4.12 Frequencies obtained on checking of vascular catheter exit site 61 

4.13 Frequencies obtained on checking of fistula and grafts 62 

4.14 Frequencies obtained on when to change vascular catheter dressing 63 

4.15 Frequencies obtained on the use of protective clothing by nursing staff 64 

4.16 Frequencies obtained on advice for patients to avoid cross 

contamination 

65 

4.17 Frequencies obtained from respondents for level of knowledge for 

preventing haemodialysis catheter-related infections 

66 

4.18 Correlation for age and level of knowledge  68 

4.19 Correlation for age and years of experience  69 

 

 

 



xiii 
 

LIST OF TABLES 

 

 
Table   Page  

4.1 Demographic data for panel of Nephrology nurse experts (n=6) 

 

46 

4.2 Distribution of demographic data obtained from nurse participants 

(n=80) 

 

48 

 

4.3 Summary of nurse’s scores for knowledge by years of experience 

(n=80) 

 

67 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



xiv 
 

LIST OF ABBREVIATIONS 

 
 

The following is a list of abbreviations used in the study: 

 

 

AVF Arteriovenous Fistula 

 

AVG Arteriovenous Graft  

 

CDC Centre for Disease Control and Prevention  

 

CRBSI  Catheter Related Bloodstream Infection 

 

CVC Central venous catheter  

 

ERA European Renal Association  

 

HPSC 

 

ICU  

Health Protection Surveillance  

 

Intensive Care Unit  

 

NKF-KDOQI National Kidney Foundation Kidney Disease Outcomes 

Quality Initiative  

 

RRT Renal Replacement Therapy  

 

UK United Kingdom  

 

USA United States of America  

 

  

  

  

 



1 
 

CHAPTER ONE 

 

OVERVIEW OF THE STUDY 

 

1.0 INTRODUCTION  

 

This chapter presents an overview of the study. The problem statement, purpose of the 

study, research objectives and the significance of the study will be described, the 

assumptions of the researcher will be discussed and operational terms defined. A brief 

overview, which will be discussed in greater detail in chapter three, will be given of the 

research methodology, validity and reliability and the ethical principles adhered to.    

 

1.1 BACKGROUND OF THE STUDY 

 

Chronic kidney disease is recognised as a worldwide public health problem (Kara, 2009; 

Yu & Petrini, 2010). It causes significant increase in the mortality, morbidity, decreased 

quality of life and burden on the healthcare expenditure (Kara, 2009). Yu and Petrini 

(2010) reported that chronic kidney disease continues to increase due to increase in the 

hypertension and diabetes. This is a slow and long-lasting loss of kidney function and the 

progress of the disease is categorised into 5 stages with the last stage being referred to as 

end stage kidney disease. It is at this stage where a patient is expected to start renal 

replacement therapy (RRT), which can be either haemodialysis or peritoneal dialysis. A 

small number of these patients may be offered the option of renal transplantation (McCann 

& Moore, 2010). 

 

Globally, there is an increase in the number of patients who need renal replacement 

therapy each year and haemodialysis is the most common means of treatment (Murphy, 

2011). In the United States of America (USA) about 90% of patients receive haemodialysis 

and 80% in the United Kingdom (UK), while the number of patient receiving 

haemodialysis in the Republic of Ireland is increasing nationally (Murphy, 2011). While 

Yu and Petrini (2010) reported that in China about 96-100 people per millions advances to 

end stage kidney disease and the number is growing by about 130, 000 each year and went 

further to say that there were 41, 755 (89.5% haemodialysis and 10.5% peritoneal dialysis) 



2 
 

of patients requiring dialysis in 1999 as reported by the Chinese 1999 Registry of Dialysis 

and Transplantation (Yu & Petrini, 2010).  

 

According to the American Kidney Fund (2012), about 31 million people developed 

chronic kidney disease in the USA (approximately 10% of the total US population). This 

report highlights that in 2009, about 116,395 of people were newly diagnosed with kidney 

failure while about 571 414 had already been living with the disease and it was reported 

that 90 118 people had already lost their lives due to the disease (most recent stats 

available). In 2009, 398 861 people were on dialysis and haemodialysis accounts for 95% 

of all people on dialysis (380 760), whilst 5% (18 101) were on peritoneal dialysis and the 

expenditure by Medicare for people with chronic kidney disease totalled $33.8 billion 

(American Kidney Fund, 2012).  

 

Africa is the second largest continent, with 53 countries and approximately 1 billion people 

comprising 14% of the world’s population. Sub-Saharan Africa has 45 countries, with a 

population of 389 million, where the majority (80%) live on less than $2.5 per day. 

Naicker (2013) stated there is an increasing need for kidney health care and renal 

replacement therapy in Africa as in the rest of the world, but only a few countries have the 

ability to care for the needs of all patients. According to Naicker (2013) dialysis and 

transplant patients use an increasing proportion of the total health budget in countries such 

as Taiwan, Japan and United States, whilst the majority of emerging countries, such as 

African nations, have limited resources of these expensive treatments. In addition, there is 

a lack of renal registries and no reliable statistics on the prevalence of chronic kidney 

disease in most African countries (Naicker, 2013).  

 

Of those patients commencing haemodialysis, 70% are admitted for temporary vascular 

access which carries a significant risk in complications, such as infections, which leads to 

an increase in morbidity and mortality (Murphy, 2011). Vascular access infections are the 

second leading cause of morbidity and mortality in patients receiving haemodialysis 

(Strong & Mukai, 2011). Hand hygiene, use of protective clothing and face shields, 

vascular access cleaning and dressing are measures used to minimize risk of infection and 

forms an integral part of vascular access care and hygiene (Higgins & Evans, 2008). For 

patient safety nurses should possess sufficient knowledge on infection control measures 

and to be able minimize infection in the haemodialysis units (Higgins & Evans, 2008). 



3 
 

Guidelines for prevention of intravascular catheter-related bloodstream infections were 

developed by Centre for Disease Control and Prevention (CDC) (CDC, 2011), European 

Renal Association (ERA) (ERA, 2012), and National Kidney Foundation Kidney Disease 

Outcomes Quality Initiative (NKF-KDOQI) (NKF-KDOQI, 2012) and the Health 

Protection Surveillance Centre (HPSC) (HPSC, 2005) for healthcare personnel working 

with intravascular catheters. It is therefore the role of nephrology nurses to have the 

necessary knowledge, skills and education on these guidelines for the prevention of 

infection in renal dialysis units (Higgins & Evans, 2008). 

 

There are different types of haemodialysis vascular access methods, namely: arteriovenous 

fistula, arteriovenous graft, and central venous catheter. In more than 80% of patients 

starting haemodialysis, the route of choice is the central venous catheter which has many 

advantages such as ease of insertion, unnecessary maturation time and can be used 

immediately without disadvantages. However, the central venous catheter carries a 

substantially higher morbidity and mortality rate than the fistulas and grafts (Mokrzycki & 

Lok, 2011). All three of these vascular access methods require highly specialized nursing 

techniques and skills to ensure patient safety. Kidney failure patients are high risk patients 

because they are not only compromised by electrolyte and metabolic disturbances, but also 

by immune-deficiencies and other comorbid conditions such as human immune virus 

(HIV) (Bedendo, Giarola & Brondani, 2011).  

 

Research showed a significant rate of vascular access infections in patients by new or 

inexperienced dialysis staff. This might be due to nurses being insufficiently trained in 

accessing the patient’s circulation and may not follow the correct arteriovenous access 

techniques, or apply the infection control procedures, or adhere to the standards in sterile 

catheter care. To prevent these life-threatening malpractices, training and competency 

assessment of nursing personnel needs to be regularly assessed and recorded, and there 

should be on-going professional development (Dorman & Dainton, 2011). This study 

therefore proposed to investigate nephrology nurses’ knowledge of evidence-based 

guidelines for the prevention of haemodialysis catheter-related bloodstream infections.  

  

 

 

 



4 
 

1.2 PROBLEM STATEMENT  

 

Dialysis catheter related infection remains a concern in patients with kidney failure and 

most deadly form of health related infections. Adherence to evidence-based guidelines on 

prevention of haemodialysis catheter-related infection would reduce its risk of occurrence 

and decrease morbidity and mortality of haemodialysis patients in the renal dialysis units. 

Research has demonstrated an increased rate of vascular access infections in patients by 

new or inexperienced dialysis staff. This might be due to nurses being insufficiently trained 

in accessing the patient’s circulation and may not follow the correct arteriovenous access 

techniques, or apply the infection control procedures, or adhere to the standards in sterile 

catheter care.  For patient safety nurses should possess sufficient knowledge on infection 

control measures and to be able minimize infection in the haemodialysis units.  

 

This study will attempt to answer the following research questions: 

 Do nurses have knowledge of evidence-based guidelines for the prevention of 

haemodialysis catheter-related bloodstream infections? 

 Are the evidence-based guidelines for prevention of haemodialysis related 

bloodstream infections being practiced in the renal dialysis units and if not, what 

are the reasons for non-adherence to the evidence-based guidelines for prevention 

of haemodialysis catheter-related bloodstream infections? 

 Does training and years of experience in renal care influence knowledge levels of 

nephrology nurses? 

 

1.3 PURPOSE OF THE STUDY  

 

The purpose of this study was to investigate nephrology nurses’ knowledge of evidence- 

based guidelines for the prevention of haemodialysis catheter-related bloodstream 

infections in the renal dialysis units from two university-affiliated, public sector and 

tertiary level hospitals in Gauteng.  

 

 

 

 

 



5 
 

1.4 OBJECTIVES 

 

The objectives of this study are: 

 To validate the instrument “Evaluation questionnaire concerning nurses’ 

knowledge of interventions for prevention of haemodialysis catheter-related 

bloodstream infections” to assess nurses’ knowledge on evidence-based guidelines 

for prevention of haemodialysis catheter-related bloodstream infections. 

 To determine and describe nephrology nurses’ knowledge of evidence-based 

guidelines for prevention of haemodialysis catheter-related bloodstream infections 

in the renal dialysis units from the public sector institutions in Gauteng.  

 To establish whether there is a relationship between age, years of experience and 

knowledge of nurses (trained and non-trained) on evidence-based guidelines of 

haemodialysis catheter-related infections. 

 

1.5 SIGNIFICANCE OF THE STUDY  

 

Haemodialysis catheter-related bloodstream infection carries high morbidity and mortality 

rates worldwide. There is evidence to support various strategies that helps prevent its 

incidence. Evidence-based guidelines have been created in the prevention of haemodialysis 

catheter-related infections and adherence to these guidelines is extremely important in 

increasing positive outcomes for haemodialysis patients in the renal dialysis units. Lack of 

knowledge has been indicated as a barrier for adherence to evidence-based guidelines. 

Therefore it is important to evaluate nephrology nurses’ knowledge and to highlight 

possible causes which prevent implementation of evidence-based guidelines on prevention 

of haemodialysis catheter-related bloodstream infections, which is what this study aimed to 

achieve.   

 

1.6 RESEARCHER’S ASSUMPTIONS  

 

This is based on a paradigm, which according to De Vos, Strydom, Fouche and Delport 

(2013), is a framework, viewpoint or worldview based on assumptions and philosophies of 

people’s social world. This study was based on the following meta-theoretical, theoretical 

and methodological assumptions.  

 



6 
 

1.6.1 Meta-theoretical Assumptions  

 

Meta-theoretical assumptions are statements that are not intended to be tested by the study. 

The meta-theoretical assumptions of nursing comprise the person, environment, health and 

nursing, particularly related to the speciality of Nephrology nursing.  

 

1.6.1.1 Person 

 

A person in this case will refer to a patient, renal nurses and doctors. A patient with a 

diagnosis of kidney failure is an individual with physical, psychological, social and 

spiritual needs and dependent on the competencies of a nephrology nurse to meet their 

needs. Family members play a supporting role and influence and enhance nurse-patient 

relationships. 

 

1.6.1.2 Environment  

 

Environment refers to a surrounding that influences a person’s physical, emotional and 

psychological well-being, it can be internal and external, positive or negative in respect of 

all the circumstances influencing and impacting on behaviour of the person. In this study 

the environment will be the renal dialysis unit. The renal dialysis unit is a complex area 

with high technology and this is unfamiliar to patient and can be a source of stress to the 

patient and their families.  

 

1.6.1.3 Health and wellness  

 

Health refers to as a state of complete physical, mental and social wellbeing and not merely 

an absence of disease. Dialysis as a treatment modality is aimed at improving quality of 

life of kidney failure patients so that they can live a near normal and productive life.  

 

1.6.1.4 Nephrology nursing  

 

A kidney failure patient is dependent on the competency and knowledge of a nephrology 

nurse to provide holistic quality care in a safe and healing environment; and act as a link 



7 
 

between patient and technology that maybe complex and threatening to ensure patients’ 

health care needs are met.  

 

1.6.2 Theoretical Assumptions 

 

A theory is an explanation of a phenomenon and its relationship between variables that are 

related to the phenomenon (De Vos, et al., 2013). This also includes the operational 

definition of terms used in the study:  

 

1.6.2.1 Operational definitions 

 

 Patient  

 

A patient is described as the recipient of care from health care professionals (Booker, 

Waugh, van Rooyen, Jordan & Kotze, 2009). Within this study, a patient will refer to a 

recipient of care from a professional nurse within the renal dialysis unit while receiving 

haemodialysis.  

 

 Renal dialysis unit  

 

A renal dialysis unit is a specifically staffed and equipped hospital unit. The management 

is dedicated to patients with all forms of kidney failure: patients spend about four to five 

hours on a dialysis machine, three times a week. There are different shifts each and 

changes per day – one in the morning, afternoon and evening and perhaps a night shift. 

There is always a member of staff in the unit to deal with any difficulties a patient may 

have and to ensure they are as comfortable as possible (Freshwater & Prothero, 2004).   

 

 Haemodialysis  

 

Haemodialysis is a medical treatment for the removal of fluid and waste products from the 

blood to correct electrolyte imbalance, which is accomplished by using a machine and a 

dialyser, also referred to an artificial kidney. It is used to treat both acute and chronic 

kidney disease. Thus it is also considered a life sustaining treatment (Gomez & Castner, 

2015).  



8 
 

 Vascular access device 

 

A vascular access device (VAD) is defined as an indwelling catheter, cannula, or other 

instrument used to obtain venous or arterial access (Mosby’s Medical Dictionary, 2009), 

Three are three types of vascular access devices: namely arteriovenous graft, arteriovenous 

fistula and central venous catheter.  

 

In this study the terms “vascular access device” and “central venous catheter” are used 

synonymously.   

 

 Central venous catheter  

 

A central venous catheter (CVC) is a catheter inserted into a centrally located vein with the 

tip residing in the vena cava or right atrium; permits intermittent or continuous 

infusion/and or access to the venous system (CDC, 2011). The same definition was applied 

to this study.  

  

 Catheter-related bloodstream infection 

 

A catheter-related bloodstream infection (CRBSI) refer to the presence of bacteraemia or 

fungaemia in a patient with an intravascular catheter with at least one positive blood 

culture obtained from a peripheral vein, clinical manifestations of infection (e.g. fever, 

chills and/or hypotension, and no apparent source for the bloodstream infection except the 

catheter (CDC, 2011). The same definition was used in this study.  

 

 Nephrology Nurse 

 

A nephrology nurse is a clinical nurse who functions at an advanced level of patient care in 

a multi-disciplinary nursing environment; s/he may be formally trained – a registered nurse 

with no formal Nephrology qualification, or formally trained.  

 

According to the South African Nursing Council (SANC), a nephrology nurse is a 

registered nurse who obtains a post basic qualification in medical-surgical; Advanced 



9 
 

Medical Surgical Nursing: Critical Care (R212 of 1983 and amended: 119:2). In this study, 

a nephrology nurse is one who has had formal training at a SANC approved learning 

facility (university or college) under R212 or informal training through orientation and in-

service training.  

 

In this study, the term “trained nurse” is synonymously applied to a nephrology nurse.  

  

 Professional Nurse  

 

A professional nurse is an individual who is registered under Section 16 of the Nursing Act 

33 of 2005. In this study, this person is a nurse who has received educational training at a 

SANC approved nursing school and has successfully completed the requirements for 

registration with the South African Nursing Council (R425/R284, as amended, 1985:2) but 

with no formal training in nephrology nursing.  

 

In this study the term professional nurse is synonymously referred to as an “untrained 

nurse” meaning that the professional registered nurse has not obtained a post basic 

qualification in nephrology nursing.  

 

 Evidence-based practice guidelines 

 

Evidence-based practice guidelines are systematically developed statements derived from 

randomised control studies based on best research evidence of clinical effectiveness which 

assists clinicians and patient decision making about appropriate measures for specific 

circumstances (Muscedere, Dodek, Keenan, Fowler, Cook & Heyland, 2008).  

 

For this study, the evidence-based guidelines referred to was derived from literature and 

recommendations from the “Guidelines for the prevention of intra-vascular catheter-

related infections” (Centre for Disease Control and Prevention [CDC], 2011). 

 

 

 

 

 



10 
 

 Knowledge 

 

Knowledge is set to be a complex and multi-faceted concept; it is defined as familiarity 

with something and can include information, factors of skills acquired through education 

or experience (Oxford Dictionary, 2007). In the same dictionary, it can also refer to both 

practical and theoretical understanding of a subject and explicit (theoretical understanding 

of a subject) or implicit (practical skill or expertise) acquired through personal experience, 

role-modelling and mentorship, intuition, reasoning and research (Grove, Burns & Gray, 

2013).   

 

In this study, knowledge of nurses will be assessed from the strategies/items derived from 

the “Guidelines for the prevention of intra-vascular catheter-related infections” (Centre 

for Disease Control and Prevention [CDC], 2011). 

 

1.6.3 Methodological Assumptions 

 

Methodological assumptions reflect the researcher’s assumptions about the nature of the 

research process. The methodological assumptions guiding this study are in line with the 

scientific method of inquiry, which proposes that the dimensions of the research process 

following step by step, starting with the problem statement, objective, paradigmatic 

perspective, considering ethical measures, research design and method up to writing the 

report and lasting publications of results (Burns & Grove, 2009).  

 

The researcher believes in nursing as a holistic approach to patient care which includes 

patient’s aspects of physical, mental, social and spiritual. A patient as a whole must be 

considered in the delivery of care. Nursing care is an integration of knowledge, skills 

experience and individual attributes. Clinical judgment is based on skills acquired through 

the process of integrating education, experiential knowledge and evidence-based 

guidelines.  

 

The researcher believes that nursing as a science relies heavily on evidence-based practice. 

Evidence-based practice is the integration of the best available external clinical evidence-

based from systemic research with individual clinical expertise and patient values to 

facilitate decision making (Bakke, 2010). The purpose of the research is to establish 



11 
 

knowledge possessed by nephrology nurses on evidence-based guidelines for prevention of 

haemodialysis catheter-related bloodstream infections.  

 

1.7 OVERVIEW OF THE RESEARCH METHODOLOGY 

 

The research methodology refers to the blueprint that guides the study to have control over 

factors that could interfere with the desired outcome (Burns & Grove, 2009). An overview 

of the research methodology used in the study is provided in the next section, which will 

be discussed in greater detail in chapter three.  

 

A non-experimental, quantitative, descriptive and cross-sectional design was used to 

achieve the objectives of the study. The study respondents were nephrology trained and 

registered nurses affiliated to renal dialysis units at two major university-affiliated, public 

sector hospitals and tertiary level institutions in Johannesburg, using a self-administered 

questionnaire developed by the Centre for Disease Control and Prevention (CDC, 2011).  

 

Ethical clearance and permission to conduct the study was sought from the relevant 

University Research Committees, the Department of Health and the hospitals. Participation 

in the study was voluntary and respondents were free to withdraw at any point in time. 

After permission was granted by the hospital and dialysis unit nurse managers, written 

consent was obtained from the nephrology nurses who agreed to participate in the study.  

 

Descriptive statistics were used to analyse the data. The statistical software package 

Statistica
TM

 version 12 was used for data analysis. Reliability of the study was maintained 

by ensuring the principal researcher was the sole collector of data, the sample size was 

achieved purposively and the data was verified by a biomedical statistician to ensure 

accuracy of the findings. Validity of the research was achieved by ensuring the data 

collection instrument was verified by nephrology clinicians to fit into the South African 

context.   

 

1.8 RELIABILITY AND VALIDITY   

 

A pre-testing process was conducted and validity scores were measured to ensure 

feasibility of the study and to detect possible flaws in the instrument used. Content validity 



12 
 

was achieved by having the data collection instrument reviewed by an expert panel of 

specialists in nephrology nursing. A prospective study will allow for investigation of 

unusual or unexpected results during data collection and investigate possible causes that 

yield such results.  

 

Reliability was maintained by ensuring consistency and precise recording of information. 

Data collection was done by the principle researcher. An appropriate sample size was 

discussed with a statistician so as to be representative of the population under study, taking 

into possible refusal rates. Sample inclusions and exclusion criteria were adhered to.  

 

1.9 ETHICAL CONSIDERATIONS 

 

The following ethical requirements were taken into consideration for this study.  

 Research proposal was presented to the University Postgraduate Committee for 

permission to conduct the study.  

 Application was made for clearance to conduct research to the Committee for 

Research on Human Subjects (Medical) of the University of the Witwatersrand.  

 Application was made for permission to conduct the study to the Hospital 

Management.  

 Permission to use the instrument was not requested as this was drawn from an open 

source document entitled “Guidelines for the prevention of intra-vascular catheter-

related infections” (Centre for Disease Control and Prevention [CDC], 2011). 

 To ensure confidentiality and anonymity of the participants code numbers were 

used during data collection and reporting.  

 Participants were informed that participation in the study was voluntary and 

participants may decline to answer any particular questions as well as discontinue 

participation in the study at any time without incurring any penalty.  

 

1.10 SUMMARY 

 

This chapter has presented an outline of the study. The problem statement, purpose of the 

study, the research objectives and the study has been described. The assumptions of the 

researcher have been discussed and the operational terms defined. A brief overview has 



13 
 

been given of the research methodology, validity and reliability of the study and the ethical 

procedures adhered to.  

 

The following chapters will include a review of the literature, the methodologies, data 

analysis, the description and interpretation of research findings. The final chapter will 

present limitations of the study, as well as summary of the study findings, conclusions and 

recommendations for future research.   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



14 
 

CHAPTER TWO 

LITERATURE REVIEW 

 

2.1 INTRODUCTION   

 

This chapter will discuss the literature reviewed in relation to the topic under study. It will 

cover the definition of catheter related infection, prevalence, pathology and pathogenesis, 

current protocols, evidence based practice and guidelines to prevent blood stream 

infections and current studies assessing knowledge. The literature review will help the 

researcher to build a legal framework for the study and set it in tradition of enquiry and 

context of related studies (De Vos, et al. 2013).  

 

2.2 OVERVIEW OF HAEMODIALYSIS 

 

Haemodialysis is described as the artificial process of eliminating metabolic waste 

products (diffusion) and unwanted water (ultrafiltration). It may be used for patients who 

have become ill and have acute kidney failure (temporary loss of kidney function), or for 

fairly stable patients who have permanently lost kidney function (stage 5 chronic renal 

failure).  Figure 2.1 shows a process whereby the blood is pumped through a 

semipermeable membrane by the haemodialysis machine in order to remove metabolic 

waste products, unwanted water and toxins from the body. 

 

 

Figure 2.1 Haemodialysis (Sourced: www.kidney.nib.gov/kudisease/pubs/haemodalysis) 

http://www.kidney.nib.gov/kudisease/pubs/haemodalysis


15 
 

2.3  END-STAGE KIDNEY DISEASE 

 

2.3.1  Prevalence 

 

According to McCann, Clarke, Mellotte and Plant (2013) in Ireland about 30-40% patients 

per million of population is a predicted annual growth of patients with end stage kidney 

disease. Haemodialysis was selected by 80% (n=330) of new end-stage kidney disease as 

their treatment modalities in Ireland in 2011, while 1 557 of patients received 

haemodialysis. Establishment of vascular access to enable patient to undergo dialysis is an 

important part of haemodialysis. 

 

Arteriovenous fistula is regarded as the golden standard globally in vascular access, 

haemodialysis patients with central venous catheter in particular are at risk of health care-

associated infections, they have high episodes of vascular access bacteraemia when 

compared with arteriovenous fistula. These patients experience a deep impact on their 

health by these infections and can lead to serious illness, longer hospital stay, long term 

disability and death (McCann, et al. 2013). 

 

According to Amato-Palumbo, Kaplan and Feinn (2013) the major impact on United States 

health system is kidney disease which is increasingly becoming a global health care crisis. 

The second highest prevalence of end stage kidney disease in the world is in the United 

States. There were 598,311 of patients with end stage kidney disease between 2009 and 

2010 in the United States and majority of those patients were on haemodialysis. 

 

2.4   OVERVIEW TO CATHETER RELATED INFECTION 

 

Amato-Palumbo, Kaplan, Feinn and Lalia (2013) reported that about 3.2% of 

haemodialysis patients develop a dialysis access-related infection every month. Vascular 

access-related infection causes range of morbidities from local infection to sepsis and 

death. 

 

Information received from 1,545 hospitals in 48 states and the District of Columbia (as 

reported by CDC, 2011) which works with monitoring infection surveillance in intensive 

care units/ or non-intensive care units highlighted that infections are influenced by many 



16 
 

factors such as severity of illness, type of illness, catheter related and institutional factors 

(CDC, 2011).  

 

Haemodialysis patients are at great danger of having vascular access infection as a result of 

uraemia, exposure to nosocomial infection from hospitalization and break in skin defence. 

50-73% of bacteria in the haemodialysis patients are caused by vascular access site and this 

can lead to meningitis, endocarditis, septic emboli, osteoarthritis and death (Higgins & 

Evans, 2008). 

 

2.4.1   Definition of Catheter related Infections 

 

A catheter related bloodstream infection is defined as an infections caused by bacteremia 

or fungaemia in a patient with an intravascular catheter in situ, and experience of one of 

the following: positive blood culture taken from a patient peripheral vein, clinical sign of 

infection (chills, fever and hypotension) and no other visible source of blood stream 

infection besides the catheter (http://www.safecarecampaign.org.crbsi). 

 

A diagnosis of a bloodstream infection is made when a central venous catheter (central 

line) has been inserted for more than 48 hours prior to the growth of the infection. Time 

interval of more than 48 hours provides compelling evidence that the infection is related to 

a central venous catheter (http://www.safecarecampaign.org.crbsi). 

 

A diagnosis of a catheter related bloodstream infection is made by accompanying signs of 

local or systemic inflammation such as fever, chills, hypotension and purulence around the 

insertion site of an intravascular device. Insertion of one extra intravascular catheter is 

needed for performing renal replacement therapy however introduction of organisms 

through the hub and lumen of the dialysis catheter puts these patients at risk (Vandijck, 

Labeau, Secanell, Rello & Blott, 2009).  

 

2.4.2   Incidence of Infection 

 

Bacteremia and exit site infection complications incidences of catheter related episodes of 

bacteremia for a non-tunnelled central venous catheter, range from 1.4 to 8.3/1000 catheter 

days and 1.6 to 6.1/1000 catheter days for tunnelled central venous catheter. Number of 

http://www.safecarecampaign.org.crbsi/
http://www.safecarecampaign.org.crbsi/


17 
 

catheter related bacteremia is reported to be corresponding with the time the catheter has 

been inserted and the site it has been inserted in (McCann & Moore, 2010).  

 

Central Venous Catheters 

 

Long-term venous access in the form of a central venous catheter has been used with 

increasing frequency in the inpatient and outpatient settings to ensure long term access for 

patients receiving haemodialysis treatment. Central venous catheters can predispose a 

patient to bacteria or fungal micro-organisms as they interrupt the integrity of the skin 

(http://www.safecarecampaign.org.crbsi). 

 

2.4.3  Pathophysiology 

 

According to Goudet, Timsit, Lucet and Lepape (2013) pathophysiology is now plainly 

understood of catheter infection. Catheter tip colonization for short-term catheters arises 

during catheter insertion and less commonly by movement of skin organisms down the 

catheter track from insertion site during catheter maintenance. Major threat of short-term 

catheters is that the density of the micro-organisms of the catheter site insertion and the 

most effective preventive measures for infection is the skin antisepsis.  

 

2.4.4   Risk Factors 

 

Blood stream infections have been linked with numerous risk factors in patients receiving 

haemodialysis, Staphylococcus aureus through nasal colonization which appears to be 

common among haemodialysis as in the general population tend to put them at risk of 

blood stream infections, however the greatest danger of blood stream infection in this 

patients is getting haemodialysis via a central venous catheter (Lincoln, 2011).  

 

Oral or Nasal secretions of the patients or healthcare workers may be the portal of exit, 

whilst direct contact or airborne such as oral, nasal secretions, patients’ skin, healthcare 

workers hands, environment or contaminated infusate, may be the mode of transmission 

(Tilton, 2006).   

 

 

http://www.safecarecampaign.org.crbsi/


18 
 

2.5   TYPES OF VASCULAR ACCESS 

 

“Vascular access is often referred to as the ‘Achilles heel’ or weak chain in haemodialysis 

adequacy, as optimal haemodialysis cannot be achieved without well maintained vascular 

access” (Murphy, 2011). It was reported that 25% of hospital admissions for 

haemodialysis was due to difficulties with vascular access and the key cause of morbidity 

is access failure. It is important therefore that there is an early referral for vascular access 

because without this, 75% of patients starting haemodialysis need to be admitted for 

temporary vascular access which can lead to complications such as infections, increased 

morbidity and even mortality (Murphy, 2011). 

 

Arterio-venous fistula is the mostly used choice of vascular access for maintenance 

haemodialysis. A 65% increase in the number of arteriovenous fistula is recommended by 

Kidney Disease Outcome Quality Initiative and the National Kidney Foundation (McCann 

& Moore, 2010). Central venous catheters vascular access are considered inferior to other 

vascular access and in 2006, Kidney Disease Outcome Quality Initiative (McCann and 

Moore, 2010) recommended less than 10% prevalence rate. It has been reported by dialysis 

outcome, that 46% to 70% of European and Canadian end stage kidney disease patients 

commencing maintenance dialysis do so via central venous catheter despite 

recommendation. The dependence on central venous catheter is also reflected in the 

prevalence rate of 18% (Europe) to 34% (Canada). Late referrals to Nephrologists, delay in 

access formation, lack of sufficient time for an arterial venous fistula to mature, or an over 

increasing older end stage kidney disease population who experience higher rates of 

vascular disease and diabetes resulting in an inadequate vascular for arteriovenous fistula 

formation attributes resulting in over reliance on catheters (McCann & Moore, 2010). 

 

Type of vascular access alone can cause patients death. The evidence is of one to three fold 

increases in the risk for infection-related death in patients dialysed with central venous 

catheter compared to arteriovenous fistula, as revealed by Choices for Healthy Outcome in 

Caring for End Stage Kidney Disease. McCann and Moore (2010) reported that Kidney 

Disease Outcome Quality Initiative guidelines state that “infection complications 

associated with catheter use in haemodialysis patients contribute to making infections the 

second leading cause of death in patients with end stage kidney disease, although there are 

no specific statistics provided”(McCann & Moore, 2010:3). 



19 
 

There are different types of haemodialysis vascular access methods, namely: arteriovenous 

fistula, arteriovenous graft and central venous catheter.  Key characteristics of the vascular 

access devices will be briefly described (Murphy, 2011).  

 

 Arteriovenous fistula  

 

An arteriovenous fistula (AVF) which is considered an ideal haemodialysis vascular access 

approach involves anastomosing an artery to a vein by a surgical procedure thereby forcing 

arterial blood into the vein forming a sufficient blood flow which is enough for successful 

cannulation. It can be created on radial-cephalic, brachial-cephalic or brachial-basilic 

vasculature (Scales, 2010).  However, not every patient can have an arteriovenous fistula 

due to diabetes, peripheral vascular diseases and being old (Murphy, 2011).  According to 

Wasse, Hopson and Clellan (2010) an arteriovenous fistula is the desired access for 

hemodialysis due to its greater health benefits, adequate blood low, a lesser risk for 

infection and thrombosis and reduced danger of mortality and morbidity compared to both 

arteriovenous graft and central venous catheter.  

 

 Arteriovenous graft  

 

An arteriovenous graft (AVG) which has a high risk of infection and thrombosis involves a 

connection of a tube developed from synthetic or biological material placed 

subcutaneously between a vein and artery (Scales, 2010). It is usually used when an 

arteriovenous fistula cannot be created or when one has failed; it can be placed straight, 

looped or curved (Murphy, 2011).  

 

 Central venous catheter  

 

A central venous catheter (CVC) is used when patients have no options for other vascular 

access devices or in an emergency situation (Scales, 2010). One advantage is that it can be 

used immediately, catheters can be inserted either on the internal jugular, subclavian or 

femoral (Murphy, 2011). The preferred site of insertion is the right internal jugular vein 

followed by the left internal jugular vein under strict aseptic technique. Use of the central 

venous catheter is discouraged, even though they are beneficial on patients who have no 

other alternative vascular access options. According to Mokrycki and Lok (2010), central 



20 
 

venous catheter carries a substantially higher morbidity and mortality rate than fistulas and 

grafts.  

 

Figure 1.2 shows a central venous catheter that is used mostly for patients receiving 

haemodialysis.  

 

Figure 2.2   Placement of a central venous catheter for haemodialysis 

 (Sourced:www.navilystmedical.com/index.cmf/112) 

 

Central venous catheters are further categorised into four main types: non-tunnelled 

devices, tunnelled devices, implantable pores and peripherally inserted central catheters 

(CDC, 2011). It is believed this helps to ensure standardization of terminologies amongst 

clinicians and healthcare institutions when considering catheter-related bloodstream 

infections (O’Grady, Alexander, Burns, Dellinger, Garland, Heard, et al. 2011).  

 

Scales (2010) mentioned that the most frequently used indwelling medical devices are 

vascular catheters, which have become necessary tools for the successful treatment of 

patients with chronic and acute illness. Central vascular access in acute care is indicated 

for:  

 Haemodynamic monitoring 

 Administration of vasoactive or inotropic drugs 

 Haemofiltration, haemodialysis, therapeutic plasma exchange, apheresis and 

immonoadsorption 



21 
 

 Transvenous pacing 

 Administration of irritant drugs and solutions 

 Reliable access for fluid and electrolyte administration 

 Reliable access for blood sampling 

 Diagnostic interventions, e.g. liver biopsy 

 

There are three main vascular access devices as outlined by Scales, 2010: Peripheral 

cannula, Midline catheter and Central venous access device.  

 

Cotogni and Pittiruti (2014) echoed the same sentiments as Scales in that there are three 

vascular devices used for critically ill patients which are peripherally inserted devices, 

midline catheters and centrally inserted devices. 

 

Peripheral cannulae/ catheters are non-tunnelled (made of silicone or ii- iii generation 

polyurethane) and usually inserted into the hand or forearm for short-term use, they are 

short devices up to 7.5 cm in length, midline catheters are also peripheral devices but are 

longer in length than standard peripheral cannulae, being between 7.5cm and 20 cm in 

length. They are inserted in the region of the anticubital fossa where the tip should be in 

the cephalic, basilica and brachial vein below level of axilla. Midline catheters are made 

from silicone or polyurethane, may be single or double lumen and are designed for 

intermediate use with a dwell time of 1 to 4 week (Cotogni & Pittiruti, 2014; Scales, 2010). 

Central venous catheters are devices (made from polyurethane) inserted into the central 

circulation; they are inserted directly or indirectly into the superior vena cava or right 

atrium. There are four main types of central venous access devices: Non-tunnelled devices 

tunnelled devices, implantable pores and peripherally inserted central catheters, they are 

inserted in intensive care and non-intensive care patients and they have one or multiple 

lumens (Cotogni & Pittiruti, 2014; Scales, 2010). 

 

Intravenous therapy can be administered peripherally or centrally, the difference between 

the two routes is the size of blood vessels and the blood flow within the vessels. Central 

blood vessels are large and blood flows fast, whilst peripheral blood vessels are small and 

often fragile with a slow blood flow. Key factors in the decision to select central venous 

access for specific infusion therapy is the physical properties of vessel size and blood flow. 



22 
 

Patients who are acutely ill cannot rely on peripheral access for a long time. An ideal 

device in the emergency setting for rapid fluid resuscitation is a short, wide-bore peripheral 

catheter and is appropriate for short-term, non-irritant fluid and drug administration 

(Cotogni & Pittiruti, 2014; Scales, 2010).  

 

According to Scales (2010) and Cotogni and Pittiruti (2014) the most commonly used 

central venous access device in acute and critical care is the non-tunnelled central catheter. 

There are three main sites for insertion of the non-tunnelled central catheter: internal 

jugular vein, subclavian vein and femoral vein. 

 

Scales (2010) continues to highlight that the referred sites for insertion are subclavian or 

jugular veins as they are associated with a lower infection rate than the femoral site. Non-

tunnelled catheters are available in a range of sizes and lengths with 1 to 5 lumens. Unless 

multiple lumens are essential, a single lumen device should always be selected as multiple 

lumens catheters are associated with an increased risk of infection. 

  

Non-tunnelled catheters safe dwell time is not known, but frequent monitoring of insertion 

site is recommended. An antimicrobial impregnated catheter is recommended for patients 

considered to be high risk for catheter related blood stream infection (Scales, 2010). 

 

Arteriovenous Fistula- Creation of arteriovenous fistula involves anastomosing an artery 

to a vein through a surgical procedure; it should be created on the non-dominant hand 

either on radial-cephalic, brachial-cephalic or brachial-basilic (Murphy, 2011). This will 

push arterial blood into the vein creating distension, vein thickening and engorgement 

leading to vein maturation that is able to produce adequate blood flow for an effective 

cannulation and sufficient blood flow for the haemodialysis machine (Murphy, 2011). 

 

According to Wasse, Hopson and Clellan (2010) arteriovenous fistula is the desired access 

for haemodialysis due to its greater health benefits, adequate blood flow, lesser risk of 

infection and thrombosis and reduced danger of mortality and morbidity compared to both 

arteriovenous graft and vascular catheter. 

 



23 
 

Arteriovenous Graft- Involves implanting a tube subcutaneously between an artery and a 

vein produced from a synthetic or biological material. Graft is used when fistula has failed; 

it is placed straight, looped or curve (Murphy, 2011).  

 

Central venous catheter- It involves inserting a catheter on the subclavian, internal 

jugular and femoral vein. The preferred position of insertion is the right internal jugular 

vein followed by the left internal jugular vein under strict aseptic technique. Use of central 

venous catheter is discouraged  even though they are beneficial on patients who has no 

other alternatives but they are advantageous in that they can be used immediately (Murphy, 

2011). 

 

All three of these vascular access methods require special nursing techniques and skills to 

ensure patient safety. Kidney patients are high risk patients because they are not only 

compromised by electrolyte and metabolic disturbances, but also by immune-deficiencies 

and other comorbid conditions such as in the case of human immune virus (HIV) (Bedendo 

et al., 2011).  

 

2.6 EVIDENCE BASED GUIDELINES TO PREVENT HAEMODIALYSIS  

           CATHETER RELATED INFECTIONS    

 

DiCenso, Guyatt and Ciliska (2005:4) described evidence-based practice as “the 

conscientious and judicious use of current best evidence in conjunction with the clinical 

expertise and patient values to guide health care decisions.” Research, past experiences, 

knowledge, experience of colleagues and family/patients all form this evidence. Oh (2008) 

defines evidence based practice as careful use of best available research in conjunction 

with clinical knowledge and judgement to get to best decision to positive patient outcome. 

Health care teams should make decisions based upon best practice in order to provide the 

best quality. Evidence-based practice is a way of providing the high quality care strived for 

and it adds evidence to clinical care decision (George & Tuite, 2008). 

 

Evidence-based practice is a critical component of health care practice today and is also a 

reality. Use of evidence based practice to promote patient safety is needed by a nurse and 

they should be aware that evidence based practice can be effectively utilised to find and 



24 
 

analyse data. Care can be provided in an effective, efficient and cost-beneficial way 

through use of evidence based practice (DiCenso et al. 2005) 

 

According to Phillips (2015), globally as the use of evidence based practise continuous to 

change, more emphasis is placed on delivery of patient oriented scientific nursing care. 

Evidence based practice as a vital part of nursing care is used as an outline to make sure 

that best existing scientific evidence, clinical knowledge and patient influence health care 

decision. 

 

Guidelines for the prevention of intravascular catheter related blood stream infections were 

designed to reduce infectious complications associated with catheter use. Nursing 

guidelines for reducing catheter related infections were published by the Centre for Disease 

Control (CDC) in 2001 and updated in April 2011 (Headly, 2011).   

 

These guidelines are the combined effort of academic institutions and government agencies 

to try to save lives and cut costs. Already these nursing guidelines have proved to be 

effective in the reduction of catheter related infections in hospital based Intensive Care 

Units by 58% from 2001 to 2009 (Headly, 2011).  

 

The Centre for Disease Control and Prevention (CDC, 2011) reported that 15 million 

central catheter days (i.e. total number of days of exposure to central venous catheters 

amongst all patients in the selected population during the selected time period) occur in 

Intensive Care Units each year. It has also been found that costs of hospitalization and time 

of stay are independently increased by infections but is not the only one that increases 

number of deaths. To reduce healthcare costs and improve patient outcome, healthcare 

providers, insurers, regulators and patient advocates have considerable interest in lowering 

occurrences these infections. Effort to reduce infection has to be done by all professionals 

involved in the inserting, caring for and maintaining intravascular catheters (CDC, 2011). 

 

Indispensable means of administering lifesaving therapies to patients in all discipline of 

nursing is intravascular catheters; however they also provide a route by which pathogens 

can gain access into the blood stream. Several million intravascular catheters are used 

annually in the United States (US) alone and in Europe as well. Unfortunately large 

numbers of patients are put at risk for catheter related bloodstream infection. Patients who 



25 
 

have indwelling catheters are at risk of acquiring catheter related blood stream Infections, 

but those admitted into the Intensive Care Unit are more prone than those admitted to a 

general ward. Consequently patients entering hospital via Emergency Departments are at 

particular risk simply because of frequent and less careful manipulation of catheters as a 

result of the urgent setting (Vandijck, et al., 2009). 

 

Catheter related blood stream Infections is one of the common nosocomial infections and 

is associated with significant morbidity, mortality, prolonged length of stay and health care 

expenditure. Efforts to decrease rate of catheter related blood stream infections, improve 

patients’ safety and quality of care are important because this is the most preventable type 

of hospital acquired infection. Evidence based recommendations for prevention catheter 

related blood stream infections has been published by the Centre for Disease Control and 

Prevention, the Society of Health care Epidemiologists of America and several other 

societies. Most of the evidence based recommendations are supported by well conducted 

clinical trials, systematic reviews and meta-analysis where level of evidence is categorised 

to each individual recommendation, from “category IA” (i.e. strongly recommended) over 

“category II” (i.e. suggested for implementation up to “no recommendation” (i.e. 

unresolved issue) (Vandijck, et al., 2009). 

 

2.6.1 Education, Training and Staffing 

 

It is recommended that health care personnel be educated regarding indications for use of 

catheters, correct maintenance and suitable control of infection measures aimed at 

preventing intravascular catheter related infections. Adherence to guidelines should be 

assessed periodically for all professionals working with insertion and maintenance of 

intravascular catheters (CDC, 2011).  

 

Only professionals who are trained and those who are competence for insertion and 

maintenance of intravascular catheters should be assigned. Appropriate level of nursing 

staff should be ensured, as it has been observed that proportion of pool staff or an elevated 

patient to nurse ratio is associated with catheter related blood stream infection in ICU’s 

where nurses are managing patients with central venous catheter’s (CDC, 2011). 

 



26 
 

Promotion of preventative strategies and staff education in clinical practice may reduce 

risks of catheter colonisation and catheter related blood stream infection in the ICU setting 

(Ramritu, Halton, Cook, Whitby & Graves, 2008).  

 

In one pre-post intervention study, facts sheets and posters were sent to the ICU and nurses 

and physicians completed a 10-page self-study module. Reportedly 4.9 cases per 1000 

catheter- days to 2.1 cases per 1000 catheter days of reduction in catheter related blood 

stream infection were found in the pre and post intervention periods (Ramritu, et al., 2008). 

 

Programmes that are well organised and enable health care providers to be educated and to 

monitor, provide and evaluate care are critical to the success of the effort. For the past four 

decades, reports have consistently demonstrated the decline for risk of infection following 

standardisation of aseptic care and that maintenance and insertion of intravascular catheters 

by inexperienced staff might increase risk of catheter colonisation (CDC, 2011).  

 

Unequivocal effectiveness in reducing the incidence of catheter related blood stream 

infection associated complications and cost was shown by specialised “IV teams.” It has 

also been shown that infection risk increases with nursing staff reduction below a critical 

level (CDC, 2011). 

 

2.6.2 Site of Insertion 

 

The site where intravascular catheter is to be inserted is very important considering the 

impact on the development of catheter related blood stream infection. A subclavian 

approach has been reported with lower rates of catheter colonisation compared to the 

internal jugular approach, but both are reported to be superior to a femoral insertion site 

(CDC, 2011). 

 

Though the reason for this is unclear, it is associated with the fact that bacteria prefers to 

reside in skin folds. Not only the site of insertion is to be considered, but factors such as 

central venous catheter already in situ, presence of local infection or haematoma and risk 

of mechanical complications also need to be considered. A subclavian approach is 

preferred by some clinicians for long-time catheterisation for its ease of fixation and 

comfort, but it does have high rates of insertion complications (CDC, 2011). 



27 
 

A greater risk for catheter-related sepsis maybe posed by the internal jugular site for its 

proximity to oropharyngeal secretions, but it is utilised preferentially with mechanically 

ventilated critically ill patients due to less common mechanical complications. The site is 

easy and safe for insertion, but more likely to cause femoral infection (CDC, 2011). 

 

A risk for infection and phlebitis is directly related to the site at which a catheter is placed. 

One high risk factor for catheter related blood stream infection is the density of skin flora 

at the site where the catheter is inserted. No trials have been done to compare number of 

infections of catheters inserted on jugular, subclavian and femoral veins (CDC, 2011). 

 

Retrospective observational studies showed an association with high risk of colonization of 

catheters inserted into an internal jugular vein than the ones inserted into a subclavian. A 

single retrospective study conducted in neonates noted similar findings. High colonisation 

rates have been demonstrated on femoral catheters compared with subclavian and internal 

jugular sites when used in adults and in some studies, higher rates of catheter related blood 

stream infection (CDC, 2011). 

 

Femoral catheters have been found to be related with a higher risk for deep venous 

thrombosis as compared with internal jugular or subclavian catheters and as such should be 

avoided if possible. It was also found out in another study that the risk of infection 

associated with catheters placed in the femoral vein is emphasized in patients who are 

obese. In contrast to adults, femoral catheters demonstrated a little occurrence of 

mechanical complications in paediatric patients and might have an equivalent infection rate 

to that of non-femoral catheters. A subclavian site is preferred in adults for infection 

control purposes, but other factors should be considered when deciding where to put the 

catheter (CDC, 2011). 

 

2.6.3 Patient Factors 

 

Patients with kidney failure are more susceptible to infection than others. In patients who 

are less than 1 year old or greater than 60 years, factors that influence the rate of catheter 

related sepsis are burns, presence of remote infection, immunodeficiency, intensity of the 

illness and host defence mechanism impairment, which occurs in shock and traumatic 

injury  (Theaker, 2004). 



28 
 

Patients who have particularly high-risk of catheter related sepsis with Staphylococcus 

aureus are the ones with acquired immunodeficiency syndrome. The presence of sepsis or 

remote infection is the most notable patient-related factors as they may act as a source of 

contaminating organisms (Theaker, 2004). 

 

2.6.4  Skin Preparation 

 

Several skin cleansing agents are available in the effort to prevent and lower level of 

micro-organisms at the insertion point of the catheter. Rate of catheter related sepsis is 

shown to be reduced by use of topical antimicrobial ointments containing multiple 

antibiotics (polymyxin-neomycin-bacitracin). However higher incidences of colonisation 

and sepsis with candida were reported as a side effect. Studies, including randomised and 

controlled trial, showed that mupirocin, which is an anti-staphylococcal agent, significantly 

reduced central venous catheter colonisation, however, others found that growth of 

resistant organisms and super infections are associated with the use of antibiotic ointment 

and, for that reason, cannot be recommended. Results of randomised trials in recent 

prospective studies suggest that 2% Chlorhexidine is superior to Povidine Iodine for 

cutaneous disinfection of the insertion site (CDC, 2011).  

 

Lesser amounts of catheter colonisation or catheter infection related with the use of 

chlorhexidine preparation has been shown by studies that are well-designed for evaluating 

the use of chlorhexidine-containing cutaneous antiseptic regimen in comparison with either 

Povidine Iodine or alcohol for the care of an intravascular catheter insertion site (CDC, 

2011). 

 

Risk of catheter related infection is reduced by 49% by use of chlorhexidine preparations 

to Povidine Iodine as suggested by a meta-analysis of 4,143 catheters. Chlorhexidine use, 

rather than Povidine Iodine, for central venous catheter care would result in a 1.6% 

decrease in the incidence of catheter related blood stream infection, a 0.23% decrease in 

the incidence of death and a saving of $113 per catheter used, as suggested by economic 

decision analysis based on available evidence (CDC, 2011).  

 

A 5%  Povidine Iodine solution of 70% ethanol was related with a large drop of central 

venous catheter-related colonisation and infection linked with 10% aqueous Povidine 



29 
 

Iodine, even though chlorhexidine has come to be  an accepted disinfection for skin 

preparation for the insertion of  central and peripheral venous catheters (CDC, 2011). 

 

2.6.5  Dressing 

 

According to CDC (2011) transparent, semi-permeable polyurethane dressings require 

does not require frequent changes like standard gauze dressing and it allows for optical 

inspection of the catheter site. Study done showed no substantial clinical difference exists 

in the incidence of colonization between transparent and gauze dressing and the use of 

dressing is seen as a matter of choice. 

 

2.6.6 Antibiotic/Antiseptic Ointment 

 

According to CDC (2011) different topical antibiotics have been used in trying to reduce 

infection of catheter insertion site and the use of Povidone Iodine or bacitracin/gramicidin 

ointment at the catheter exit site is recommended as long as it does not interact with the 

material of the catheter. Use of topical Mupirocin at the catheter insertion site 

demonstrated reduction in the risk of catheter related blood stream infection. 

 

2.6.7 Anticoagulation 

 

Catheter is quickly coated with conditioning film, plasma proteins, fibrin, cellular elements 

such as platelets and red blood cell after it is inserted. Anticoagulants have been used to 

reduce thrombosis and risk of infection as there is a close relationship between catheter and 

infection. Catheters are provided with antimicrobial activity which provides it with anti-

thrombotic effect because they are heparin bonded but heparin-induced thrombocytopenia 

can hence clinicians have opted to using Trisodium citrate (CDC, 2011). 

 

2.6.8  Full Barrier Precautions 

 

Full sterile barrier precautions such as the use of a mask, cap, sterile gloves, gown and 

sheet drapes are needed for insertion of a central venous catheter to minimise the risk of 

iatrogenic induced catheter related blood stream infection. Nurses can make a substantial 

contribution in reducing incidence of catheter related blood stream infection by keeping an 



30 
 

eye on the catheter insertion procedure even though they are not authorised to place central 

venous catheters (CDC, 2011). 

 

Use of maximal sterile barrier precautions during placement of central venous catheter 

should be standard care, but costs and workload associated with its use during insertion of 

peripheral and artery catheters should be considered, however in immune compromised 

patients, such as the ones requiring renal replacement therapy, it might be advisable to use 

all precautions regardless of extra costs (CDC, 2011). 

 

2.6.9 Hand Hygiene 

 

Improper hand washing techniques, which result in the cross contamination of patients 

have been identified as the biggest nurse-related factor for CRBSI. Hand decontamination 

before and after patient contract is one of the most important measures to reduce the spread 

of germs. Hand hygiene includes one of the following washing hands with soap and water 

if there is visible dirt or soiling with body fluids or using an alcohol based antiseptic in the 

absence of soiling.  

 

Cornerstone of infection prevention and control is effective hand hygiene with either 

conventional antiseptic soap, water or alcoholic hand rubs. Hand hygiene must be 

performed before and after every palpation, repairing, manipulation and dressing of 

intravascular catheter (CDC, 2011). 

 

2.7 NURSES KNOWLEDGE RELATED TO EVIDENCE-BASED GUIDELINES 

FOR CATHETER RELATED BLOODSTREAM INFECTIONS  

 

A number of studies were found during the literature search that demonstrated nurses’ poor 

knowledge related to prevention of catheter-related bloodstream infections.  

 

In the first study, Labeau et al. (2009) aimed to determine nurses’ knowledge of guidelines 

in preventing central venous catheter-related infections from the CDC guidelines. This 

large multi-national study was conducted in 22 European countries, using a validated 

multiple-choice questionnaire of 10 recommendations for central venous catheter-related 



31 
 

infection prevention. A total of 3 405 questionnaires were collected, yielding a response 

rate of 70.9%, and the mean test score was 44.4% (Labeau et al. 2009).  

 

Results from this study revealed, slightly more than half of the sample knew that central 

venous catheters should be replaced on indication only; and 74% knew this also concerns 

replacement over a guide-wire; less than half (43%) of the sample knew that central line 

dressings need to be changed on indication and at least once weekly; 25% of the sample 

knew that both polyurethane dressings and gauze dressings are recommended.; only 15% 

of the sample checked the recommended 2% aqueous solution as the recommended 

disinfection solution; a close one third (30%) of the sample knew antibiotic ointment 

solutions are not recommended because they trigger resistance; most (90%) nurses knew to 

replace administration sets after lipid infusions, but only 26% knew sets need to be 

replaced every 96 hours (Labeau et al. 2009). The study also reported, professional 

seniority and number of ICU beds was an independent factor associated with a better test 

score (Labeau et al. 2009).  

 

A recent study by Chen, Yao, Chen, Liu, Miu, Jiang, Zhu, Tang and Chen (2015) aimed to 

evaluate nurses’ knowledge of the updated guidelines CDC (2011) guidelines. This 

national study was conducted on a sample of 455 Chinese nurses, using a validated 

questionnaire developed by the researchers. The mean score was 8.17 of 20, and higher 

scores were significantly associated with years of ICU experience.   

 

Results of this study indicated, 49 (10.7%) nurses had not heard about the CDC guidelines, 

whereas 231 (50.7%) nurses heard of the guidelines but had not received training for them. 

Trained nurses’ scores were higher than untrained nurses’ scores. The three major barriers 

to compliance with the guidelines were unfamiliarity with them, an excessive workload 

due to nurse shortages and a lack of training (Chen, et al. 2015).  

 

A further search of the literature was undertaken, which yielded 2 important studies 

conducted in the renal dialysis units that demonstrated similar results to the afore-

mentioned studies (Chen, et al. 2015; Labeau, et al. 2009).  

 

For example, in a study conducted by Abdelsatir (2013), that aimed to evaluate nurses’ 

awareness and practice of haemodialysis vascular access care. This national study was 



32 
 

conducted on a sample of 50 nurses in Khartoum, Sudan, whereby nurses’ knowledge was 

evaluated using a self-administered questionnaire and their practices were evaluated by 

direct observation.   

 

Results of this study (Abdelsatir, 2013) revealed, females constituted 72% of the sample, 

most (83%) were university graduates and more than half (58%) had more than 2 years of 

clinical experience. Most of the respondents received dialysis training (56%) and vascular 

access management (54%): all respondents thought proper haemodialysis access care 

prevent infection, but only 54% stated that it maintained access function. Most nurses 

(98%) indicated that hand hygiene was necessary to prevent infection, but only a close 

three-quarters of nurses (70%) followed hand washing procedures before haemodialysis 

access manipulation; most nurses evaluated it before connection but only 52% evaluated it 

for signs of infection (Abdelsatir, 2013). In addition, the study also reported that nurses 

with a higher level of education (graduates) were more compliant to hand washing 

procedures (72.5% vs. 42.9%; p=0.1), and the use of gloves (100% vs. 85.7%; p=0.1) 

compared to diploma level prepared nurses, however, these differences were found not to 

be statistically significant (Abelsatir, 2013).   

 

In the next study, Higgens and Evans (2008) investigated nurses’ knowledge and practice 

of vascular access infection control among adult patients in Ireland. A questionnaire was 

used in the study to assess knowledge and behaviours in infection control of 190 nurses in 

9 haemodialysis units.  Results of this study, revealed that although most of the 

respondents (92%) reported that policies had been developed in their units but less than 

half of respondents (47%) received infection control training, knowledge and adherence to 

best practice demonstrated scope for improvement (Higgens & Evans, 2008). They 

recommended development of standard guidelines, regular reviews and updates of policies 

to ensure a high level of compliance (Higgens & Evans, 2008).   

 

2.8 BARRIERS AND FACILITATORS TO EVIDENCE BASED PRACTICE 

GUIDELINES 

 

A study conducted by Oh (2008) aimed to identify the utilization of evidence for practice 

and to examine factors related to research barriers among Korean critical care nurses. Data 



33 
 

was analysed from 63 critical care nurses from a national study at university affiliated and 

educational hospitals in Korea. 

 

Perception of barriers to research utilization total mean scores from the study was 2.37 

(SD=0.42), administrative factors was the highest mean barrier score for each factor and 

five top perceived barrier items were: “Implementation for practice is not clear”; “There 

is insufficient time on the job to implement new ideas”; “There is not a documented need 

to change practice”; “The facilities are inadequate for implementation”; The nurses does 

not have time to read research” (Oh, 2008). 

 

The study findings indicated that nurses share a solid sense of value for input that research 

makes to advance their practice but also perceived barriers in the absence of administrative 

support for evidence based practice. Absence of practical implications of research was the 

most problematic barrier (Oh, 2008). 

 

Another study was done by Phillips (2015) to establish relationship between duration of 

practice, educational level, and perception of barriers to implement evidence based practice 

among critical care nurses, 30 critical care nurses took part and the response rate was 60% 

(30/50). Majority of the participants were women 83% (n= 25) between the ages of 30 to 

39 years and holding a Bachelor’s or higher degree. 

 

Participants were asked question to determine knowledge, attitudes and use of evidence 

based practice, a scale of 1 to 7 was used to rate current evidence based practice attitude, 

knowledge and practice where 7 was an ideal score. Attitude towards evidence based 

practice showed highest mean score (mean = 4.89), then by knowledge (mean = 4.37) and 

uses of evidence-based practice (mean = 4.30) (Phillips, 2015). 

 

In addition, the Pearson correlation was computed on results and strong relationship was 

established among scale measuring barriers to implementation of evidence based practice, 

strongest correlation was between ‘knowledge of evidence based practice’ and ‘attitudes 

towards evidence-based practice (r= 0.848; p <0.001) indicating that participants with high 

knowledge scores had positive attitudes towards use of evidence based practice (Phillips, 

2015). 

 



34 
 

Phillips (2015) highlighted that an important relationship was established between 

characteristics of organization and of the nurses (r=0.830, p< 0.001) this means the more 

organizational boundaries that exist for nurses the more likely they are to devalue the 

importance of evidence based practice. 

  

As Phillips (2015) indicates again, nurses were asked to rate their perceived barrier to 

evidence based practice implementation, “the mean barrier scores was 2.58, which is 

highest in communication factor (mean = 2.58), then the setting at (mean = 2.48), nurse 

adopter (mean = 2.11) and quality research at (mean = 1.84)”. The highest three 

perceived barriers items to use of evidence-based practice were: ‘unwillingness to change 

or try new approaches (76.7%)’; there is insufficient time to read research relevant to 

practice and the evidence is no kept in a central location (73.3%)’; lack of authority to 

initiate changes relevant to patient care (66.7%). 

 

2.9 SUMMARY 

 

Literature has indicated that the number of people developing kidney failure and requiring 

renal replacement therapy is increasing. The majority of these people use vascular access 

catheters which carry a significant risk of catheter related blood stream infection and leads 

to high medical cost, length of stay, mortality and morbidity.  

 

Research has shown that vascular access infections are the second leading cause of 

morbidity and mortality in patients receiving haemodialysis, which is said to be caused by 

new or inexperienced dialysis staff, nurses not well trained in accessing the patient’s 

circulation and not following the correct arteriovenous access techniques, applying the 

infection control procedures or adhering to the standards in sterile catheter care. It is 

recommended that to prevent these life-threatening malpractices, training and competency 

assessment of staff needs to be regularly assessed and recorded with on-going professional 

skills development.  

 

In the prevention of catheter related blood stream infection, the Centre for Disease Control 

came up with strategies/guidelines for the prevention of intravascular catheter related 

blood stream infection. The guidelines were designed with the aim of reducing 

complications related to catheter use. Nursing guidelines for reducing catheter related 



35 
 

infections were published by the Centre for Disease Control (CDC) in 2001 and updated in 

April 2011 (CDC, 2011). These guidelines are the combined effort of academic institutions 

and government agencies to try to save life’s and reduce hospitalisation costs. Already 

these guidelines have proved effective in the reduction of catheter related infections in 

hospital based Intensive Care Units by 58% from 2001 to 2009 (Headly, 2011).  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



36 
 

CHAPTER THREE 

RESEARCH METHODOLOGY 

 

3.1 INTRODUCTION  

 

In this chapter research methodology will be presented and will include the research 

design, the research setting, population, sample and sampling, the criteria which includes, 

collection of data, a description of the data collection instrument used including the 

reliability and validity of the instrument and the ethical procedures followed. The purpose 

of the study was to determine nephrology nurses knowledge of evidence-based guidelines 

for the prevention of haemodialysis catheter-related bloodstream infections in the renal 

dialysis units from two university-affiliated, public sector and tertiary level hospitals in 

Gauteng.  

 

3.2 OBJECTIVES OF THE STUDY  

 

For consistency in the study, the objectives are repeated. 

 To validate the instrument “Evaluation questionnaire concerning nurses’ 

knowledge of interventions for prevention of haemodialysis catheter associated 

infections” to assess nurses’ knowledge on evidence-based guidelines for 

prevention of haemodialysis catheter-related bloodstream infections. 

 To determine and describe nurses’ knowledge of evidence-based guidelines for 

prevention of haemodialysis catheter-related bloodstream infections in the 

haemodialysis units from public sector institutions in Gauteng.  

 To establish whether there is a relationship between age, experience and 

knowledge of nurses on evidence-based guidelines of haemodialysis catheter-

related bloodstream infections 

 

3.3 RESEARCH DESIGN  

 

A research design is the logical steps taken to answer the research question by the 

researcher and forms the blue print of the study and determines the methodology used to 



37 
 

gather information (Brink, van der Walt & van Rensburg, 2010). A non-experimental, 

descriptive, prospective and contextual research design was used to meet the objectives of 

the study. 

 

3.3.1 Non Experimental  

 

In a non-experimental design the units that have been chosen to take part in the research 

are measured on all the relevant variables at their natural setting and there is no 

manipulation of variables that take place and no experiments involved (De Vos et al, 

2013). 

 

The purpose of non-experimental research is to define occurrences’ in order to describe 

relationships between variables. A non-experimental design was selected for the study 

because the independent variables cannot be manipulated, there are no experiments 

required and variables will be studied in their natural setting (renal dialysis unit). 

 

3.3.2 Descriptive  

 

A descriptive design is used to obtain more information about characteristics within a 

particular field of study with the purpose of providing a picture of situations as they occur 

in their natural setting (Burns & Grove, 2009). The descriptive design was used in this 

study to identify problems and gain knowledge on current nursing practices. 

 

3.3.3 Prospective 

  

Prospective design is used when causes have occurred but the proposed effect has not; the 

researcher starts with an effect and determines the cause. Prospective studies are more 

powerful when inferring causality: for example it can demonstrate that risk factors 

occurred before illness and are related to the illness positively (Burns & Grove, 2009). 

 

3.3.4 Contextual Design  

 

According to Burns and Grove (2009), the setting is the location where the research study 

is conducted, and it can be described as natural, partially controlled or highly controlled. 



38 
 

The research setting for this study was five haemodialysis units in two (n=2) university 

affiliated, public sector and tertiary level hospitals in Gauteng. Data was collected strictly 

from nephrology nurses working in the five (n=5) renal dialysis units.  

 

3.4 RESEARCH METHOD 

 

The instrument of the study was based on evaluation of nurse’s knowledge of 

haemodialysis catheter-related bloodstream infections prevention evidence-based 

guidelines taken from Centre for Diseases Control and Preventions (CDC) (CDC, 2011). 

The instrument was validated for suitability for the South African context by a panel of six 

(n=6) experts. 

 

The data collection instrument was used to gather demographic data from participants, 

followed by collection of data using the data collection instrument which was validated by 

the expert group. Prior to commencement of the study the instrument was subjected to a 

pre-testing process.  

 

A non-probability purposive sampling method was used to select experts for content 

validity of the data collection instrument. Highly educated nephrology nurses were 

approached to participate in the validation of the instrument. 

 

3.4.1  Population 

 

A population is the entire element that meets the sampling criteria for inclusion in the 

study and who the researcher is interested in, a targeted population is the entire element 

who meets the sampling criteria, whereas accessible population is the portion of targeted 

population that the researcher has access to for purpose of the study (Brink et al., 2010).  

 

The population of the study in objective I (instrument validation by experts) contains 

nephrology nurses (experienced and trained) and currently working in haemodialysis units 

and also nephrology specialist nurse educators (n=6). The population was chosen because 

they are nephrology nurses who possess knowledge in the nephrology field and nursing 

education and are involved in research and evidence-based practice. Population of 



39 
 

objective two of the study included registered nurses who are experienced and working at 

five haemodialysis units in two public sector hospitals in the Johannesburg region.   

 

3.5 SAMPLE AND SAMPLING  

 

Objective I 

According to Brink et al. (2010), sample is defined as a part of a whole or a subset of a 

larger population, which is selected by the researcher to be part of the study. Sampling is 

the process of choosing a sample from a population in order to obtain answers regarding 

phenomena under study in a manner that represents the interest of the population (Brink et 

al. 2010).   

 

Experts were selected using a non-probability purposive sampling in order to validate 

instrument for data collection as to ensure it is applicable in the South African context. Six 

nephrology specialist nurses, as well as specialist nurses in education, were requested to 

take part in a pilot testing group to help with the validation process of the instrument. 

Experts Nurses who meets the criteria for inclusion were sent an information letter 

(Appendix A) and requested to take part in the study. A consent form (Appendix B) and 

the tool for data collection (Appendix C) were also sent to the participants.  

 

Inclusion criteria for the expert group were:  

 Nephrology nurses employed in both acute and chronic haemodialysis units, who 

were willing to participate in the study and provided signed consent to participate 

in the study. 

 Nurses with expert knowledge in nephrology or nursing education and willing to 

participate in the study and had signed consent to participate in the study. 

 

Objective II 

The sample consists of nephrology nurses in the five haemodialysis units. Biostatisticians 

from the University of the Witwatersrand were approached to decide on the appropriate 

number of subjects that will offer a sample that is representative of the population under 

study. Following discussion with a statistician, the sample size decided upon was 80 

nephrology nurses (n=80), from the five (n=5) haemodialysis units of two public sector 



40 
 

hospitals (n=2). A non-probability purposive sampling method was used to select the study 

participants.  

 

Inclusion criteria for the prospective nurse participants were: 

 Nephrology nurses and agency nurses (trained and untrained), working in all five 

haemodialysis units in public healthcare institutions.  Nephrology nurses from two 

(n=2) public health care institutions were chosen based on the similarity in 

practices between both institutions. 

 

Exclusion criteria include: 

 Lower categories of nurses (Enrolled and auxiliary) were excluded as they are not 

expected to be skilled and have advanced knowledge of haemodialysis catheter-

related sepsis and best practice guidelines on prevention of haemodialysis catheter-

related infections. 

 

Information letter (Appendix F) was given to nurses who met the criteria for inclusion and 

were asked to take part in the study. A consent form (Appendix E) and the data collection 

tool (Appendix D) were also given to the participants. 

 

3.6 DATA COLLECTION  

 

3.6.1 Instrument  

 

The instrument used in the study was developed from the Centre for Disease Control and 

Prevention (CDC) “Guidelines for the Prevention of Intravascular Catheter-Related 

Infections” (CDC, 2011). Permission to use the guidelines to formulate a research 

instrument was not requested as it was developed from an open source.  

 

The instrument is a validated and reliable questionnaire, designed to assess nurse’s 

knowledge of haemodialysis catheter-related infection prevention evidence-based 

guidelines (CDC. 2011). Eleven (11) strategies, which are relevant to practice of nursing 

and proven in literature, to prevent haemodialysis catheter-related infections were recorded 

and where respondents had four response to choose from: there was one right response and 

three other incorrect alternatives, which included the choice “I don’t know” to prevent 



41 
 

participant’s taking a chance and with other two choices having been proven to have a 

preventive value in haemodialysis catheter-related infections.  

 

The instrument included demographic data of the participants such as gender, years of 

experience working in haemodialysis and whether they had a degree or diploma in 

nephrology nursing. The second part of the questionnaire asked participants for their 

opinion on whether they thought they had sufficient information on the prevention of 

haemodialysis catheter-related infections.  

 

3.6.2 Validity and reliability of Instrument  

 

Experts were selected to ensure that the instrument for data collection is valid and 

applicable for South Africa. Six nurses specializing in nephrology and nursing education 

were asked to take part in a pre-testing group for a validation process of the data collection 

instrument.  

 

3.6.3 Procedure  

 

Permission to conduct the study was sought from the Universities Ethics Committee and 

the Chief Executive Officer (CEO) of the hospitals participating in the study and where 

data collection will take place. 

 

Information letters (Appendix A) were sent to expert nurses who met the inclusion criteria 

and requested to participate in the study. A consent form (Appendix B) and the tool for 

collection of data (Appendix C) were sent to the participants. A focus group was held, to 

discuss the validity of the instrument and suitability for South Africa, based on Lynn’s 

Model of Level of Agreement (Lynn, 1986).  

 

A letter of request was send to management of the institutions were the study was going to 

be conducted requesting permission to conduct the study (Appendix I). Once permission 

was granted, the nursing managers were approached for permission to conduct the study in 

their units. Nephrology nurses in the selected haemodialysis units were to be informed 

about the research purpose and objectives. Confidentiality of data and anonymity was 

ensured and it was explained that participation in the study was voluntary. Potential 



42 
 

participants were invited to ask questions they may have in relation to the study and were 

informed that they can refuse to take part in the study or refuse to respond to any particular 

question and can withdraw from participation at any given time without penalty. An 

information letter was distributed to prospective participants and they were requested to 

sign a consent form (Appendix E and Appendix F). The data collection tool was given to 

nurse participants who gave permission to participate in the study by the researcher 

(Appendix D). Completed questionnaires were placed in a sealed envelope and collected 

by the researcher from each unit on a week basis. 

 

3.6.4 Data Analysis 

 

Descriptive and inferential statistics were used to analyse demographic data and to evaluate 

nephrology nurses knowledge of evidence-based guidelines for the prevention of 

haemodialysis catheter-related infections.  

 

According to Burns and Grove (2009), descriptive statistics allows the researcher to 

organise data in a manner that gives meaning and facilitates insight and inferential 

statistics allows for making conclusions from a sample to a population. The following 

statistical tests were used: 

 Frequency distribution, measures of central tendency, measures of variability and 

degree of freedom were used to describe participants’ data. 

 Content validity was used to calculate the percentage of experts that judged the 

content of the instrument items as valid (with a score of 3 and 4). 

 A Pearson correlation coefficient (r) was employed to assess the amount and 

direction of the relationship between ages, years of experience in the unit, 

qualification and knowledge of evidence-based guidelines for the prevention of 

dialysis catheter-related infections. 

 Non-parametric statistical tests of Kruskal-Wallis and Chi-Square were used to 

assign rank to the scores of the group and to compare distribution of responses. 

 A one way analysis of variance (ANOVA) was used to determine scores and 

significance of the data. 

 



43 
 

A statistician from the postgraduate office was consulted to assist with the analysis of the 

data. The statistical software package Statistica
TM

 version 12 was used, and testing was 

done on the 0.05 level of significance (p<0.05).  

 

3.7 VALIDITY AND RELIABILITY  

 

3.7.1 Validity 

 

Validity refers to the extent to which the instrument accurately measures what it should 

measure (De Vos, et al., 2011). In this study validity was ensured by using an instrument 

that was validated by panel of experts and the researcher did not deviate from procedures 

stipulated. Advice was sought from a statistician in terms of data capturing, processing, 

analysis and interpretation. A safe environment was ensured by informing participants that 

participation was voluntary and anonymity would be ensured. 

 

A process of pre-testing was done to ensure feasibility of the study and detect possible 

flaws in the instrument used. Content validity index (CVI) was achieved by having the data 

collection instrument reviewed by expert nephrology specialist nurses. Prospective studies 

allowed for investigation of unusual or unexpected results during the data collection and 

possible causes that yield such results.  

 

3.7.2 Reliability 

 

Reliability refers to accuracy and consistency of the measures obtained when using a 

particular instrument, meaning the same results should be obtained if the test is 

administered to the same individuals at different times and it indicates the extent of a 

random error in the measurement method (Burns & Grove, 2009). 

 

Reliability was maintained by ensuring consistency and accurate recording of data. Only 

the researcher undertook data collection; data was verified by the statistician for accuracy. 

An appropriate sample size was determined by the statistician to ensure representativeness 

of the population under study. Sample inclusion and exclusion criteria were followed. 

 

 



44 
 

3.8 PRE-TESTING THE INSTRUMENT 

 

Burns and Grove (2009) define pre-testing as a lesser version of the planned study and 

usually conducted with the objective to refine the methodology. A pre-testing process was 

carried out prior to the commencement of the main study. Its purpose was to fine tune the 

instrument for the main study and also to determine whether the methodology and ana