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Journal of Applied Medical Sciences, vol.7, no. 1, 2018, 11-20
ISSN: 2241-2328 (print version), 2241-2336 (online)
Scienpress Ltd, 2018

Knowledge and Attitude of Nurses on the Practice

of Surgical Conscience in Surgical Management of
Patients at University College Hospital, Ibadan.

Ifeoluwapo Oluwafunke Kolawole1 and Rose E. Ilesanmi1

Abstract
Surgical conscience is an in-built discipline of consistent awareness and practice
of surgical rules in an individual. Increased cost of treatment, prolonged hospital
stay coupled with patients’ agony has increased their awareness of their legal
rights. This study aimed at assessing nurses’ knowledge and attitude on the
practice of surgical conscience in University College Hospital. Ibadan. This
descriptive study consists of 159 nurses (randomly selected) who are working in
the purposely selected surgical units. A self -developed 33 item questionnaire was
designed to capture the socio-demographic data and the objectives of the study.
Descriptive and inferential statistics were used to analyze the data at alpha 5%.
Majority (79.2%) of respondents were females. Almost (96%) all respondents have
good knowledge of surgical conscience. 47.8% saw it as a guiding principle.
There is a significant relationship between nurses knowledge and practice of
infection control (0.00<0.05), there was also a significant relationship between their
years of experience and attitudes towards surgical conscience (0.00<0.05) but there
was no significant relationship between barriers and surgical conscience practices
(0.22>0.05). There may be need to explore systemic issues, the practice of surgical
conscience should also be encouraged and personnel should demonstrate excellent
practice towards the use of all available resources to ensure patient safety.

Keywords: Knowledge, Attitude, Practice, Nurses, Surgical patient, Surgical

conscience.

1
Department of Nursing, University of Ibadan, Ibadan, Nigeria
12 Ifeoluwapo Oluwafunke Kolawole and Rose E. Ilesanmi

1 Introduction
Reports from IOM (Institute of Medicine) drew attention to patient safety issues
and with more stringent economic measures in healthcare, greater efforts are
required to reduce the burden of surgical patients through practice of surgical
conscience. Surgical conscience is an in-built discipline of consistent awareness
and practice of surgical rules in an individual, even in the absence of external
monitoring of such individual [1]. It is the foundation upon which the skills and
techniques employed by the surgical personnel are built. The “knowledge” and
“application” of the principles of sterile technique by all theatre staff and others
caring for surgical patients is the hallmark of the doctrine of surgical conscience,
and indifference to this doctrine is a precursor to surgical infractions [2].
The advent of surgery, no doubt, has brought succor to man’s quest for improved
health status. Many illnesses that hitherto proved incurable or recurrent have been
tackled by the timely emergence of surgical practice. Acting on personal surgical
conscience involves knowledge, self-awareness, intelligence, and the courage to
make ethical and moral decisions that benefits the patients [3]. In her view,
surgical conscience is evidenced by consistently exhibiting ethical behaviour,
promoting patient safety, and doing the right thing even when no external
monitors are present. Surgical conscience was described as an awareness that
develops from a knowledge base of the importance of strict adherence to
principles of aseptic techniques. She concluded that optimal patient care requires
an inherent surgical conscience, self-discipline, and the application of principles of
sterile and aseptic techniques, which are all inseparable related. The concept of a
surgical conscience may simply be stated as a surgical Golden Rule: do unto the
patients as you would have others do unto you. The caregiver should consider
each patient as himself or herself or as a loved one. Once an individual develops a
surgical conscience, it remains inherent thereafter [4].
It is appalling to discover that despite the expertise of operating suites workers and
those caring for surgical patients in the study setting, complications such as
prolonged wound healing, breakdown and blood borne infections still occur,
which results in patients spending more money and time in the hospitals. The
question to ask is ‘what account for these complications despite the level of
training in such hospitals?’ Is it due to absence of surgical conscience?
The study was therefore designed to assess nurses’ knowledge and practice of
surgical conscience.

The following research questions were raised;

1. Do nurses working with surgical patients know about surgical conscience
and sources of infections in the hospital?
2. What is the attitude of nurses caring for surgical patients towards
decontamination and disinfection of surgical instruments and other
reusable items?
 Knowledge and Attitude of Nurses on the Practice of Surgical Conscience in … 13

3. Do nurses apply the principles of aseptic and sterile techniques in everyday

surgical practice?
4. What is the effect of environmental preparation on the outcome of care in
surgical patients?
5. What are the limitations/barriers to effective practice of the doctrine of
surgical conscience in the management of surgical patient?

2 Preliminary Notes
Definition 2.1
Knowledge: Person’s conversance with a particular subject.
Attitude: A way of eliciting a behavior
Practice: The act of doing something on a regular basis.
Nurses: These are all registered nurses working in the surgical units, that is,
nurses working in various operating theatres, male and female surgical wards,
surgical outpatient clinic, intensive care unit, etc.
Surgical patient: An individual who is under the care of nurses before, during and
after surgery or who is being managed with surgical related conditions.
Surgical conscience: This is the inner man, developed to guide the actions of
surgical personnel to do the right thing even if no one is present and to feel guilty
if one is wrong.
Surgical units: Areas where surgical patients can be found e.g. operating theatres,
surgical wards, surgical out-patient departments. etc.

3 Main Results
3.1 Findings
From the table 2 below, 85(53.5%) respondents have heard about surgical
conscience before while 74(46.5%) of the respondents have not heard about it. Of
those who have heard about surgical conscience before, 44.7% heard about it in
the classroom, 30.5% read about it in textbooks. Among those who have heard
about surgical conscience, majority of the respondents (58, 67.4%) understood it
to be the police of the mind, 23.3% respondents understood it to be the act of
maintaining aseptic technique.
Table 3 shows that the respondents agreed to the identified sources of infection as
being valid sources. For the nurses, it is 94.2%, for the patients, it is 98.1%, for the
instruments, it is 99.4%, for the surgeon, it is 94.9%, for the patients’
environment, it is 98.1% and for the other health care workers, it is 96.0%.
Table 4 below shows that there are varying attitude towards the practice of
surgical conscience among the respondents. While 99.2% believe it will benefit
patients, 47.8% saw it as a guiding principle.
 14 Ifeoluwapo Oluwafunke Kolawole and Rose E. Ilesanmi

From the table 5 below, 152(95.6%) respondents said that adequate environmental
preparation when carrying out a sterile procedure is highly essential while 3(1.9%)
respondents said adequate environmental preparation is not highly essential when
carrying out a sterile procedure. 4(2.5%) respondents are not sure whether it is
essential or not. Conduct of surgical conscience and its promotion can be achieved
by providing an environment of safety for the surgical team and the patients [3]. The
principles of aseptic technique as adequate preparation of the setting including
decontamination of the working surface or tray to be used with detergent and water
or detergent wipes and then dry, removal of hand and wrist jewelry, performance of
hand hygiene in accordance with Hand Hygiene Policy, assembling of all
appropriate packaged sterile items for the procedure, and checking if packaging is
intact and expiry date has not been exceeded. All these will prevent complications
and reduce the risk of staying extra days in managing complications [5].
From the results below, it is obvious that adequate preparation is essential when
carrying out a sterile procedure as identified by 152(96.5%) respondents. The table
6 below shows that 49(30.8%) respondents said that insufficiency of materials to
work with is a barrier to shortage of staff, 30(18.9%) said it is time factor,
28(17.6%) said the barrier is working with difficult surgeons/doctors while
15(9.4%) respondents said that unconducive working environment is the barrier to
an effective application of surgical conscience. A good communication skill is very
important in assisting the development of surgical conscience. A team member
should not be criticized for any error, that person should be given for admitting the
error and should be helped to correct the violation [4]. The external forces and
powers that control health care practices today may interfere with personal surgical
conscience and make it very difficult to uphold [3].

3.2 Hypotheses Testing

Hypothesis one: There will be no significant relationship between nurses’
knowledge and practice of infection control in the hospitalThe result from table 7
shows that r= 0.259, degrees of freedom (df) = 156 and p=0.000. Since
p=0.000<0.005 it implies that there is a significant relationship between nurses’
knowledge and practice of infection control in the hospital.
Decision: The null hypothesis is rejected and therefore concludes that there is
significant relationship between nurses’ knowledge and practice of infection control
in the hospital.
Hypothesis two: There will be no significant relationship between nurses’ year of
experience and their attitude towards decontamination and disinfection of surgical
instruments.
The result from table 8 shows that r=0.28, degree of freedom (df) is 158 and
p=0.000. Since p=0.00<0.05
Decision: The null hypothesis is rejected. It is therefore suggests that there is
significant relationship between nurses’ years of experience and their attitude
towards decontamination and disinfection of surgical instruments.
Hypothesis three: There will be no relationship between the barriers to the practice
 Knowledge and Attitude of Nurses on the Practice of Surgical Conscience in … 15

of doctrine of surgical conscience and the infection control practices.

The result from table 9 shows that r=0.09, degree of freedom (df) = 158 and p=0.22.
Decision: Since p=0.22> 0.05 it implies that the null hypothesis holds and the
researcher conclude that there is no significant relationship between the barriers to
the practice of doctrine of surgical conscience and the infection control practices in
the care of surgical patients.

3.3 Discussion
The result of the revealed that 83(52.9%) of the respondents have heard about
surgical conscience and 61.4% of them defined it as a police of the mind. About
63.7% still mistaken it to be synonymous with aseptic technique. [3] The art of
surgery is expanding in geometric proportion, this call for a necessity for theatre
workers and other personnel to gain commensurate knowledge in this field
especially in the area of surgical conscience.
In spite of high level of knowledge of surgical conscience, the attitude and practice
is still poor among nurses working in the surgical units as only 39.9% indicated that
it is discussed daily in their unit. As identified, surgical conscience still guides
surgical care today to some extent and it is not easy to practice due to time factor,
lack of knowledge, insufficient equipment, and that it is tasking. Also, it is easy to
develop surgical conscience through self-discipline and improved knowledge. Most
practitioners would refuse to admit committing errors because they are highly
ranked officers. [6]A break in technique compromises patient care and possibly
threatens the patient’s life. If a personnel recognizes a break in technique, he/she
must admit the break and take corrective action. [7] Surgical conscience should
prompt practitioners to admit committing an error if need be, and to correct the
situation. [8] If all principles of asepsis are practiced effectively, recovery of
patients will be quick and risk of complications will be minimal. [9] If surgical
conscience is well practiced, surgical complications will be prevented and patients
will not have the course to stay extra days on the hospital beds managing
complications.

4 Labels of figures and tables

Table 1: Socio- Demographic Characteristics of Respondents
Variables N Percentage
Age(In Years)
16-25 16 10.1
26-35 74 46.5
36-45 52 32.7
46 and Above 17 10.7
Total 159 100
Sex
16 Ifeoluwapo Oluwafunke Kolawole and Rose E. Ilesanmi

Male 33 20.8
Female 126 79.2
Total 159 100
Wards/units
South East 1 14 8.8
East 1 12 7.5
ICU 25 15.7
West 2 11 6.9
Burn Unit 3 1.9
South West 1 14 8.8
A&E Theatre 7 4.4
West 1 24 15.1
LW Theatre 26 16.4
O&G Theatre 5 3.1
Main Theatre 18 11.3
Total 159 100
Religion
Christianity 118 74.2
Islam 41 25.8
Total 159 100
Educational Qualifications
RN 7 4.4
RN; RM 83 52.2
RPON 40 25.1
BNSc (Degree) 17 10.7
Others 12 7.5
Total 159 100
Years of Experience
1-5 45 28.3
6-10 54 34.0
11-15 39 24.5
16-20 7 4.4
21-25 8 5.0
≥ 26 6 3.8
Total 159 100
 Knowledge and Attitude of Nurses on the Practice of Surgical Conscience in … 17

Table 2: Nurses’ knowledge of surgical conscience

Have you heard about surgical conscience? N %
Yes 85 53.5
No 74 46.5
Total 159 100
Source of information N %
Journals 9 10.5
Scientific conference 3 3.5
Textbook 26 30.5
Internet 9 10.5
Classroom 38 44.7
Total 85 100
Definition of surgical conscience No %
The act of maintaining aseptic technique 20 23.3
Police of the mind 58 67.4
Hand washing and gloving 1 1.2
Sterilization of instrument 7 8.1
Total 86 100

Table 3: Nurses’ knowledge of surgical conscience as measured by perceived sources of

infections in the hospital
Sources of infection N Percentage of cases

The nurse 146 92.4%

The patient 155 98.1%
Instrument/equipment 153 98.6%
The surgeon 148 93.7%
Patients’ environment 154 97.5%
Other health care workers 145 91.8%

Table 4: Nurses’ Attitude towards practice of surgical conscience

Attitude towards practice of surgical N %
conscience

It is still guiding surgical care today 76 47.8%

It is a rule in their units 79 50.3%
It is easy to develop 89 63.6%
It prompts personnel to admit committing 98 63.2%
error
Patient will benefit from it 147 99.2%
18 Ifeoluwapo Oluwafunke Kolawole and Rose E. Ilesanmi

Table 5: Nurses’ attitude towards environmental preparation when carrying out surgical
procedures
Adequate preparation is essential when carrying out N Percentage
a sterile procedure
Yes 152 95.6
No 3 1.9
Not sure 4 2.5
Total 159 100

Table 6: Barriers to effective practice of the doctrine of surgical conscience in surgical

management of patients
Barriers to effective application of surgical N Percentage
conscience
Time factor 30 18.9
Insufficient material 49 30.8
Shortage of staff 37 23.3
Working with difficult surgeons 28 17.6
Unconducive environment 15 9.4
Total 159 100

Table 7: Correlation table showing the relationship between nurses’ knowledge and
practice of infection control in the hospital.
Nurses N Df X bar SD R P Remark
Knowledge 157 156 2.19 1.24 0.259 0.000 Significant
Practice 157 1.17 0.44

Table 8: Correlation table showing the relationship between nurses’ years of experience
and their attitude towards decontamination and disinfection of surgical instruments.
Nurses N df X bar SD R p Remark
Years of 157 156 10.19 1.24 0.280 0.00 Significant
experience
Attitude to 157 2.13 1.77
decontamination
and disinfection
 Knowledge and Attitude of Nurses on the Practice of Surgical Conscience in … 19

Table 9: Correlation table showing the relationship between the barriers to the practice of
doctrine of surgical conscience and the infection control practices
Nurses’ N Df X bar SD R p Remark
Barriers 159 158 0.22 0.44 0.09 0.22 Not
significant
Infection control 159 1.09 0.29
practices

5 Conclusion
The caregiver should consider each patient as himself or herself or as a loved one.
Once an individual develops a surgical conscience, it remains inherent thereafter.
Conscience is the inner voice which warns us that someone may be looking. It is
however important to mention that surgical conscience does not involve having
someone else notice an infraction. A nurse knows that long, false or painted
fingernails can be potential source of danger to a patient. The theatre nurse knows
that a cap should cover all the hair on the head and facial hair, the nurse knows
that wearing dangling or bogus earrings is wrong, as it may fall into patient’s
wound. Having the awareness and taking the appropriate actions to protect the
patient will lead to practice that is internally directed by intellect and desire to do
no harm.

From the study, most nurses have the knowledge but few of them practice surgical
conscience in their day-to-day nursing care of surgical patients, and there is a wide
gap between knowledge and attitude (practice) of surgical conscience especially in
the aspect of maintaining aseptic technique in all invasive procedures and
protecting surgical patients from harm as much as possible.

There are some barriers to the practice of surgical conscience such as,
unconducive working environment, insufficient materials to work with, working
with difficult surgeons and time factor. Also the factors that can make a
practitioner refuse to admit committing errors, such as high rank of the officer, too
simple error and so on.

ACKNOWLEDGEMENTS
I wish to express my appreciation to the Almighty God for His love, mercies,
protection and for giving me the strength to carry out this study. May His name
forever be praised.
My profound gratitude goes to my late amiable and untiring mentor- Dr. Modupe
O. Oyetunde who despite her busy schedule guide and supported me throughout
the process of the research work. I also thank other lecturers and the entire staff of
Department of Nursing including other departments of the University (most
 20 Ifeoluwapo Oluwafunke Kolawole and Rose E. Ilesanmi

especially, Dr. Roslyn Ilesanmi) as they have contributed meaningfully to my life.

I thank the management and patients of the University College Hospital, Ibadan,
for their permission, cooperation and participation during the research work.
I say big thank you to the entire members of staff of Perioperative Nursing School,
University College Hospital, Ibadan for their love and supports throughout the
course of this study, may you all continue to receive God’s favour. Amen. My
gratitude also goes to my classmates, friends and partners in progress who in one-
way or the other have contributed to the success of this programme.
Finally, my unreserved thanks goes to my angels-Anita and Anthonia Kolawole
for their understanding and to you SAMUEL (my husband) for your supports,
indeed you are the best friend. I say a big thank you. I am very grateful to my
parents- Mr. and Mrs. E.B. Abolarin, for their financial, spiritual and moral
supports, may you live long to reap the fruit of your labour in good health. Amen.
My thanks goes to my siblings for their supports, Mr. Oluwole who assisted me
during analysis, may God grant you your heart desires in life.

References
[1] W.R. Hopper and R. Moss, “Common breaks in sterile technique: clinical
perspectives and perioperative implications,” AORN J., vol 91, no 3, 350-
365. (2010)
[2] G. Denver, “Standards and Recommended Practices, Association of
Operating Room Nurses’ Journal,” Vol 20, no 4, 145 (2014).
[3] N. Girard, “Surgical Conscience Still Pertinent, Association of Operating
Room Journal,” vol 28, no 4, (2014).
[4] N. P. Fortunato, “Berry and Kohn: Operating Room Technique,” 9th Ed,
USA, Mosby Inc, (2012).
[5] “Gale Encyclopedia of Public Health,” Gale Cengage Learning, London, pp
1-6, (2012).
[6] K.B. Frey & P. Price, “Microbiology for Surgical Technologists,” 5th Ed,
London, Cengage Learning, Pg 96, (2013).
[7] E.I. Evans, “Annals of Surgery,” 15th Ed, Baltimore, Williams & Wilkins
Company, (2014).
[8] M.A. Bankole & G.A. Awokola, “Pocket Manual of Appropriate Conduct
and Activities in the Surgical Operating Suite,” 1sted, Nigeria, Twinstwo
Publishers Ltd, (2014).
[9] D. Austin, “Principles of Aseptic Technique,” AORN Journal. Vol. 14, no 6,
pp 129, (2014).

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