Sepsis is a rapidly growing public health crisis. It is one of the deadliest and most expensive conditions to treat in hospitals in the United States, affecting 1.7 million adults and contributing to nearly 270,00 deaths (Rhee et al., 2017). However, early recognition and prompt treatment can increase the odds of survival for patients (van den Hengel et al., 2016). Because of their close and constant patient contact, nurses play a vital role in this early recognition and have the potential to save lives. In fact, a study from Norway found that early identification of sepsis by bedside nurses reduced disease progression and increased overall survival rates (Torsvik et al., 2016).
Evidence-based guidelines for monitoring and treatment have been created to combat the high mortality and morbidity of sepsis; however, several barriers exist to following these guidelines consistently (Breen & Rees, 2018). Sepsis knowledge deficits of the care team, including nurses, are a top barrier to implementing best practice guidelines (Breen & Rees, 2018). Proper sepsis education for nurses has a positive influence on patient outcomes (Braddock et al., 2015) and should be a top priority when planning hospital education. However, when trying to educate hospital staff, shortage of resources and time are common limitations.
Methods of sepsis education have evolved over time as new guidelines have emerged and new technologies have become available. Classroom instruction is beneficial for many reasons, such as providing opportunities for learners to ask questions, clarify ideas, and network with peers (Davis et al., 2016). However, electronic methods for education can be more convenient, save time, and cost less to deliver (Davis et al., 2016). Although electronic methods are not appropriate for every situation, innovative practices are being used for sepsis education (Davis et al., 2016). It is imperative that the best methods of education are explored to provide nurses with accessible, efficient, affordable, and effective training to translate best practice guidelines into bedside care and positive patient outcomes.
To increase the use of sepsis treatment guidelines, quality improvement projects have been designed to address the education gaps, among other factors, in the plan of care. The descriptions of these education methods often contain few details (Herron et al., 2019). This raises questions about how the current education methods are designed and whether they are meeting the unique gaps in knowledge. The purpose of this article was to review the literature to identify how current sepsis education methods are addressing gaps in nursing knowledge of sepsis.
Search Engines and Key Search Terms
We performed a literature search using access provided by The University of Alabama at Birmingham Lister Hill Library. PubMed® and CINAHL® were chosen as the search engines. Key search terms included sepsis education, sepsis training, sepsis recognition, sepsis identification, nurse, nursing, nursing school, sepsis knowledge, and knowledge assessment. Boolean strings were used to combine search terms into several unique searches. The total number of articles found was 162. Fifty duplicate articles were identified using EndNote™ X9, leaving an initial total yield of 112 articles.
Inclusion and Exclusion Criteria
We determined exclusion criteria after an initial read of each title and abstract. Sepsis is experienced in every country of the world and in all patient populations (Fleischmann et al., 2016). Therefore, no exclusions were made based on location or patient population. Articles were excluded if the main disease process discussed was not sepsis or if nurses were not involved in the main intervention. Articles also were excluded if they did not contain an educational intervention or an assessment of nursing knowledge. Finally, articles were eliminated if the educational interventions were focused mainly on prevention as opposed to early recognition. If titles and abstracts could not provide enough needed information for inclusion, full-text versions were accessed and reviewed to further eliminate articles based on these criteria.
Final Article Yield
The final yield was 14 articles. We read and analyzed the full-text version of each. Of these 14 articles, nine were chosen for further literature review based on the most relevant content and the highest level of evidence available (Table 1). These articles were categorized by level of evidence using the Johns Hopkins Nursing Evidence Based Practice Levels of Evidence Rating scale. The final nine articles included four at level II and five at level III (Dearholt et al., 2012).
Final Article Yield Levels of Evidence and Summary
Synthesis of Evidence
The rising number of hospitalizations, health care costs, and deaths associated with sepsis has attracted the attention of the health care industry worldwide (Delaney et al., 2015). The importance of the bedside nurse in early identification and treatment is becoming more supported by studies (Herron et al., 2019). This literature search produced several articles related to improving nurse sepsis education. Topics included sepsis knowledge assessments, developing and implementing various modes of sepsis education and training programs, assessing these programs, incorporating varying levels of the interdisciplinary care team, or a combination of these topics. While synthesizing the available evidence, three major themes emerged: (a) assessing nurse sepsis knowledge, (b) using electronic learning methods for education, and (c) incorporating simulation into sepsis training.
Health care education is often developed to meet regulatory requirements, rather than customized requirements to address unique knowledge gaps. Educators are urged to develop education based on the specific deficits related to clinicians in professional practice (Schilinski et al., 2019). This includes sepsis training of nurses. The literature produced few articles specifically addressing the specific sepsis knowledge gaps in nurses; however, several articles provided evidence on demographic, nursing experience, and education factors that affect sepsis knowledge in nurses.
Three studies found years of nursing experience and exposure to septic patients to be strong indicators of sepsis knowledge (Boettiger et al., 2017; van den Hengel et al., 2016; Woods et al., 2019). Stamataki et al. (2014) found a correlation in sepsis symptom identification and the level of nursing education in Greek nurses; however, Boettiger et al. (2017) and Schilinski et al. (2019) found no educational correlation in American neonatal and critical care nurses, respectively. The study by van den Hengel et al. (2016) conducted in the Netherlands also found that recent sepsis-focused education was the strongest predictor of knowledge and could even compensate for having low exposure to septic patients. This suggests that factors related to sepsis knowledge differ in each nursing and patient population; however, timely education on the topic can produce better knowledge overall.
Electronic Learning Methods
Once a need for education has been established, the best modes of education should be put into place for maximum effectiveness. Several studies implemented pre- and posttests to assess interactive electronic learning modules on the recognition and treatment of sepsis (Delaney et al., 2015; Schilinski et al., 2019; Woods et al., 2019). Woods et al. (2019) and Delaney et al. (2015) saw an increase in posttest scores. It is equally important that nurses can retain this knowledge to bring it to practice. Woods et al. (2019) found initial improvement in posttest scores of 15.7%, but only a 5.2% retention improvement after a 3-month period. Posttest scores found by Schilinski et al. (2019) that originally increased were back at baseline after just 1 month. Electronic learning modules may not offer an opportunity to develop the lasting and intuitive skills for recognizing sepsis symptoms, but it can help fill immediate knowledge gaps and create the underpinnings of awareness required to recognize and react quickly to sepsis (Davis et al., 2016).
Simulation provides a safe learning environment where nurses can experience emergency situations, react, and develop critical thinking skills without the risk of harming patients (Davis & Hayes, 2018). Another advantage of simulation training is the ease of incorporating other disciplines into the training simultaneously. The literature revealed studies that have taken advantage of this opportunity with simulation training to advance interdisciplinary teamwork (Braddock et al., 2015) and empower nurses to initiate early treatment (Herron et al., 2019). Sepsis simulations with the entire care team have led to nursing staff escalating concerns earlier, increased treatment plan completion, and improved posttest knowledge (Herron et al., 2019).
Simulation requires time, equipment, skilled leaders, and scenario development; however, this has been found to be a beneficial method of providing sepsis education to improve confidence and build on knowledge learned in the clinical setting (Davis & Hayes, 2018).
Conducting studies at a high level of evidence would be beneficial in advancing knowledge on the effectiveness of different sepsis training techniques and how they address the educational needs of nurses. The available literature includes quasi-experimental and qualitative studies at levels II and III, respectively, of the Johns Hopkins School of Nursing Evidence-Based Practice Levels of Evidence scale (Dearholt et al., 2012). This literature review revealed several articles with strong, statistically relevant results; however, the participants were tested only against themselves. A controlled trial with or without randomization would provide a higher level of evidence by testing the methods on a control population. Implementing randomized control trial guidelines in a hospital could be a challenge when hospitals have regulatory guidelines to provide all staff with consistent education. However, an intervention with additional education could be developed and tested in a controlled trial method.
Implications for Care
Several implications can be drawn from this review. Assuming the knowledge or competence gaps of certain populations of nurses is not enough. Custom assessments of the groups should be completed before developing sepsis education. Electronic, self-guided methods of education can be used for short-term instruction, but more effective methods should be used to show moderate to long-term effects in knowledge retention, team dynamics, and patient outcomes. This could include different levels of simulation and engaging the entire interdisciplinary team to clarify standards for reacting to suspected sepsis. This may require greater investment of time and money, but higher quality sepsis education can produce overall better patient outcomes and nurses who are more confident in caring for their patients.
It is imperative to instill a high standard of sepsis education to combat this leading cause of death in United States hospitals (Rhee et al., 2019). Nurses are essential players in the war against sepsis at the frontlines of identifying and implementing treatment. This requires that the most appropriate and effective methods of education be used for all nurses.
- Boettiger, M., Tyer-Viola, L. & Hagan, J. (2017). Nurses' early recognition of neonatal sepsis. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 46(6), 834–845 doi:10.1016/j.jogn.2017.08.007 [CrossRef] PMID:28987479
- Braddock, C. H. III. , Szaflarski, N., Forsey, L., Abel, L., Hernandez-Boussard, T. & Morton, J. (2015). The TRANSFORM patient safety project: A microsystem approach to improving outcomes on inpatient units. Journal of General Internal Medicine, 30(4), 425–433 doi:10.1007/s11606-014-3067-7 [CrossRef] PMID:25348342
- Breen, S. J. & Rees, S. (2018). Barriers to implementing the sepsis six guidelines in an acute hospital setting. British Journal of Nursing, 27(9), 473–478 doi:10.12968/bjon.2018.27.9.473 [CrossRef] PMID:29749778
- Davis, A., Henderson, J. & Langmack, G. (2016). Development of an e-learning package for sepsis care. British Journal of Nursing, 25(6), 292–296 doi:10.12968/bjon.2016.25.6.292 [CrossRef] PMID:27019164
- Davis, A. H. & Hayes, S. P. (2018). Simulation to manage the septic patient in the intensive care unit. Critical Care Nursing Clinics of North America, 30(3), 363–377 doi:10.1016/j.cnc.2018.05.005 [CrossRef] PMID:30098740
- Dearholt, S. & Dang, D.Sigma Theta Tau International, & Johns Hopkins School of Nursing (2012). Johns Hopkins School of Nursing evidence-based practice: Model and guidelines (2nd ed.). Sigma Theta Tau International.
- Delaney, M. M., Friedman, M. I., Dolansky, M. A. & Fitzpatrick, J. J. (2015). Impact of a sepsis educational program on nurse competence. The Journal of Continuing Education in Nursing, 46(4), 179–186 doi:10.3928/00220124-20150320-03 [CrossRef] PMID:25856453
- Fleischmann, C., Scherag, A., Adhikari, N. K. J., Hartog, C. S., Tsaganos, T., Schlattmann, P., Angus, D. C. & Reinhart, K.the International Forum of Acute Care Trialists. (2016). Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. American Journal of Respiratory and Critical Care Medicine, 193(3), 259–272 doi:10.1164/rccm.201504-0781OC [CrossRef] PMID:26414292
- Herron, J. B. T., Harbit, A. & Dunbar, J. A. T. (2019). Subduing the killer—Sepsis: Through simulation. BMJ Evidence-Based Medicine, 24(1), 26–29 doi:10.1136/bmjebm-2018-110960 [CrossRef] PMID:30054373
- Rhee, C., Dantes, R., Epstein, L., Murphy, D. J., Seymour, C. W., Iwashyna, T. J., Kadri, S. S., Angus, D. C., Danner, R. L., Fiore, A. E., Jernigan, J. A., Martin, G. S., Septimus, E., Warren, D. K., Karcz, A., Chan, C., Menchaca, J. T., Wang, R., Gruber, S. & Klompas, M.the Centers for Disease Control and Prevention Prevention Epicenters Program. (2017). Incidence and trends of sepsis in us hospitals using clinical vs claims data, 2009–2014. Journal of the American Medical Association, 318(13), 1241–1249 doi:10.1001/jama.2017.13836 [CrossRef] PMID:28903154
- Rhee, C., Jones, T. M., Hamad, Y., Pande, A., Varon, J., O'Brien, C., Anderson, D. J., Warren, D. K., Dantes, R. B., Epstein, L., Klompas, M., Control, C. D. & Program, P. P. E.the Centers for Disease Control and Prevention Prevention Epicenters Program. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in U.S. acute care hospitals. JAMA Network Open, 2(2), e187571 doi:10.1001/jamanetworkopen.2018.7571 [CrossRef] PMID:30768188
- Schilinski, S., Hellier, S. D. & Cline, T. W. (2019). Evaluation of an electronically delivered learning module intended for continuing education of practicing registered nurses: A pretest-posttest longitudinal study. The Journal of Continuing Education in Nursing, 50(7), 331–336 doi:10.3928/00220124-20190612-09 [CrossRef] PMID:31233608
- Stamataki, P., Papazafiropoulou, A., Kalaitzi, S., Sarafis, P., Kagialari, M., Adamou, E., Diplou, A., Stravopodis, G., Papadimitriou, A., Giamarellou, E. & Karaiskou, A.the Hellenic Sepsis Study Group. (2014). Knowledge regarding assessment of sepsis among Greek nurses. Journal of Infection Prevention, 15(2), 58–63 doi:10.1177/1757177413513816 [CrossRef] PMID:28989356
- Torsvik, M., Gustad, L. T., Mehl, A., Bangstad, I. L., Vinje, L. J., Damås, J. K. & Solligård, E. (2016). Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival. Critical Care, 20(1), 244 doi:10.1186/s13054-016-1423-1 [CrossRef] PMID:27492089
- van den Hengel, L. C., Visseren, T., Meima-Cramer, P. E., Rood, P. P. & Schuit, S. C. (2016). Knowledge about systemic inflammatory response syndrome and sepsis: A survey among Dutch emergency department nurses. International Journal of Emergency Medicine, 9, 19 doi:10.1186/s12245-016-0119-2 [CrossRef] PMID:27416936
- Woods, J. M., Scott, H. F., Mullan, P. C., Badolato, G., Sestokas, J., Sarnacki, R., Wolff, M., Lane, R., Dawson, E., Kaplan, R. & Zaveri, P. (2019). Using an elearning module to facilitate sepsis knowledge acquisition across multiple institutions and learner disciplines. Pediatric Emergency Care. Advance online publication. doi:10.1097/PEC.0000000000001902 [CrossRef] PMID:31464879
Final Article Yield Levels of Evidence and Summary
|Study||Johns Hopkins Nursing Evidence-Based Practice Level of Evidence||Summary of Findings|
|Boettiger et al. (2017)||III||Nurses in a women's and children's hospital in an academic medical center completed an electronic survey to determine their perceptions of which physiologic and behavioral indicators were most often associated with neonatal sepsis. Recognition of indicators was not related to level of nursing education but was associated with work experience in the neonatal intensive care unit.|
|Braddock et al. (2015)||II||A combination of interventions for nurses and medical residents were implemented including in situ simulation training. After 1 year, rate of hospital-acquired sepsis decreased, and days between sepsis cases increased. Results from a survey showed increased culture of safety and teamwork within the unit.|
|Davis et al. (2016)||III||Education was provided through PowerPoint® and an interactive elearning package. The package was peer reviewed with positive feedback. The package is available online to the public.|
|Delaney et al. (2015)||II||A selected sample of nurses participated in two multimodal educational sessions including PowerPoints, interactive discussion, videos, and high-fidelity simulation scenarios. Posttests showed a statistically significant increase in scores. Sepsis-specific competence showed a significant improvement.|
|Herron et al. (2019)||II||A combination of teaching methods including simulation were used for residents and nurses. After training, septic patients were identified earlier and sepsis-six bundle compliance increased.|
|Schilinski et al. (2019)||II||Researchers tested the knowledge retention of elearning modules on sepsis. Knowledge increased initially but decreased back to baseline after 1 month. Participants reported that the module did not increase their knowledge, but they did value the education.|
|Stamataki et al. (2014)||III||Nurses from major hospitals in Greece were asked to complete a survey about sepsis knowledge. Demographic data were also collected on educational status and work experience to form comparison groups.|
|van den Hengel et al. (2016)||III||Emergency department nurses participated in a questionnaire about sepsis knowledge. Results were compared to demographic data, education, and work experience. Experience in an intensive care unit or a high-level trauma center was associated with higher scores. Recent sepsis focused education was the main indicator of higher scores.|
|Woods et al. (2019)||III||An elearning module was used to test sepsis knowledge retention. An immediate increase in knowledge was found, as well as some retention after a 3-month delay.|