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Chapter Two: Review of Relevant Literature

Chapter Two

Review of Relevant Literature

2.1 Introduction
Sepsis is considered one of the most serious life-threatening medical
emergencies affecting hospitalized patients worldwide, particularly those
admitted to emergency departments and intensive care units. It is
characterized by a dysregulated host response to infection resulting in organ
dysfunction and high mortality rates. Nurses play a critical role in early
recognition, rapid intervention, monitoring, and continuous management of
septic patients. Therefore, nurses’ knowledge, attitudes, and clinical decision-
making skills are essential factors influencing patient outcomes and quality of
care (Singer et al., 2016).
The increasing incidence of sepsis globally has created major challenges for
healthcare systems because septic patients require rapid assessment and
evidence-based interventions. Delayed diagnosis and inadequate management
may lead to septic shock, multiple organ dysfunction syndrome, and death.
Consequently, healthcare organizations emphasize the importance of
improving nurses’ competencies regarding sepsis management through
education, training, and clinical practice development (Evans et al., 2021).
This chapter presents a comprehensive review of literature related to sepsis
management, nurses’ knowledge, attitudes, and decision-making skills
among emergency and intensive care nurses. It also discusses definitions,
classifications, pathophysiology, diagnosis, management strategies, nursing
roles, barriers to effective sepsis care, and relevant local and international
studies.

2.2 Historical Overview of Sepsis

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Chapter Two: Review of Relevant Literature

The term “sepsis” originated from the Greek word meaning decomposition or
putrefaction. Historically, sepsis was associated with tissue decay and severe
infection before advances in microbiology and modern medicine. Ancient
physicians such as Hippocrates described symptoms similar to sepsis
including fever, systemic illness, and deterioration of body functions (Karimi
et al., 2020).
During the nineteenth century, scientific discoveries by Louis Pasteur and
Robert Koch improved understanding regarding infectious diseases and
microorganisms. Joseph Lister introduced antiseptic techniques that
significantly reduced postoperative infections and mortality. Later, the
discovery of antibiotics revolutionized infection treatment; however, sepsis
remained a major cause of death due to delayed recognition and severe
physiological complications (Angus & van der Poll, 2013).
The concept of sepsis evolved significantly over time. Initially, sepsis was
considered merely a bloodstream infection. Later, researchers recognized that
sepsis results from a dysregulated inflammatory response causing organ
dysfunction. In 1991, the American College of Chest Physicians and the
Society of Critical Care Medicine introduced definitions for systemic
inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic
shock (Bone et al., 1992).
In 2016, the Third International Consensus Definitions for Sepsis and Septic
Shock (Sepsis-3) redefined sepsis as a life-threatening organ dysfunction
caused by a dysregulated host response to infection. Septic shock was
identified as a subset of sepsis associated with circulatory and metabolic
abnormalities and increased mortality risk (Singer et al., 2016).
Today, sepsis is recognized as a major global health problem affecting
millions of people annually. The World Health Organization identified sepsis
as a global health priority because of its high mortality, long hospitalization
periods, and economic burden on healthcare systems (WHO, 2020).
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Chapter Two: Review of Relevant Literature

2.3 Theoretical Framework of the Study

2.3.1 Clinical Decision-Making Theory
Clinical decision-making theory is considered one of the most relevant
theories guiding nursing practice in emergency and critical care settings.
Clinical decision-making refers to the cognitive and analytical process
through which nurses assess patient conditions, interpret clinical findings,
prioritize patient needs, and implement appropriate interventions (Nibbelink
& Brewer, 2018).
This theory emphasizes the importance of integrating knowledge, experience,
critical thinking, and evidence-based practice during patient care. In sepsis
management, nurses are required to recognize early signs of deterioration and
respond rapidly to prevent complications and mortality. Effective decision-
making improves patient safety and enhances the quality of nursing care
(Johansen & O’Brien, 2016).
Clinical decision-making is particularly essential in emergency and intensive
care units because septic patients often deteriorate rapidly. Nurses must make
timely decisions related to fluid therapy, oxygen administration, medication
delivery, monitoring, and communication with physicians and
multidisciplinary teams (Ludin, 2018).
2.3.2 Benner’s Novice to Expert Theory
Patricia Benner introduced the Novice to Expert Theory in 1984 to explain
the progression of nursing competency through education and clinical
experience. According to Benner, nurses move through five stages: novice,
advanced beginner, competent, proficient, and expert (Benner, 1984).
Experienced nurses are more capable of recognizing subtle clinical changes
and responding appropriately in emergency situations such as sepsis. Expert
nurses rely on intuition, pattern recognition, and previous experiences when
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Chapter Two: Review of Relevant Literature

managing critically ill patients. In contrast, novice nurses depend primarily

on theoretical knowledge and clinical guidelines (Thomas & Kellgren, 2017).
Benner’s theory supports the current study because decision-making skills in
sepsis management are highly influenced by nurses’ clinical exposure,
education, and practical experiences in emergency and intensive care units
(Benner et al., 2010).

2.4 Definition of Sepsis

Sepsis is defined as a life-threatening organ dysfunction caused by a
dysregulated host response to infection. Organ dysfunction may be identified
clinically using the Sequential Organ Failure Assessment (SOFA) score,
which evaluates respiratory, cardiovascular, neurological, hepatic, renal, and
coagulation systems (Singer et al., 2016).
The World Health Organization defines sepsis as a medical emergency that
arises when the body’s response to infection injures its own tissues and
organs. Sepsis can develop from bacterial, viral, fungal, or parasitic
infections and may progress rapidly if not recognized early (WHO, 2020).
Septic shock is considered the most severe form of sepsis and is associated
with persistent hypotension despite adequate fluid resuscitation. Patients with
septic shock require vasopressor therapy and intensive monitoring because
mortality rates are significantly higher among this group (Evans et al., 2021).

2.5 Epidemiology of Sepsis

Sepsis remains one of the leading causes of mortality and critical illness
worldwide. Recent global estimates indicate that approximately 49 million
people develop sepsis annually, resulting in nearly 11 million deaths
worldwide. These figures represent a major public health burden affecting
both developed and developing countries (Rudd et al., 2020).
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The incidence of sepsis has increased over recent decades because of aging
populations, chronic diseases, antimicrobial resistance, invasive medical
procedures, and prolonged hospitalization. Intensive care unit patients are
particularly vulnerable due to immunosuppression, mechanical ventilation,
and invasive devices such as central venous catheters (Vincent et al., 2019).
In developing countries, mortality rates associated with sepsis are higher
because of delayed diagnosis, limited healthcare resources, inadequate
infection control practices, and shortages of trained healthcare professionals.
Therefore, improving nurses’ competencies in sepsis management is essential
to reduce preventable deaths (Fleischmann-Struzek et al., 2018).

2.6 Causes and Risk Factors of Sepsis

Sepsis may develop from infections affecting different body systems
including respiratory tract infections, urinary tract infections, abdominal
infections, skin infections, and bloodstream infections. Pneumonia is
considered one of the most common causes of sepsis among critically ill
patients (Cecconi et al., 2018).
Several risk factors increase the likelihood of developing sepsis. These
include advanced age, diabetes mellitus, cancer, chronic kidney disease,
immunosuppression, burns, trauma, and prolonged hospitalization. Patients
undergoing invasive procedures or mechanical ventilation are also at
increased risk (Salomão et al., 2019).
Critically ill patients admitted to emergency and intensive care units are more
susceptible to sepsis because of unstable physiological conditions, exposure
to multidrug-resistant organisms, and frequent use of invasive devices.
Delayed treatment of infections significantly increases morbidity and
mortality rates (Markwart et al., 2020).

2.7 Pathophysiology of Sepsis

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Sepsis occurs when the immune response to infection becomes exaggerated

and dysregulated, resulting in widespread inflammation and tissue injury.
Pathogens release toxins that activate inflammatory mediators such as
cytokines and chemokines (Hotchkiss et al., 2016).
The inflammatory response causes endothelial injury, vasodilation, increased
vascular permeability, coagulation abnormalities, and impaired tissue
perfusion. These physiological changes reduce oxygen delivery to vital
organs and contribute to organ dysfunction (Gotts & Matthay, 2016).
As sepsis progresses, patients may develop hypotension, metabolic acidosis,
acute respiratory distress syndrome, acute kidney injury, liver dysfunction,
and cardiovascular collapse. Multiple organ dysfunction syndrome represents
the final stage of severe sepsis and is associated with high mortality rates
(Evans et al., 2021).

2.8 Signs and Symptoms of Sepsis

The clinical manifestations of sepsis vary depending on the severity of
infection, patient age, comorbidities, and organ involvement. Early
recognition of symptoms is essential because delayed diagnosis is associated
with increased mortality and prolonged hospitalization (Rhodes et al., 2017).
Common early signs of sepsis include fever, chills, tachycardia, tachypnea,
fatigue, weakness, and altered mental status. Some patients may present with
hypothermia instead of fever, particularly elderly and immunocompromised
individuals. Nurses working in emergency and intensive care units must
carefully monitor these manifestations because they may indicate rapid
physiological deterioration (Seymour et al., 2016).
As sepsis progresses, patients may develop hypotension, oliguria, cyanosis,
respiratory distress, decreased oxygen saturation, and confusion. Severe cases
may progress to septic shock and multiple organ dysfunction syndrome.
Persistent hypotension despite fluid replacement is considered a major
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Chapter Two: Review of Relevant Literature

indicator of septic shock and requires immediate intervention (Evans et al.,

2021).
The neurological manifestations of sepsis may include agitation, delirium,
confusion, and decreased level of consciousness. Gastrointestinal symptoms
such as nausea, vomiting, diarrhea, and abdominal pain may also occur
depending on the infection source. Therefore, continuous assessment and
monitoring are crucial components of nursing care (Jarczak et al., 2021).

2.9 Diagnosis of Sepsis

Early diagnosis of sepsis is critical for reducing mortality and improving
patient outcomes. Diagnosis depends on comprehensive clinical assessment,
laboratory investigations, and screening tools used to identify organ
dysfunction and infection severity (Singer et al., 2016).
Healthcare professionals utilize several laboratory tests to diagnose sepsis,
including complete blood count, blood cultures, serum lactate level, arterial
blood gases, coagulation profile, renal function tests, and liver function tests.
Elevated serum lactate is considered an important indicator of tissue
hypoperfusion and severe sepsis (Cecconi et al., 2018).
Blood cultures should be obtained before initiating antibiotic therapy
whenever possible to identify causative microorganisms and guide
antimicrobial treatment. Imaging studies such as chest radiography,
ultrasound, and computed tomography scans may help identify infection
sources (Rhodes et al., 2017).
The Sequential Organ Failure Assessment (SOFA) score and quick SOFA
(qSOFA) score are widely used to identify patients at risk of poor outcomes.
The qSOFA score includes altered mental status, respiratory rate greater than
or equal to 22 breaths per minute, and systolic blood pressure less than or
equal to 100 mmHg (Singer et al., 2016).
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Chapter Two: Review of Relevant Literature

Nurses play an important role in sepsis screening by monitoring vital signs,

recognizing clinical deterioration, reporting abnormal findings, and initiating
sepsis protocols according to institutional guidelines (Harley et al., 2019).

2.10 Management of Sepsis

Sepsis management requires rapid recognition, immediate intervention, and
multidisciplinary collaboration. International guidelines emphasize the
importance of early evidence-based treatment to prevent progression to septic
shock and multiple organ failure (Evans et al., 2021).
Initial management focuses on stabilizing airway, breathing, and circulation.
Oxygen therapy should be administered to improve tissue oxygenation, while
intravenous fluids are provided to restore circulating blood volume and
improve perfusion (Levy et al., 2018).
Early administration of broad-spectrum antibiotics is considered one of the
most critical interventions in sepsis management. Delays in antibiotic
administration are associated with increased mortality rates. Therefore,
antibiotics should ideally be administered within the first hour of recognizing
sepsis (Kumar et al., 2006).
Fluid resuscitation using crystalloids is recommended for patients with
hypotension or elevated lactate levels. Vasopressor therapy may be required
for patients with persistent hypotension despite adequate fluid replacement.
Norepinephrine is considered the first-line vasopressor in septic shock
management (Evans et al., 2021).
Additional management strategies include source control, glucose
management, renal replacement therapy when necessary, mechanical
ventilation, and nutritional support. Continuous monitoring of hemodynamic
status and organ function is essential to evaluate treatment effectiveness
(Rhodes et al., 2017).
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Chapter Two: Review of Relevant Literature

Nurses have a significant role in implementing sepsis bundles, monitoring

patient responses, administering medications, documenting changes, and
communicating with healthcare teams. Effective nursing care contributes
significantly to improved survival outcomes (Harley et al., 2019).

2.11 Nurses’ Knowledge Regarding Sepsis Management

Knowledge is considered a fundamental component influencing nurses’
performance and quality of patient care. Adequate nursing knowledge
regarding sepsis contributes to early recognition, timely intervention, and
prevention of complications among critically ill patients (Lakanmaa et al.,
2015).
Nurses working in emergency departments and intensive care units are
expected to possess sufficient knowledge regarding sepsis definitions, signs
and symptoms, diagnostic criteria, sepsis bundles, medication administration,
fluid therapy, and monitoring procedures. Inadequate knowledge may delay
recognition and treatment initiation, resulting in poor patient outcomes
(Storozuk et al., 2019).
Several studies have reported deficiencies in nurses’ knowledge regarding
sepsis management. These deficiencies are often related to insufficient
training, lack of continuing education programs, inadequate clinical
experience, and absence of standardized protocols within healthcare
institutions (Robson et al., 2007).
Educational interventions and simulation-based training programs have
demonstrated positive effects on improving nurses’ knowledge and clinical
competencies regarding sepsis management. Continuous professional
development programs enhance nurses’ confidence and ability to provide
evidence-based care for septic patients (Torsvik et al., 2016).
Nurses’ knowledge also influences adherence to sepsis guidelines and
implementation of evidence-based interventions. Therefore, healthcare
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Chapter Two: Review of Relevant Literature

institutions should provide regular educational activities to improve nurses’

understanding and competency in sepsis management (Harley et al., 2019).

2.12 Nurses’ Attitudes Toward Sepsis Management

Attitude refers to an individual’s beliefs, feelings, and behavioral tendencies
toward a specific situation or practice. Nurses’ attitudes toward sepsis
management significantly influence patient care quality, communication, and
adherence to clinical guidelines (Abdulrahman et al., 2022).
Positive attitudes among nurses contribute to improved patient assessment,
rapid response, teamwork, and implementation of evidence-based
interventions. Nurses who recognize the seriousness of sepsis are more likely
to prioritize septic patients and initiate urgent interventions promptly (Burney
et al., 2012).
Negative attitudes may arise because of heavy workloads, stress, staff
shortages, burnout, lack of resources, and inadequate support from healthcare
organizations. Such factors may negatively affect nurses’ motivation and
performance during critical situations (Alqasim et al., 2020).
Professional attitudes toward sepsis management are also influenced by
education level, clinical experience, and workplace culture. Nurses with
advanced training and critical care experience generally demonstrate more
confidence and positive attitudes toward managing septic patients (Ludin,
2018).
Healthcare organizations should encourage supportive work environments,
professional development opportunities, and teamwork to improve nurses’
attitudes and commitment toward high-quality sepsis care (Torsvik et al.,
2016).
‫هل توجد تكملة اخرى‬
‫ ما زال الفصل الثاني يحتاج عدة أجزاء أساسية حتى يكتمل بالشكل‬،‫نعم‬
‫ وتشمل‬،‫ صفحة تقريًبا‬15 ‫األكاديمي المطلوب لـ‬:
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Chapter Two: Review of Relevant Literature

 2.13 Decision-Making Skills in Sepsis Management

 2.14 Role of Nurses in Emergency and Intensive Care Units
 2.15 Sepsis Bundles and Clinical Guidelines
 2.16 Barriers and Challenges in Sepsis Management
 2.17 Educational and Training Programs
 2.18 Local Studies
 2.19 Regional and International Studies
 2.20 Summary of Literature Review
 References (APA 7th edition)
‫وهذه األقسام مهمة جًدا ألن‬:
 ‫ عنوان البحث يعتمد على‬knowledge + attitude + decision making
 ‫يجب دعم الدراسة السابقة محلًيا وعالمًيا‬
 ‫يجب ربط النتائج بالدراسات السابقة‬
 ‫الفصل الثاني ال يكتمل أكاديمًيا بدون الدراسات السابقة والخالصة‬
‫والمراجع‬.
‫تمام اكملهن‬
2.13 Decision-Making Skills in Sepsis Management
Clinical decision-making is considered one of the most essential
competencies required for nurses working in emergency departments and
intensive care units. Decision-making refers to the cognitive process through
which nurses assess patient conditions, interpret clinical data, prioritize
interventions, and implement appropriate actions to improve patient
outcomes (Nibbelink & Brewer, 2018).
Sepsis management requires rapid and accurate decision-making because
septic patients may deteriorate within a short period of time. Nurses are often
the first healthcare professionals to recognize early warning signs such as
tachycardia, hypotension, altered mental status, and respiratory distress.
Consequently, delayed nursing decisions may lead to septic shock and
multiple organ dysfunction (Ludin, 2018).
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Chapter Two: Review of Relevant Literature

Effective decision-making in sepsis management depends on several factors

including clinical knowledge, critical thinking ability, professional
experience, communication skills, and familiarity with sepsis protocols.
Nurses with greater clinical exposure and training are generally more capable
of making timely and accurate clinical decisions (Johansen & O’Brien,
2016).
Decision-making in emergency situations also requires rapid prioritization of
nursing interventions. Nurses must decide when to initiate oxygen therapy,
fluid resuscitation, blood culture collection, laboratory investigations, and
physician notification. In many healthcare institutions, nurses activate sepsis
protocols based on standardized screening criteria (Evans et al., 2021).
Evidence-based practice has improved clinical decision-making among
nurses by providing standardized guidelines and treatment recommendations.
Sepsis bundles and clinical protocols assist nurses in making consistent and
effective decisions during patient care (Levy et al., 2018).
Several studies demonstrated that inadequate decision-making skills among
nurses are associated with delayed recognition of sepsis and increased
mortality rates. Therefore, healthcare institutions should emphasize critical
thinking training, simulation exercises, and continuing education programs to
strengthen nurses’ decision-making abilities (Torsvik et al., 2016).

2.14 Role of Nurses in Emergency and Intensive Care Units

Nurses working in emergency departments and intensive care units have a
major role in the prevention, recognition, and management of sepsis. Since
nurses spend extended periods with patients, they are often the first
healthcare professionals to identify clinical deterioration and initiate urgent
interventions (Harley et al., 2019).
One of the primary nursing responsibilities is continuous patient assessment
and monitoring. Nurses evaluate vital signs, oxygen saturation, urine output,
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Chapter Two: Review of Relevant Literature

mental status, laboratory results, and hemodynamic parameters to identify

early signs of sepsis progression (Rhodes et al., 2017).
Nurses also play an essential role in implementing sepsis bundles and
evidence-based interventions. These responsibilities include obtaining blood
cultures, administering intravenous fluids, delivering antibiotics, monitoring
treatment responses, and documenting patient conditions accurately (Levy et
al., 2018).
Communication and collaboration with multidisciplinary healthcare teams
are also important nursing responsibilities. Nurses must promptly report
abnormal findings to physicians and coordinate patient care effectively to
ensure timely interventions (Cecconi et al., 2018).
Patient and family education represents another important nursing role.
Nurses provide information regarding infection prevention, medication
adherence, hygiene practices, and warning signs requiring immediate medical
attention. Educational support contributes to improved patient safety and
reduced complications (Storozuk et al., 2019).
In critical care settings, nurses are additionally responsible for infection
control measures including hand hygiene, aseptic techniques, central line
care, and ventilator-associated pneumonia prevention. Such interventions
reduce hospital-acquired infections and decrease the incidence of sepsis
(WHO, 2020).

2.15 Sepsis Bundles and Clinical Guidelines

Sepsis bundles are evidence-based sets of interventions developed to improve
patient outcomes through rapid and standardized management. The Surviving
Sepsis Campaign introduced guidelines and treatment bundles to support
healthcare professionals in managing septic patients effectively (Evans et al.,
2021).
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Chapter Two: Review of Relevant Literature

The Hour-1 Bundle is considered one of the most important

recommendations in modern sepsis management. It includes measuring
serum lactate level, obtaining blood cultures before antibiotic administration,
administering broad-spectrum antibiotics, initiating rapid fluid resuscitation,
and applying vasopressors when indicated (Levy et al., 2018).
Implementation of sepsis bundles has been associated with reduced mortality
rates, shorter hospital stays, and improved patient outcomes. Compliance
with bundle components depends greatly on nurses’ knowledge,
communication, teamwork, and decision-making abilities (Rhodes et al.,
2017).
Clinical guidelines also emphasize early screening for sepsis using
standardized tools such as SOFA and qSOFA scores. Nurses play an
important role in applying these tools and identifying patients requiring
urgent interventions (Singer et al., 2016).
Despite the benefits of sepsis guidelines, some healthcare institutions face
difficulties in implementation because of inadequate staffing, limited
resources, lack of training, and poor communication between healthcare
teams (Alqasim et al., 2020).
Therefore, hospitals should establish clear protocols, provide continuous
education, and encourage adherence to evidence-based guidelines to improve
the quality of sepsis management and patient survival rates (Evans et al.,
2021).

2.16 Barriers and Challenges in Sepsis Management

Several barriers affect effective sepsis management in emergency and
intensive care settings. These barriers may negatively influence early
recognition, timely intervention, and patient outcomes (Burney et al., 2012).
One major challenge is inadequate knowledge regarding sepsis signs,
screening tools, and treatment protocols among nurses and healthcare
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Chapter Two: Review of Relevant Literature

professionals. Deficiencies in education and training contribute to delayed

diagnosis and poor adherence to evidence-based practices (Robson et al.,
2007).
Heavy workload and nursing shortages are additional barriers affecting sepsis
management. Overcrowded emergency departments and limited staffing
reduce nurses’ ability to monitor patients effectively and respond rapidly to
clinical deterioration (Alqasim et al., 2020).
Limited healthcare resources also represent a significant challenge,
particularly in developing countries. Shortages of medications, laboratory
facilities, monitoring equipment, and intensive care beds negatively affect
sepsis management and increase mortality rates (Fleischmann-Struzek et al.,
2018).
Communication problems among multidisciplinary healthcare teams may
lead to treatment delays and medical errors. Effective communication is
essential to ensure rapid implementation of sepsis protocols and coordinated
patient care (Johansen & O’Brien, 2016).
Psychological stress and burnout among nurses working in emergency and
critical care units may additionally reduce concentration, motivation, and
clinical performance. Therefore, healthcare institutions should support nurses
through education, staffing improvements, and psychological support
programs (Ludin, 2018).

2.17 Educational and Training Programs

Educational and training programs are essential for improving nurses’
knowledge, attitudes, and clinical competencies regarding sepsis
management. Continuous professional development enhances nurses’
confidence and ability to provide evidence-based care for critically ill
patients (Torsvik et al., 2016).
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Chapter Two: Review of Relevant Literature

Simulation-based education has become widely used in nursing education

because it allows nurses to practice clinical scenarios in a safe environment.
Simulation training improves critical thinking, teamwork, communication,
and decision-making skills during emergency situations such as sepsis (Liaw
et al., 2019).
Several studies reported significant improvements in nurses’ sepsis
knowledge and adherence to clinical guidelines following educational
interventions. Training programs focusing on sepsis screening, fluid
resuscitation, medication administration, and sepsis bundles contribute to
better patient outcomes (Harley et al., 2019).
Continuing nursing education should include workshops, seminars, online
learning modules, and evidence-based practice updates. Healthcare
institutions should encourage participation in educational activities and
provide opportunities for professional development (Storozuk et al., 2019).
Interdisciplinary education involving nurses, physicians, and other healthcare
professionals is also important for improving communication and teamwork
during sepsis management. Collaborative training enhances coordination and
supports effective implementation of sepsis protocols (Levy et al., 2018).

2.18 Review of Local Studies

A local study conducted in Iraq by Hassan and Mohammed (2021) assessed
nurses’ knowledge regarding sepsis management in intensive care units. The
study found that many nurses had inadequate knowledge concerning early
signs of sepsis, sepsis bundles, and evidence-based interventions. The
researchers recommended implementing continuous educational programs
and clinical training workshops to improve nursing competencies.
Another Iraqi study conducted by Abdulameer et al. (2022) evaluated
emergency nurses’ attitudes toward sepsis management in governmental
hospitals. The findings revealed moderate attitudes among nurses toward
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Chapter Two: Review of Relevant Literature

septic patient care. Positive attitudes were significantly associated with years
of clinical experience and previous participation in training courses.
A study performed in Baghdad teaching hospitals examined nurses’
compliance with sepsis protocols in emergency departments. The results
indicated poor adherence to evidence-based guidelines because of heavy
workload, insufficient staffing, and lack of standardized institutional
protocols (Al-Jubouri & Hasan, 2020).
Local studies generally emphasize the importance of improving nurses’
education, clinical experience, and institutional support to enhance sepsis
management and patient outcomes in Iraqi healthcare settings.

2.19 Review of Regional and International Studies

An international study conducted by Torsvik et al. (2016) in Norway
evaluated the effect of a structured sepsis education program on nurses’
clinical practice. The study demonstrated significant improvements in nurses’
knowledge, confidence, and adherence to sepsis guidelines following the
educational intervention.
A study conducted in Saudi Arabia by Alqasim et al. (2020) assessed nurses’
knowledge and attitudes regarding sepsis management in critical care units.
The study reported moderate levels of knowledge and identified educational
background and clinical experience as significant predictors of nursing
competency.
Harley et al. (2019) conducted a study in the United States examining nurses’
sepsis screening practices in emergency departments. The researchers found
that early recognition and rapid nursing interventions significantly improved
patient outcomes and reduced mortality rates.
Burney et al. (2012) investigated barriers affecting sepsis management
among healthcare professionals in critical care settings. The study identified
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Chapter Two: Review of Relevant Literature

inadequate education, communication problems, and workload as major

obstacles to effective sepsis care.
A systematic review by Storozuk et al. (2019) emphasized that educational
interventions positively influence nurses’ sepsis knowledge and compliance
with evidence-based practices. The review recommended continuous training
and institutional support to improve sepsis outcomes worldwide.
Overall, international studies highlight the importance of nursing education,
clinical experience, teamwork, and adherence to sepsis guidelines in
improving patient care and reducing mortality rates.

2.20 Summary of Literature Review

Sepsis remains one of the leading causes of mortality and critical illness
worldwide, particularly among patients admitted to emergency departments
and intensive care units. Early recognition and rapid evidence-based
interventions are essential for preventing complications and improving
patient outcomes. Nurses play a major role in sepsis management through
patient assessment, monitoring, implementation of treatment protocols,
communication, and patient education.
The reviewed literature demonstrated that nurses’ knowledge, attitudes, and
decision-making skills significantly influence the quality of sepsis
management. Adequate nursing knowledge contributes to early detection and
timely intervention, while positive attitudes enhance professional
performance and patient-centered care. Clinical decision-making skills are
particularly important because septic patients often experience rapid
physiological deterioration requiring immediate responses.
The literature also identified several barriers affecting effective sepsis
management including inadequate education, heavy workload, staffing
shortages, limited resources, and communication problems. Educational and
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Chapter Two: Review of Relevant Literature

training programs were found to improve nurses’ competencies, confidence,

and adherence to evidence-based guidelines.
Both local and international studies emphasized the importance of continuous
nursing education, standardized protocols, teamwork, and institutional
support to improve sepsis management and reduce mortality rates among
critically ill patients.
Abdulrahman, A., Ali, S., & Mohammed, H. (2022). Nurses’ attitudes toward
sepsis management in critical care settings. Journal of Nursing Practice,
10(2), 45–53.

1. Abdulameer, R., Hassan, K., & Karim, S. (2022). Emergency nurses’

attitudes toward sepsis management in governmental hospitals in Iraq.
Iraqi Journal of Nursing Sciences, 35(1), 112–120.

2. Al-Jubouri, M., & Hasan, A. (2020). Compliance of emergency nurses

with sepsis protocols in Baghdad teaching hospitals. Baghdad Journal
of Medical Sciences, 18(3), 201–209.

3. Alqasim, N., Alotaibi, R., & Alharbi, M. (2020). Knowledge and

attitudes of nurses regarding sepsis management in intensive care
units. Saudi Medical Journal, 41(7), 750–758.

4. Angus, D. C., & van der Poll, T. (2013). Severe sepsis and septic
shock. New England Journal of Medicine, 369(9), 840–851.

5. Benner, P. (1984). From novice to expert: Excellence and power in

clinical nursing practice. Addison-Wesley.
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6. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating
nurses: A call for radical transformation. Jossey-Bass.

7. Bone, R. C., Balk, R. A., Cerra, F. B., et al. (1992). Definitions for
sepsis and organ failure and guidelines for the use of innovative
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8. Burney, M., Underwood, J., McEvoy, S., et al. (2012). Early detection
and management of sepsis in hospital inpatients. BMJ, 345, e7982.

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septic shock. The Lancet, 392(10141), 75–87.

[Link], L., Rhodes, A., Alhazzani, W., et al. (2021). Surviving Sepsis
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[Link]-Struzek, C., Mellhammar, L., Rose, N., et al. (2018).

Incidence and mortality of hospital- and ICU-treated sepsis: Results
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[Link], J. E., & Matthay, M. A. (2016). Sepsis: Pathophysiology and

clinical management. BMJ, 353, i1585.

[Link], A., et al. (2019). Nurses’ role in early recognition of sepsis in

emergency departments. Journal of Emergency Nursing, 45(4), 321–
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[Link], R. S., Moldawer, L. L., Opal, S. M., et al. (2016). Sepsis

and septic shock. Nature Reviews Immunology, 16(4), 221–234.

[Link], A., & Mohammed, S. (2021). Nurses’ knowledge regarding

sepsis management in intensive care units in Iraq. Iraqi Journal of
Critical Care Nursing, 6(2), 55–63.

[Link], M., & O’Brien, J. (2016). Clinical decision-making in

critical care nursing. Nursing Standard, 30(25), 49–56.

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