Received: 14 April 2022 | Revised: 26 July 2022 | Accepted: 20 August 2022

DOI: 10.1111/jan.15435

ORIGINAL RESEARCH: EMPIRICAL

R E S E A R C H - ­ Q U A N T I TAT I V E

Nurses' knowledge and confidence in recognizing and

managing patients with sepsis: A multi-­site cross-­sectional
study

Wei Ling Chua1 | Chin Shim Teh2 | Muhammad Amin Bin Ahmad Basri3 |
Shi Ting Ong4 | Noel Qiao Qi Phang3 | Ee Ling Goh5

1
Alice Lee Centre for Nursing Studies,
Yong Loo Lin School of Medicine, National Abstract
University of Singapore, Singapore City,
Aims: (1) To examine registered nurses' knowledge and confidence in recognizing and
Singapore
2
Nursing Department, Alexandra Hospital,
managing to patients with sepsis and (2) identify nurse and workplace factors that
National University Health System, influence their knowledge on sepsis.
Singapore City, Singapore
3
Design: A multi-­site, cross-­sectional survey.
Nursing Department, Ng Teng Fong
General Hospital, National University Methods: An online survey was developed and content validated. Data was collected
Health System, Singapore City, Singapore from registered nurses working in the inpatient wards and emergency departments
4
Nursing Department, National University
of three hospitals of a single healthcare cluster in Singapore during August 2021.
Hospital, National University Health
System, Singapore City, Singapore Statistical analyses of closed-­ended responses and content analysis of open-­ended
5
Department of Emergency Medicine, responses were undertaken.
Ng Teng Fong General Hospital, National
University Health System, Singapore City, Results: A total of 709 nurses completed the survey. Nurses possessed moderate
Singapore levels of knowledge about sepsis (mean score = 10.56/15; SD = 2.01) and confi-
Correspondence dence in recognizing and responding to patients with sepsis (mean score = 18.46/25;
Wei Ling Chua, Alice Lee Centre for SD = 2.79). However, only 369 (52.0%) could correctly define sepsis. Nurses' job
Nursing Studies, Yong Loo Lin School
of Medicine, National University of grade, nursing education level and clinical work area were significant predictors of
Singapore, Singapore City, Singapore. nurses' sepsis knowledge. Specifically, nurses with higher job grade, higher nursing
Email: chuaweiling@[Link]
education level or those working in acute care areas (i.e. emergency department,
Funding information high dependency units or intensive care units) were more likely to obtain higher total
Lee Foundation Research Fellow Start Up
Grant sepsis knowledge scores. A weak positive correlation was observed between sepsis
knowledge test scores and self-­confidence (r = .184). Open comments revealed that
participants desired for more sepsis education and training opportunities and the im-
plementation of sepsis screening tool and sepsis care protocol.
Conclusion: A stronger foundation in sepsis education and training programs and the
implementation of sepsis screening tools and care bundles are needed to enhance
nurses' knowledge and confidence in recognizing and managing patients with sepsis.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.

616 | 
[Link]/journal/jan J Adv Nurs. 2023;79:616–629.
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CHUA et al. 617

Impact: The findings of this study are beneficial to administrators, educators and re-
searchers in designing interventions to support nurses in their role in recognizing and
responding to sepsis.

KEYWORDS
acute care, confidence, education, knowledge, management, nursing, recognition, registered
nurse, sepsis, survey

1 | I NTRO D U C TI O N can result in multiorgan system failure and ultimately death (Singer
et al., 2016). The International Surviving Sepsis Campaign (SSC), led
Sepsis, a clinical syndrome of dysregulated host response to infec- by the Society of Critical Care Medicine and the European Society of
tion leading to life-­threatening organ dysfunction, is a leading cause Intensive Care Medicine, has provided evidence-­based recommen-
of global morbidity and mortality (Singer et al., 2016). It is a major dations for clinicians to improve sepsis care (Dellinger et al., 2004).
challenge for healthcare systems worldwide because it leads to sig- Increased adherence to sepsis guideline bundles has led to bet-
nificant consumption of healthcare resources (Rudd et al., 2018). ter outcomes with reduced need for ICU admission, shorter hos-
Sepsis imposes a large economic burden; for example, the annual pital length of stay and lower mortality (Levy et al., 2015; Milano
cost on hospital care for patients with sepsis in the United States is et al., 2018). Compelling evidence has shown that delay in execut-
estimated at more than US$24 billion (Paoli et al., 2018). In addition, ing each intervention and completing the bundle was associated
each year, there are approximately 14 million sepsis survivors who with higher mortality (Pruinelli et al., 2018; Seymour et al., 2017).
have an increased risk of recurrent infections and hospital readmis- Nevertheless, it is noteworthy that management of sepsis can only
sions, and this comes with grave physical and financial consequences commence after appropriate assessment and diagnosis have been
(Prescott & Angus, 2018). At present, the estimated burden of sep- made. Yet, identifying patients, especially in the earlier stages of
sis is reported to be 48.9 million cases worldwide and 11 million of sepsis continuum, poses a significant challenge due to its highly
sepsis-­related deaths, suggesting a 20% mortality rate for sepsis variable and non-­specific clinical manifestations (Vincent, 2016). As
(Rudd et al., 2020). In Singapore alone—­a high income country with such, the need to recognize sepsis accurately and quickly has led to
5.6 million population, close to 5000 deaths were attributed to sep- development of sepsis screening tools which is an important element
sis from pneumonia and urinary tract infection in 2019 (Singapore of sepsis performance improvement programs (Evans et al., 2021).
Ministry of Health, 2020). This was an approximate 13% increment In the healthcare system, nurses play a pivotal role in identifying
from those reported in 2012 (Singapore Ministry of Health, 2020). patients with sepsis and promptly escalate care for commencing di-
Incidence of sepsis will continue to rise with interplay of multiple agnostic work and initiating treatment (See, 2022). In the emergency
factors including aging population with more predisposing comor- department (ED), triage nurses are often the first point of contact
bidities, use of immunosuppressive therapy, and emergence of for assessing patients with community-­acquired sepsis. In the ward
multi-­drug antimicrobial resistance (Rhee & Klompas, 2020). The settings, nurses are in a privileged position to identify hospital-­onset
considerable impact of sepsis highlights the importance of raising sepsis at its earliest possible time because they spend the most con-
awareness to promote early recognition and treatment. Nurses play tact hours doing routine bedside monitoring of patients. Nurse-­led
a pivotal role in the early recognition and management of sepsis be- sepsis screening interventions have demonstrated positive impact
cause they are uniquely positioned to make the first crucial assess- on reducing mortality and improving process measures of sepsis care
ment in detecting sepsis and implementing timely intervention to bundles (McDonald et al., 2018; Torsvik et al., 2016). It is therefore
prevent clinical deterioration. crucial that nurses understand the importance of their role in sepsis
recognition, are trained to identify possible sepsis and have the self-­
confidence to respond and intervene with appropriate actions.
1.1 | Background Internationally, there are several papers that published on
nurses' level of knowledge on sepsis (Nucera et al., 2018; Rahman
Sepsis is recognized as a global health priority by the World Health et al., 2019; Stamataki et al., 2014; Storozuk et al., 2019; van den
Organization (WHO) which has adopted a resolution on improv- Hengel et al., 2016). The findings were consistent and revealed knowl-
ing the prevention, diagnosis and management of sepsis (Reinhart edge deficits on systemic inflammatory response syndrome, signs and
et al., 2017). As a time-­critical medical emergency that is treat- symptoms of sepsis, and its initial management. However, these stud-
able and preventable, early recognition of sepsis with expeditious ies often asked lower order questions that relied on participants' fac-
interventions is paramount in reducing the progression of sepsis tual recall of sepsis knowledge instead of higher order application and
and improving patient outcomes (See, 2022). Delays in sepsis rec- analytical questions that simulate real sepsis scenarios. Furthermore,
ognition and treatment could lead to septic shock, a condition that it is important to note that the questions asked in a few of the earlier
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618 CHUA et al.

studies were no longer in line with the updated sepsis-­3 definitions and integrated general hospital that provides holistic and seamless care
management guidelines (Nucera et al., 2018; Stamataki et al., 2014; from acute, subacute to rehabilitative settings, catering to the needs
van den Hengel et al., 2016). With improved research leading to better of residents living in the oldest housing estate in Singapore and
understanding of sepsis pathophysiology, the Sepsis Task Force pub- Southwest of Singapore. The hospital has a 24-­h urgent care centre
lished The Third International Consensus Definitions for Sepsis and Septic (UCC) that provides immediate medical attention to walk-­in patients
Shock (Sepsis-­3) was published in 2016 (Singer et al., 2016). Sepsis-­3 and patients conveyed via private ambulance with acute and urgent
encompasses organ dysfunction resulting from the patient's response medical conditions. Hospital B is a 700-­bed acute hospital offering
to an infection (Singer et al., 2016). This was significantly different from a range of comprehensive medical services, except obstetrics and
Sepsis-­2, which emphasized on the presence of two or more systemic gynaecology, paediatrics and transplant medicine. Hospital C is a
inflammatory response syndrome criteria with a concomitant infection 1200-­bed university-­affiliated tertiary referral hospital with more
to define sepsis. With the new definitions of sepsis, the SSC recom- than 50 medical, surgical and dental specialties, offering a compre-
mended the initiation of a set of sepsis care bundle upon recognition hensive range of specialist care for adults, women and children. At
of sepsis, which includes obtaining blood cultures followed by admin- the point of study, none of the hospitals had a hospital sepsis proto-
istration of antimicrobials, measuring lactate levels, initiating at least col or care bundle in place. Except for the ED of Hospital B, the rest
30 ml/kg intravenous crystalloids in sepsis-­induced hypoperfusion or of the study sites and clinical areas do not have a sepsis screening
septic shock and starting vasopressors to maintain mean arterial pres- tool in place. The ED of Hospital B adopts the national early warning
sure ≥ 65 mmHg during or after fluid resuscitation (Evans et al., 2021). score 2 (NEWS2), which predicts risk of clinical deterioration and
In addition to sepsis knowledge, nurses' level of self-­confidence—­ in-­hospital mortality based on a patient's physiological parameters
one's beliefs about their capability and skills—­has been identified as (Royal College of Physicians, 2017). A cut-­off point of NEWS2 ≥ 5
an important factor contributing to the recognition, escalation and serves as a trigger to alert clinicians to attend to these patients im-
management of paediatric sepsis (Harley, Schlapbach, et al., 2021). mediately and initiate evaluation for possible sepsis.
However, research on nurses' self-­confidence in recognizing and man- In Singapore, the basic preparatory education for RNs can be
aging adult sepsis is lacking. Thus, the interest in undertaking this study attained through either a 3-­year nursing diploma programme or a
arose with the intent to assess if nurses are in keeping with the sepsis-­3 3-­year nursing bachelor's degree programme (Chua et al., 2019).
definitions and guidelines using applied knowledge test and to examine Following the basic nursing preparatory education, RNs can choose
their confidence levels in recognizing and managing sepsis. The find- to acquire further in-­depth speciality-­specific skills and knowledge
ings from this study will help identify gaps in nurses' knowledge and through advanced diplomas, graduate diplomas and post-­graduation
competencies, thereby providing insights into developing future sepsis education (Woo et al., 2020). A convenience sample of RNs, includ-
education and practice interventions to improve clinical outcomes. ing advanced practice nurses (APNs), involved in the clinical care of
patients in inpatient wards, including intensive care units (ICUs) and
high dependency units (HDUs), ED or UCC of the three hospitals was
2 | TH E S T U DY recruited for the study. RNs who were working in the paediatrics
settings, operating theatres or ambulatory surgery and outpatient
2.1 | Aims clinics were excluded from the study.

This study aimed to explore registered nurses' (RN) knowledge and

confidence in recognizing and managing patients with sepsis. The 2.4 | Data collection
specific objectives were to: (1) examine RNs' knowledge of sepsis
and level of self-­confidence in recognizing and managing patients Data collection was conducted over a one-­month period starting in
with sepsis and (2) identify nurse and workplace factors that influ- early August 2021. Participants were recruited through a three-­step
ence their knowledge on sepsis. process: (1) An email invitation to the study, comprising a letter to
invite all RNs to participate, an electronic recruitment poster, the
survey's hyperlink and a quick response (QR) code to access the sur-
2.2 | Design vey, was first sent to the nursing leaders overseeing nursing research
activities of the three hospitals. (2) The nursing leaders dissemi-
A multi-­site, cross-­sectional design using an anonymous online sur- nated the study invitation to the nursing officers (i.e. nurse manag-
vey was conducted. ers and nurse clinicians) and APNs of their respective hospitals. (3)
Subsequently, the nursing officers of inpatient settings and ED/UCC
circulated the study information face-­to-­face during roll calls and
2.3 | Participants and setting virtually via announcement portals to the ground nurses. The hard-
copy recruitment poster was also pinned on the wards' noticeboard.
This study was conducted in three hospitals of one public healthcare To gather a higher response rate, the email invitation to the nursing
cluster in the western region of Singapore. Hospital A is a 326-­bed leaders was re-­sent at 2 and 4 weeks after the first email and 3 days
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CHUA et al. 619

prior to closure of data collection. Participants were compensated work area, education level, sepsis education and training in the last
S$5 (≈US$3.55) as remuneration for the time and effort they have 1 year, and presence of sepsis screening tool) found to be statistically
provided in participating in the research. significant at p ≤ .1 in the univariate linear regression analyses were
The online survey was collected using Qualtrics and piloted to used as independent variables in the subsequent multiple linear re-
ensure user friendliness, ease of electronic interface and effective gression analysis.
response collection. The survey was developed by the study team Pearson product–­moment correlation coefficients were calcu-
and designed to evaluate RNs' knowledge about sepsis and their per- lated to examine the association between sepsis knowledge and
ceived confidence in recognizing and managing patients with sep- level of self-­confidence. Chi-­square test was used to compare the
sis. The survey instrument comprised four sections (Supplementary item-­level responses in their level of self-­confidence towards recog-
file 1). Section one, consisting of 10 items, gathered demographic and nizing and managing patients with sepsis grouped according to the
workplace data. Section two consisted of five items, which asked the presence of sepsis screening tool and clinical work area. In all other
participants to rate their perceived confidence in recognizing and analyses, the level of statistical significance was set at .05.
managing patients with sepsis, on a 5-­point Likert scale. The total A content analysis of the open-­ended responses collected in
confidence scores ranged from 1 to 25, with higher scores indicating Section four of the survey was conducted. Line-­by-­line open coding
higher confidence in caring for patients with sepsis. Section three of the short free-­texts was performed. Codes with similar meanings
assessed RNs' knowledge about sepsis. It comprised 15 multiple were grouped into the same categories and related categories were
choice questions (MCQs), of which four questions were on general clustered into themes (Graneheim & Lundman, 2004). Regular dis-
knowledge of sepsis and 11 questions were scenario based MCQs. cussions were held among the authors to finalize the themes derived
There were three short case scenarios (diabetic foot sepsis, uro- from the content analysis process.
sepsis and catheter-­related sepsis) and the questions covered four
domains: early clinical manifestations of sepsis, sepsis laboratory
investigations, patient monitoring and management of sepsis. The 2.7 | Validity, reliability and rigour
last section has an open-­ended component to allow participants to
provide free texts to comment on organizational support to improve The survey instrument was assessed for content and face valid-
nurses' roles in early recognition and management of patients with ity by a panel of seven content experts, who were APNs, a nurs-
sepsis. ing academic, and an intensive care specialist. Each content expert
was asked to independently rate the relevance of each item using
a 4-­point Likert scale (1 = not relevant to 4 = very relevant) and
2.5 | Ethical considerations was also asked to provide comments. The item-­level content validity
index of the confidence scale and sepsis knowledge MCQs ranged
Ethical approval was obtained from the National Healthcare Group between 0.86 and 1.00, with a scale-­level content validity index of
Domain Specific Review Board (Ref No.: 2020/01480). Participation 1.00. Based on the results of the content validation assessments and
in the survey occurred on a voluntary basis and the completion and comments from the content experts, minor revisions were made for
submission of the online survey implied the participant's consent. the final version of the survey. The international consistency of the
No personal identifiable data was collected. Confidentiality and confidence scale estimated by Cronbach's alpha was .870.
anonymity about the survey responses were assured for all the
participants.
3 | R E S U LT S

2.6 | Data analysis 3.1 | Nurse and workplace characteristics

For all statistical analyses, the IBM SPSS Statistics for Windows A total of 709 RNs (response rate: 23.1%) across the three study sites
Version 26.0 was used (IBM Corp., 2019). Descriptive statistics completed the questionnaire. The demographic characteristics and
(mean and standard deviations (SD), medians and interquartile ranges workplace data of the participants are presented in Table 1. Over
(IQR), proportions and percentages) were computed to summarize 80% of the participants held the job grade of staff nurse and senior
the participants' demographic characteristics, workplace data, sep- staff nurse, and close to one-­third (n = 217, 30.6%) had between
sis knowledge scores and self-­confidence scores. Independent sam- 6 and 10 years of nursing experience. Almost one-­fifth (n = 136,
ple t-­test and one-­way analysis of variance (ANOVA) with Bonferroni 18.1%) of the respondents had attained a specialization within their
correction were used to examine the differences in nurses' total field of practice. Twenty-­five of the 29 participants with a master's
sepsis knowledge and total self-­confidence scores among the vari- degree had attained master's degree in nursing and were either APN
ous categorical demographic and workplace subgroups. To explore or APN interns.
the factors influencing nurses' sepsis knowledge (dependent vari- For workplace data, most participants worked in the general
able), the variables (years of nursing experience, job grade, clinical ward settings (n = 380, 53.6%). Ninety-­six respondents (13.5%)
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620 CHUA et al.

TA B L E 1 Demographics and workplace characteristics of participants (n = 709)

Total, n (%) Hospital A, n (%) Hospital B, n (%) Hospital C, n (%)

Characteristics n = 709 (100%) n = 130 (18.3%) n = 252 (35.6%) n = 327 (46.1%)

Age
25 and below 131 (18.5) 21 (16.2) 46 (18.3) 64 (19.6)
26–­3 0 228 (32.2) 38 (29.2) 98 (38.9) 92 (28.1)
31–­35 186 (26.2) 26 (20.0) 69 (27.4) 91 (27.8)
36–­4 0 79 (11.1) 16 (12.3) 19 (7.5) 44 (13.5)
41 and above 85 (12.0) 29 (22.3) 20 (7.9) 36 (11.0)
Job grade
Staff nurse 311 (43.9) 57 (43.8) 126 (50.0) 128 (39.1)
Senior staff nurse 284 (40.1) 45 (34.6) 105 (41.7) 134 (41.0)
Assistant nurse clinician 48 (6.8) 9 (6.9) 7 (2.8) 32 (9.8)
Nursing officer 66 (9.3) 19 (14.6) 14 (5.6) 33 (10.1)
APN or APN Intern 25 (3.5) 3 (2.3) 7 (2.8) 15 (4.6)
Years of nursing practice
Less than 1 year 38 (5.4) 10 (7.7) 12 (4.8) 16 (4.9)
1–­2 years 92 (13.0) 13 (10.0) 31 (12.3) 48 (14.7)
3–­5 years 156 (22.0) 32 (24.6) 61 (24.2) 63 (19.3)
6–­10 years 217 (30.6) 26 (20.0) 94 (37.3) 97 (29.7)
More than 10 years 206 (29.1) 49 (37.7) 54 (21.4) 103 (31.5)
Nursing education level
Diploma in nursing/ 333 (47.0) 50 (38.5) 155 (61.5) 128 (39.1)
Basic nursing training
certification
Advanced/graduate/specialist 136 (18.1) 17 (13.1) 61 (24.2) 47 (14.4)
diploma in nursing
Bachelor of Nursing 473 (66.7) 103 (79.2) 133 (52.8) 237 (72.5)
Master's degree 29 (4.1)a 4 (3.1) 7 (2.78) 18 (5.5)
Area of practice
ED/UCC 155 (21.9) 29 (22.3) 67 (26.6) 59 (18.0)
ICU/HDU 174 (25.4) 16 (12.3) 56 (22.2) 102 (31.2)
General ward 380 (53.6) 85 (65.4) 129 (51.2) 166 (50.8)
Received sepsis education/ 96 (13.5) 11 (8.5) 38 (15.1) 47 (14.4)
training in the last 1 year
Sepsis screening tool in area of practiceb
Yes 100 (14.1) 15 (11.5) 65 (25.8) 20 (6.1)
No 280 (39.5) 53 (40.8) 68 (27.0) 159 (48.6)
Unsure 329 (46.4) 62 (47.7) 119 (47.2) 148 (45.3)

Abbreviations: APN, advanced practice nurse; ED, emergency department; HDU, high dependency unit; ICU, intensive care unit; UCC, urgent care
centre.
a
25 attained Master's degree in nursing.
b
Only ED of Hospital B has sepsis screening tool.

attended sepsis education or training in the last 1 year from the time 3.2 | Nurses' sepsis knowledge
of data collection. One hundred participants indicated the presence
of sepsis screening tool in their area of practice. However, only the The total sepsis knowledge score ranged from 3 to 15, with a mean
ED of study Hospital B has implemented a sepsis screening tool. Yet, score of 10.56 ± 2.01 out of a maximum score of 15. The greatest
only 50 (74.6%) out of the 67 participants were aware of the pres- proportion of participants (n = 135, 19.0%) answered 12 questions
ence of a sepsis screening tool, while 14 were unsure and three were correctly and only 6 participants (0.8%) correctly answered all the
oblivious to it.
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CHUA et al. 621

questions in the sepsis knowledge test. Table 2 summarizes the par- 8.3% (n = 59) could identify high respiratory rate as an early clinical
ticipants' sepsis knowledge performance at item level. manifestation of sepsis.
The correct responses for the four questions related to general As presented in Table 2, chi-­squared tests showed that nurses
knowledge of sepsis ranged between 52.0% (definition of sepsis) working in acute care areas such as ED/UCC and ICU/HDU had
and 91.0% (risk factors of sepsis). Most selected “bacteria in blood” greater knowledge than general ward nurses in questions related
(n = 167, 23.6%) and “infection” (n = 140, 19.7%) as the definition to the immediate management of sepsis and septic shock. Nurses
of sepsis. About half responded incorrectly to the question on the working in the ICU/HDU were shown to fare significantly better in
cause of sepsis (n = 378, 53.3%) and close to one-­third responded their assessment and evaluation of septic shock treatment (Q15)
incorrectly to the question about epidemiological data of sepsis compared to nurses working in ED/UCC and general wards.
(n = 246, 34.7%).
In the short case scenarios section, the four questions (Q9, Q10,
Q13 and Q14) that addressed the treatment of sepsis were an- 3.3 | Differences in sepsis knowledge among
swered correctly by between 66.0% (Q13. vasopressors therapy for different groups of nurses
septic-­shock induced hypotension) and 91.1% (Q14. blood culture
prior to starting intravenous antibiotics) of the participants. On the The total sepsis knowledge scores by nurses' and workplace charac-
questions related to sepsis laboratory investigations, close to two-­ teristics are presented in Table 3. Significant differences in nurses'
thirds correctly identified blood culture as the most essential septic sepsis knowledge scores were observed between nurses of dif-
workup (n = 456, 64.3%) and about half of the participants were ferent years of nursing experience, clinical work area, nursing job
able to identify serum lactate level of 4.0 mmol/L as a concern for grade and education level. Nurses with more than 10 years of nurs-
patients with sepsis (n = 376, 53.0%). However, of concern, only ing experience scored significantly higher in sepsis knowledge test

TA B L E 2 Nurses' sepsis knowledge item-­level performance, based on numbers of correct answers (n = 709)

Overall ED/UCC ICU/HDU General ward

Items/Topic n (%) n (%) n (%) n (%) χ2 p-­value

General sepsis knowledge

Q1. Definition of sepsis 369 (52.0) 84 (54.2) 108 (62.1) 177 (46.6) 11.84 .003
Q2. Risk factors of sepsis 645 (91.0) 135 (87.1) 162 (93.1) 348 (91.6) 3.97 .138
Q3. Cause of sepsis 378 (53.3) 77 (49.7) 107 (61.5) 194 (51.1) 6.28 .043
Q4. Epidemiological data of sepsis 463 (65.3) 120 (77.4) 110 (63.2) 233 (61.2) 13.04 .001
Case scenario 1
Q5. Predisposing factor of sepsis 669 (94.4) 142 (91.6) 168 (96.6) 359 (94.5) 3.78 .151
Q6. Early manifestation of sepsis 59 (8.3) 26 (16.8) 8 (4.6) 59 (8.3) 19.19 <.001
Q7. Blood culture as most essential 456 (64.3) 105 (67.7) 91 (52.3) 456 (64.3) 14.53 .001
septic workup
Q8. Serum lactate as a biomarker of 376 (53.0) 105 (67.7) 104 (59.8) 167 (43.9) 29.23 <.001
sepsis
Case scenario 2
Q9. Prioritized immediate management 556 (78.4) 139 (89.7) 134 (77.0) 283 (74.5) 15.31 <.001
of sepsis
Q10. Antibiotics administration as key 591 (83.4) 130 (83.9) 151 (86.8) 591 (83.4) 2.37 .306
to improve sepsis clinical outcome
Q11. Monitoring of patient with sepsis 587 (82.8) 136 (87.7) 144 (82.8) 307 (80.8) 3.74 .154
Case scenario 3
Q12. Source of infection leading to 675 (95.2) 146 (94.2) 169 (97.1) 360 (94.7) 1.94 .380
sepsis
Q13. Vasopressors therapy for septic-­ 468 (66.0) 117 (75.5) 130 (74.7) 221 (58.2) 22.52 <.001
shock induced hypotension
Q14. Blood culture prior to starting 646 (91.1) 137 (88.4) 167 (96.0) 342 (90.0) 7.09 .029
intravenous antibiotics
Q15. Assessment and evaluation of 549 (77.4) 111 (71.6) 158 (90.8) 280 (73.7) 23.87 <.001
septic shock treatment

Abbreviation: ED, emergency department; HDU, high dependency unit; ICU, intensive care unit; UCC, urgent care centre.
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622 CHUA et al.

TA B L E 3 Differences in sepsis knowledge and self-­reported confidence scores among different group of RNs (n = 709)

Total sepsis knowledge score Total self-­confidence score

Variables n Mean (SD) Mean (SD)

Years of nursing experiencea

2 years and below 130 10.02 (2.00) 16.96 (2.89)
3–­5 years 156 10.21 (1.96) 18.27 (2.61)
6–­10 years 217 10.73 (1.85) 18.76 (2.75)
More than 10 years 206 10.99 (2.10) 19.23 (2.51)
c
F-­value (p-­value) 8.630 (<0.001 ) 19.041 (<0.001d)
Job gradea
Staff nurse 311 9.95 (2.02) 17.71 (2.91)
Senior staff nurse 284 10.88 (1.79) 18.87 (2.62)
Assistant nurse clinician/nursing officer 114 18.87 (2.62) 19.49 (2.27)
F-­value (p-­value) 31.291 (<0.001e) 23.656 (<0.001f )
Area of practicea
ED/UCC 155 11.03 (1.94) 18.52 (2.69)
ICU/HDU 174 10.98 (1.71) 18.83 (2.65)
General Ward 380 10.17 (2.09) 18.27 (2.79)
F-­value (p-­value) 15.787 (<0.001g) 2.488 (0.084)
Nursing education levela
Group I: Without any nursing 557 10.32 (1.95) 18.22 (2.75)
specialization
Group II: With nursing advanced/ 123 11.24 (1.84) 19.15 (2.80)
graduate/specialist diploma
Group III: With master's degree 29j 12.34 (2.26) 20.14 (2.49)
F-­value (p-­value) 23.894 (<0.001h) 11.498 (<0.001i)
Advanced nursing practiceb
APN/APN intern 25 12.92 (1.58) 20.56 (2.18)
Non-­APN 684 10.47 (1.97) 18.38 (2.78)
t-­statistic (p-­value) −7.535 (<0.001) −4.849 (<0.001)
Received sepsis education/training in the last 1 yearb
Yes 96 10.64 (2.23) 19.81 (2.26)
No 613 10.55 (1.97) 18.25 (2.80)
t-­statistic (p-­value) −0.396 (0.693) −6.082 (<0.001)
Sepsis screening tool in area of practiceb
Yes 67k 10.75 (1.89) 18.34 (3.13)
No 642 10.54 (2.02) 18.47 (2.75)

t-­statistic (p-­value) 0.797 (0.425) −0.360 (0.719)

Abbreviations: APN, advanced practice nurse; ED, emergency department; HDU, high dependency unit; ICU, intensive care unit; UCC, urgent care centre.
a
One-­way ANOVA test.
b
Independent sample t-­test.
c
Post-­hoc test with Bonferroni correction: 0–­2 years versus 6–­10 years (p = .007), 0–­2 years versus >10 years (p < .001), 3–­5 years versus >10 years (p = .001).
d
Post-­hoc test with Bonferroni correction: 0–­2 years versus 3–­5 years (p < .001), 0–­2 years versus 6–­10 years (p < .001), 0–­2 years versus >10 years (p < .001),
3–­5 years versus >10 years (p = .005).
e
Post-­hoc test with Bonferroni correction: staff nurse versus senior staff nurse (p < .001), staff nurse versus assistant Nurse Clinician/nursing officer (p < .001),
senior staff nurse versus assistant Nurse Clinician/nursing officer (p = .009).
f
Welch ANOVA due to unequal variance assumed, post-­hoc test with Bonferroni correction: staff nurse versus senior staff nurse (p < .001), staff nurse versus
assistant Nurse Clinician/nursing officer (p < .001).
g
Welch ANOVA due to unequal variance assumed, post-­hoc test with Bonferroni correction: emergency department versus general ward (p < .001), ICU/HDU
versus general ward (p < .001).
h
Post-­hoc test with Bonferroni correction: Group I versus Group II (p < .001), Group I versus Group III (p < .001), Group II versus Group III (p = .018).
i
Post-­hoc test with Bonferroni correction: Group I versus Group II (p = .002), Group I versus Group III (p = .001).
j
25 attained master's degree in nursing.
k
Hospital B emergency department.
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CHUA et al. 623

than those under 6 years of nursing experience (F = 8.63, p < .001). higher total self-­confidence scores (t = −6.08, p < .001). There were
Total sepsis knowledge scores differed significantly by clinical work no significant differences in total self-­confidence scores among
area, with nurses working in ED/UCC (mean = 11.03, SD = 1.94) nurses based on their clinical work area as well as between the pres-
reporting higher scores compared to nurses working in ICU/ ence of sepsis screening tool subgroups.
HDU (mean = 10.98, SD = 1.71) and general wards (mean = 10.17, Figure 1 summarizes the participants' item-­level self-­reported
SD = 2.09). Total sepsis knowledge scores were also observed to confidence. Of the five items, more than three-­quarters of the
be highest among assistant nurse clinicians and nursing officers nurses believed that they know when to escalate possible sepsis to
(F = 31.29, p < .001), master's-­prepared nurses (F = 23.89, p < .001) the medical team and had knowledge in monitoring patients with
or APNs and APN interns (t = −7.54, p < .001). No significant differ- sepsis. Conversely, slightly over half are confident in identifying and
ences in total sepsis knowledge score were observed in relation to assessing patients for sepsis.
attendance in sepsis education and training in the last 1 year and the A further analysis was done to examine if there were significant
presence of sepsis screening tool subgroups. differences in the level of self-­confidence towards recognizing and
managing patients with sepsis among nurses grouped according to
clinical work area and presence of sepsis screening tool in their work
3.4 | Factors affecting nurses' sepsis knowledge area (i.e. nurses in ED of hospital B). At item level, no significant dif-
ference was found between nurses in ED of Hospital B (presence of
Univariate linear regression analyses were done to examine the re- sepsis screening tool) and nurses working in clinical areas without a
lationship between RNs' characteristics and their total sepsis knowl- sepsis screening tool in their confidence towards recognizing sepsis
edge score. Given post hoc test with Bonferroni correction did not symptoms, monitoring and assessment of sepsis, escalation of sepsis
demonstrate any significant difference between RNs with 0–­2 years to the medical team and initial management of sepsis.
and 3–­5 years of nursing experience as well as between RNs with
6–­10 years and more than 10 years of nursing experience, RNs were
regrouped into two groups: (1) 0–­5 years of nursing experience and 3.6 | Organizational support for improving sepsis
(2) more than 5 years of nursing experience. care: Open-­ended results
Years of nursing experience, nursing job grade, clinical work area
and education level were identified to be sufficient for inclusion Of the 709 participants, 591 (83.3%) provided their responses in the
(p ≤ .1) in the multiple linear regression analysis. Nurses' job grade free text on the open-­ended question regarding organizational sup-
(F = 10.82, p < .001), nursing education level (F = 7.70, p < .001) and port for improving sepsis care. Three main themes, each supported
clinical work area (F = 9.18, p < .001) were found to be significant by subthemes, were derived from the content analysis of the 591
predictors of nurses' sepsis knowledge, which accounted for 12.6% valid entries (Supplementary file 2). Participants indicated the need
variance (R 2 = .126). A nursing specialization or master's level edu- for more regular and formal “sepsis training and education” (n = 450)
cation, holding a higher job grade and working in acute care areas on assessing patients with sepsis, sepsis management and sepsis
(i.e. ED/UCC/ICU/HDU) were predictors of higher sepsis total sepsis prevention. The suggested mode of education delivery included
knowledge scores. Details of the univariate and multiple linear re- regular in-­service talks and seminars, e-­learning, case sharing and
gression model are presented in Table 4. discussions, clinical teaching by physicians, and simulation. To aid
nurses in caring for patients with sepsis, many also suggested having
a hospital “sepsis workflow and protocol” (n = 173) which included a
3.5 | Nurses' self-­reported confidence sepsis screening tool and escalation policy, and a sepsis management
bundle or algorithm. Cue cards and posters could be placed in clini-
The total self-­confidence scores in recognizing and managing patients cal areas to facilitate adherence to sepsis workflow and protocol.
with sepsis ranged from 5 to 25, with a mean score of 18.46 ± 2.79 Lastly, some suggestions cited were associated with “nursing em-
out of a maximum score of 25. The greatest proportion of partici- powerment” (n = 26). Participants reported the importance of phy-
pants (n = 201, 28.3%) scored 20 for total self-­confidence score. sicians listening to nurses' inputs or concerns regarding a patient's
Overall, there was a weak positive correlation between nurses' sep- condition, having workflows that empower ward nurses to initiate
sis knowledge and self-­perceived confidence in the recognition and initial sepsis management within their capacity and having a sepsis
management of sepsis (r = .184, p < .001). resource or outreach nurse to raise the profile of sepsis recognition
The differences in self-­reported confidence among differ- and management.
ent groups of nurses are presented in Table 3. Higher total self-­
confidence scores were observed among nurses with more than
10 years of nursing experience (F = 19.04, p < .001), assistant nurse 4 | DISCUSSION
clinicians and nursing officers (F = 23.66), master's-­prepared nurses
or APNs and APN interns (t = −4,85, p < .001). Nurses who received This cross-­s ectional study sampled RNs from three hospitals of
sepsis education and training in the last 1 year also had significantly one public healthcare cluster in Singapore and explored their
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624 CHUA et al.

TA B L E 4 Univariate linear regression analysis and multiple linear regression examining factors affecting nurses' sepsis knowledge
(n = 709)

Univariate analysis Multiple linear regression

Variables n B (95% CI) SE p-­value B (95% CI) SE p-­value

a
Years of nursing experience .161
0–­5 years 286 Reference Reference
>5 years 423 0.733 (0.436, 1.031) 0.151 <.001
Area of practicea <.001
ED/UCC 155 0.859 (0.490, 1.227) 1.88 <.001 0.696 (0.337, 1.055) 0.183 <.001
ICU/HDU 174 0.809 (0.455, 1.163) 1.80 <.001 0.553 (0.203, 0.903) 0.178 .002
General Ward 380 Reference Reference
Job gradea <.001
Staff nurse 311 Reference 0.211 <.001 Reference
Senior staff nurse 284 0.928 (0.617, 1.239) 0.158 <.001 0.814 (0.403, 1.226) 0.210 <.001
Assistant nurse clinician/Nursing 114 1.490 (1.075, 1.905) 0.211 <.001 1.212 (0.671, 1.753) 0.276 <.001
officer
Nursing education levela .001
Without any nursing 557 Reference Reference
specialisationb
With nursing advanced/graduate/ 123 0.918 (0.537, 1.299) 0.1.94 <.001 0.483 (0.083, 0.884) 0.204 .018
specialist diplomac
With Master's degreed 29 2.027 (1.299, 2.755) 0.371 <.001 1.366 (0.600, 2.132) 0.390 <.001
Received sepsis education/training 96 0.087 (−0.346, 0.521) 0.221 .693 —­ —­ —­
in the last 1 year
Presence of sepsis screening tool 67e 0.206 (−0.301, 0.712) 0.258 .425 —­ —­ —­

Abbreviations: ED, emergency department; HDU, high dependency unit; ICU, intensive care unit; UCC, urgent care centre.
a
Included in the multiple linear regression.
b
Nursing diploma only, nursing diploma and degree only, or nursing degree only.
c
Nursing advanced/graduate/specialist diploma + a.
d
Nurses with master's degree, 25 out of 29 had attained master's degree in nursing and were either advanced practice nurse or advanced practice
nurse intern.
e
Hospital B emergency department.

knowledge and confidence in recognizing and managing adult This may suggest an underappreciation of the severity of sepsis as
patients with sepsis. In contrast to previous studies that tended a life-­threatening medical condition, which could have a negative
to ask lower order factual sepsis knowledge questions, the sep- impact on patient outcomes. The findings also suggest a signifi-
sis knowledge test developed for this study focused more on cant knowledge gap among nurses in recognizing tachypnoea as an
higher order thinking skills, involving the application and analy- early manifestation of sepsis, and other aspects of sepsis bundle in-
sis of sepsis knowledge using case scenarios questions. The cluding collection of blood cultures, serum lactate's thresholds and
findings of this study provide meaningful evidence to suggest management of septic shock. This knowledge gap was observed to
that RNs across different areas of practice have average knowl- correspond with the participants' lower confidence in identifying,
edge on sepsis care and identify gaps in nurses' sepsis knowl- performing clinical assessment and initiating initial management of
edge. The results are consistent with previous studies despite sepsis. The limited knowledge on sepsis care and lack of confidence
the difficulties in making direct comparisons due to the diverse were not surprising given that less than 15% of the participants re-
sepsis knowledge quizzes used and differing ward settings ported receiving any education or training activities about sepsis
where the studies were conducted (Nucera et al., 2018; Rahman in the past 1 year. However, it is encouraging that majority of the
et al., 2019; Stamataki et al., 2014; Storozuk et al., 2019; van den participants indicated their desire for further sepsis education and
Hengel et al., 2016). training, suggesting they were well aware of their knowledge deficit
While our results showed that nurses displayed good awareness and the need to renew and advance their knowledge.
of sepsis risk factors, there is a significant lack of awareness of the Our study showed that while those nurses who received sepsis
updated sepsis-­3 definitions and epidemiological data of sepsis. education and training in the past 1 year had significantly higher
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CHUA et al. 625

Q1. I am confident in identifying symptoms of sepsis. [Mean: 3.56 ± 0.71; Median: 4 (3-4)]
57.6 37.5 4.9

Q2. I am competent in performing clinical assessment of patients with suspected sepsis. [Mean: 3.48 ± 0.72; Median: 4 (3-4)]
52.5 39.9 7.6

Q3. I know when to escalate to the doctor when I identify patients with sepsis. [Mean: 3.91± 0.65; Median: 4 (4-4)]
81.8 15.2 3.0 Strongly agree/agree
Neutral
Q4. I know how and what to monitor in patients with sepsis. [Mean: 3.82 ± 0.65; Median: 4 (4-4)]
Strongly disagree/disagree
77.3 19.5 3.2

Q5. I know the initial management of patients with sepsis. [Mean: 3.68 ± 0.70; Median: 4 (3-4)]

68.0 26.7 5.3

0.0 25.0 50.0 75.0 100.0

Percentage (%)

F I G U R E 1 Nurses' self-­reported confidence in recognizing and managing sepsis (n = 709).

confidence scores than those who did not, their knowledge scores nursing. For nurses without specialization, they would have limited
were only marginally higher. This contrasts with findings in stud- exposure to sepsis education in their pre-­licensure nursing educa-
ies that have demonstrated improvement in nurses' attitudes, tion curriculum, and further sepsis education and training programs
knowledge and confidence in recognizing and managing sepsis would be usually dependent on their workplace training. Similar to
with sepsis education and training (Delaney et al., 2015; Edwards Australia (Harley, Massey, et al., 2021), the apparent deficit in sepsis
& Jones, 2021; O'Shaughnessy, 2017), and even more so if it was content in the pre-­licensure nursing curricula may be attributed to
done recently (van den Hengel et al., 2016). One plausible reason nursing curriculum planners being adaptable and responsive to the
for this could be related to the characteristics of the sepsis ed- healthcare needs in Singapore. Key population health issues such
ucation and training activities (i.e. learning content, educational as diabetes, stroke, mental health disorders and healthy aging have
delivery method and teaching approach) that the participants had taken precedence. In addition, sepsis is a complex syndrome that
recently attended, which unfortunately was not captured in our may pose a challenge for educators to impart to nursing students
questionnaire. We postulate that the methods of education and who have limited clinical exposure. On the other hand, sepsis may
training delivery may have played an integral part in the learner's have been given greater focus in the curriculum of higher nursing ed-
learning. This is supported by a recent systematic review of 32 in- ucation. This may explain why nurses with higher educational levels
ternational studies demonstrating sepsis education and training have higher sepsis knowledge scores which was also found in Öztürk
that incorporated active learning strategies were shown to en- Birge et al. (2021).
hance learners' knowledge retention and transfer of learning to Our findings show that nurses working in acute care areas
clinical practice than didactic teaching (Choy et al., 2022). Nurses such as the ED/UCC, HDU and ICU generally have higher sepsis
should therefore be provided with experiential learning opportu- knowledge and self-­confidence scores than general ward nurses,
nities such as simulation training or rotations to critical care areas a result that echoes those of Stamataki et al. (2014). While there
with higher sepsis caseload. This allows them to apply their theo- has been an observed increase in the prevalence of sepsis in gen-
retical knowledge in practice, which can strengthen their compe- eral wards (Szakmany et al., 2016; Zaccone et al., 2017), nurses'
tence and build their confidence levels. exposure to sepsis is higher in ICU/HDU and ED. As patients with
In this study, factors such as nursing education level, clinical sepsis often develop multiple organ-­s ystem failure that requires
work area and job grade in recognizing and managing sepsis were aggressive management and close monitoring, they are usually
found to be predictors of nurses' sepsis knowledge. Nurses who treated in the ICUs or HDUs (Evans et al., 2021). Furthermore,
had attained a nursing specialization or a master's level education, patients in ICUs or HDUs have an increased risk of acquiring nos-
worked in acute clinical areas such as ED/UCC or ICU/HDU, and held ocomial infections due to various risk factors such as severity of
a more senior nursing position were found more likely to have better illness, invasive procedures and multiple invasive catheters (Mayr
sepsis knowledge scores. This result is expected because teachings et al., 2014). In the ED, the triage nurses are often the first-­line
on sepsis for nurses without a specialization qualification—­RNs with responders to patients presenting with community-­o nset sepsis
a diploma and/or bachelor's degree only—­would be lacking in depth which accounted for almost 90% of hospitalized cases with sepsis
compared to nursing specialization programs and master's degree in (Rhee et al., 2019). The exposure to high volume caseload in their
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626 CHUA et al.

daily clinical practice may have contributed to better knowledge and perceptions around recognizing and managing patients with
on sepsis presentation and its initial management. sepsis was not elicited through the survey, in which these insights
Our study observed a poor correlation between sepsis and may be valuable to inform local policies and enrich nursing educa-
knowledge test scores and self-­confidence. A possible explanation tional packages.
for this outcome is that knowledge test does not allow for direct
conclusion on participants' abilities and skills to provide sepsis care
in their respective work environment (Liaw et al., 2012). Instead, the 5 | CO N C LU S I O N
use of objective measures to evaluate nurses' clinical competencies
and skills should be considered. This may include using a simula- Nurses are placed in an opportunistic position to recognize and
tion test with an assessor checklist, workplace-­based assessment manage patients with sepsis. In congruent with previous studies,
or sepsis-­related performance indicators. In addition, self-­reported this multi-­site study revealed gaps in nurses' clinical knowledge
competence and confidence may be limited by a cognitive bias of sepsis recognition and management, albeit nurses working in
where participants may have reported themselves as being more ca- the acute clinical areas such as ED/UCC, HDU and ICU had higher
pable than they really are (Kruger & Dunning, 1999). knowledge and confidence than general ward nurses. Sepsis
There is a growing body of knowledge advocating the im- screening tools and sepsis bundles have been identified by partici-
plementation of sepsis screening tools and sepsis care bundles, pants as useful adjuncts in clinical practice to facilitate nurses in
which have been demonstrated to improve the recognition and timely recognition and management of patients with sepsis. This
management of sepsis, and lead to better patient outcomes (Evans study augments the need for a stronger foundation in sepsis edu-
et al., 2021). In this study, almost 30% of the open comments were cation and training programs for nurses and the implementation of
related to implementing a hospital sepsis screening tool and sep- systems improve nurses' knowledge and confidence in recognizing
sis management bundle or algorithm and surrounded empower- and managing sepsis.
ing ward nurses to initiate initial sepsis management within their With the ongoing research to understand the pathophysiology
capacity. This would be particularly helpful for nurses with little and immunological mechanisms of sepsis and approach in manag-
clinical experience or limited sepsis knowledge. However, it is ing sepsis, nurse educators and academics are responsible to en-
noteworthy that this study found no association between sepsis sure that sepsis education content are in keeping with the latest
screening tool and nurses' knowledge and confidence in recog- evidence-­based knowledge and best practices. There is a need to re-
nizing sepsis symptoms and performing clinical assessment of pa- view the current pre-­licensure nursing curriculum and the delivery of
tients with suspected sepsis. This is contrary to previous studies current sepsis educational programs in workplace-­based nursing ed-
that found improved confidence among nurses in the identification ucation. In addition, we should consider adopting a multidisciplinary
of patients with sepsis with the implementation of a sepsis screen- approach involving nurses, physicians and pharmacists to formulate
ing tool (Edwards & Jones, 2021). Our finding may be explained by nurse-­driven sepsis screening algorithms and sepsis care protocols
25% of the nurses lacking awareness of the sepsis screening tool; that are specific to different clinical areas. Efforts should also be
which prompted us to pay attention to the implementation and aimed at continuous education, regular reviews of clinical processes,
dissemination process of clinical protocols. It also underlines the clinical audits and feedback to ensure sustainability.
importance of continuous education and sepsis training of ground
staff so as to improve compliance with sepsis clinical protocols AU T H O R C O N T R I B U T I O N S
and achieve a synergistic effect (Damiani et al., 2015; Roberts All the listed authors have (1) made substantial contributions to con-
et al., 2017). ception and design, or acquisition of data, or analysis and interpreta-
tion of data; (2) been involved in drafting the manuscript or revising
it critically for important intellectual content and (3) given final ap-
4.1 | Limitations proval of the version to be published.

This study had a few limitations. First, the low response rate of AC K N OW L E D G E M E N T S
23.1% limits the generalisability of the study to a wider popula- We would like to thank the 7 content experts for their time and in-
tion of RNs working in acute-­tertiary hospitals and to community valuable expert opinions in content validating the sepsis question-
nurses. The study was conducted during the coronavirus disease naire. We would also like to thank all the nurses who participated in
(COVID-­19) pandemic period where nurses' low morale and fatigue this study. We extend our appreciation to Ms Diana Lau for contrib-
might have influenced participation rate. Second, even though we uting to the development of the sepsis questionnaire.
attempted to test the application and analysis of sepsis knowledge
using case scenarios questions, MCQs may not be an accurate rep- F U N D I N G I N FO R M AT I O N
resentation of participants' sepsis knowledge and clinical competen- This study was internally funded by the Lee Foundation Research
cies and skills. Third, an in-­depth exploration of nurses' experiences Fellow Start Up Grant awarded by the Alice Lee Centre for Nursing
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13652648, 2023, 2, Downloaded from [Link] by Readcube (Labtiva Inc.), Wiley Online Library on [06/01/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CHUA et al. 627

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