An estimated 234 million surgical procedures are performed worldwide annually, which makes surgical care an integral part of healthcare.1,2 Surgical site infection (SSI) occurs within 30 d (or within 90 d in case of placement of implants) following surgery.3 Although most patients recover from an SSI without permanent sequelae, postoperative mortality in patients with SSI is related to the infection itself in 77% of patients.4 As a result, the cost increases substantially per patient. SSI is a major patient safety issue, a primary risk to patients, and a major source of concern in the healthcare setting.5
Hair follicles on our skin, the most important barrier between our body and the outside environment, are small channels that open to the external environment.6 Hair follicles have features such as self-renewal, regeneration of surrounding tissues, a transitional replicator that undergoes rapid proliferation and differentiation during the high proliferative phase of wound healing in the damaged dermis and epidermis layer, participation in tissue regeneration and repair, and the ability to transform into multiple cell types and cell formation.7,8 The purpose of preoperative skin preparation is to cleanse the surgical procedure site from microorganisms, reduce the resident flora, prevent skin irritation while cleaning the surgical site, and reduce the growth of microorganisms in the area for some time9 because persistent microorganisms on the skin with surgical intervention could settle in deep tissues and cause SSIs.10
Appropriate hair removal as part of preoperative preparation is an important component of skin preparation. The three most popular methods used for preoperative hair removal include shaving with a razor, clipping with a surgical hair clipper, and using chemical hair removal with a depilatory cream.11 Shaving with a razor, a longstanding practice, is still popular in developing countries. A systematic review of several randomized controlled trials in the Cochrane Database indicated that when hair removal is necessary, clippers or depilatory creams cause fewer SSIs compared to shaving with a razor.11–15
In the guidelines prepared in light of clinical studies and expert opinions, international health organizations recommend that shaving with a razor is a great risk for SSI and that, if necessary, hair should be removed only with a clipper.16–20
The majority of healthcare workers include nurses. nurses’ lack of knowledge and low-standard practices may lead to transmission of infection, especially in open wound/site surgeries.21 No evidence-based studies were found to have investigated nurses’ levels of knowledge and practice regarding preoperative hair removal and prevention of SSIs in Turkey. Therefore, the purpose of this study was to evaluate nurses’ levels of knowledge and practice regarding preoperative hair removal and prevention of SSI.
This study sought answers to the following questions:
Which preoperative hair removal methods do nurses think should be used for patients?
Who do the nurses think should perform preoperative hair removal?
Do nurses have adequate levels of knowledge about the timing of preoperative hair removal and its relationship with SSI?
This descriptive and cross-sectional study was conducted between February and May 2023. While the target population of the study consisted of 145 nurses working in a public hospital in northern Turkey, the sample consisted of 123 nurses who were aged ≥18 years, graduated at least from high school, and agreed to participate in the study. With a 95% confidence interval, ±5% sampling error, and equal probabilities of occurrence and non-occurrence (0.50 P = q) using the sampling method with a known population, a sample of 106 individuals is recommended in a population of 145 people (https://www.calculator.net/sample-size-calculator). Considering a 10% potential data loss from the sample, it was decided to include at least 120 individuals in the study. When the post hoc power analysis of the effect size was performed after the study, n was found to be 124, indicating a sufficient sample size.
The data were collected through the Personal Information Form and the Assessment Form for Nurses’ Levels of Knowledge and Practice regarding Preoperative Hair Removal and Prevention of Surgical Site Infection. After the forms were given to the participants who agreed to participate in the study and worked in the previously determined district public hospital, data were collected by the researcher by visiting the wards repeatedly. The nurses working in the hospital wards were informed about the purpose of the study, and those who agreed to participate were administered the questionnaires. The researcher waited for the participants to fill in and complete the forms, which took 10–15 min on average.
The Personal Information Form prepared by the researchers in line with the literature22 included 11 questions to determine nurses’ demographic and professional characteristics. The form included questions about the participant’s age, gender, education level, duration of working in the profession, having received training on SSI, the institution where training was received, preoperative hair removal methods they found appropriate to use, the timing of preoperative hair removal, etc.
A total of 23 statements responded as “Yes,” “No,” and “I do not know” were prepared by the researchers in line with the literature and assessed nurses’ levels of knowledge and practice regarding preoperative hair removal and SSI.22–24
The data obtained from the study were analyzed using the SPSS 21.0 package program (IBM Corporation, Armonk, New York, United States). Descriptive statistics (numbers, percentages, etc.) were used for data analysis. The results obtained were analyzed at a 95% (P < 0.05) significance level. The normality assumption of the data obtained from the study was tested using the Kolmogorov–Smirnov test, and the data were found to be distributed non-normally (P < 0.05). Chi-square independence analysis was used for the relationship and differentiation analysis of the research data.
Before the data collection process, ethics committee approval with decision number 2022-944 was obtained on November, 25 2022. The necessary permissions were obtained from the institution where the study would be conducted. Before the data collection process, participating nurses were informed about the study, their verbal and written consent was obtained, and those who agreed to participate were included in the study. The participants were not asked to indicate their names for the confidentiality of the data.
It was found that 68.3% of the nurses participating in the study were female, the majority (39.8%) were in the 21–30 years age group, 65.9% had an undergraduate degree, and 49.5% had been in the profession for more than 10 years. An analysis of their training background on SSI showed that 71.5% received training on this topic before (Table 1).
Distribution of nurses’ demographic and professional characteristics (N = 123).
| Variables | N | Percentage (%) |
|---|---|---|
| Age (years) | ||
| 19–20 | 4 | 3.3 |
| 21–30 | 49 | 39.8 |
| 31–40 | 33 | 26.8 |
| ≥41 | 37 | 30.0 |
| Gender | ||
| Male | 39 | 31.7 |
| Female | 84 | 68.3 |
| Education level | ||
| High school | 13 | 10.6 |
| Associate degree | 18 | 14.6 |
| Undergraduate degree | 81 | 65.9 |
| Postgraduate degree | 11 | 8.9 |
| Duration of working in the profession (years) | ||
| 0–10 | 62 | 50.4 |
| 11–20 | 42 | 34.1 |
| ≥21 | 19 | 15.4 |
| Having received training on SSI | ||
| Yes | 88 | 71.5 |
| No | 34 | 27.6 |
Note: SSI, surgical site infection.
The majority of the participants (98.3%) thought that there was a relationship between SSI and preoperative hair removal. The methods used for preoperative hair removal were indicated as shaving with a razor by 64.2%, clipping with a clipper by 25.2%, and using chemical hair removal with a depilatory by 10.6%. Optimal timing of hair removal was indicated as the night before surgery by 74% of the nurses and 2–4 h before surgery by 26% of the nurses. Of all the participating nurses, 70.7% thought that hair removal should be done by the patient/patient’s relative, and 29.3% thought that it should be done by the nurse (Table 2).
Nurses’ views about preoperative hair removal (N = 123).
| Variables | N | Percentage (%) |
|---|---|---|
| Do you think there is a relationship between SSI and hair removal? | ||
| Yes | 121 | 98.3 |
| No | 2 | 1.7 |
| Hair removal method to be used before surgery | ||
| Razor/shaving | 79 | 64.2 |
| Clipper/clipping | 31 | 25.2 |
| Using a depilatory cream | 13 | 10.6 |
| Timing of preoperative hair removal | ||
| The night before surgery | 91 | 74.0 |
| 2–4 h before surgery | 32 | 26.0 |
| The person to perform preoperative hair removal | ||
| Nurse | 36 | 29.3 |
| Patient/patient relative | 87 | 70.7 |
Note: SSI, surgical site infection.
This study, which aimed to determine nurses’ levels of knowledge and practice regarding preoperative hair removal and prevention of SSI in the institution where the study was conducted, found that nurses’ rates of correct answers to the statements were high, but the rates of correct answers were lower to the statements related to preoperative hair removal methods, the optimal timing of hair removal, and the person to perform hair removal (Table 3).
Distribution of nurses’ answers to the statements about preoperative hair removal and prevention of SSI.
| No | Questions | Yes | No | I do not know | |||
|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | ||
| 1 | SSI is an infection that develops following or due to a surgical intervention and occurs within 30 d or 90 d following surgery. | 98 | 79.7 | 8 | 6.5 | 17 | 13.8 |
| 2 | Chlorhexidine gluconate is the best antiseptic solution recommended for preoperative skin preparation. | 78 | 63.4 | 14 | 11.4 | 31 | 25.2 |
| 3 | The purpose of preoperative skin preparation is to reduce the number of microorganism colonies in the patient’s skin flora by using an appropriate antiseptic agent. | 101 | 82.1 | 16 | 13.0 | 6 | 4.9 |
| 4 | I make sure that the patient takes a bath/shower with an antiseptic agent before surgery. | 53 | 43.1 | 46 | 37.4 | 24 | 19.5 |
| 5 | It is acceptable not to remove hair if it does not impede the visual field in the surgical incision area. | 55 | 44.7 | 62 | 50.4 | 6 | 4.9 |
| 6 | If preoperative hair removal is to be performed, immediately before the incision is the optimal time. | 41 | 33.3 | 68 | 55.3 | 14 | 11.4 |
| 7 | If preoperative hair removal is to be performed, using a razor is the best method. | 37 | 30.1 | 61 | 49.6 | 25 | 20.3 |
| 8 | If preoperative hair removal is to be performed, using depilatory cream is the best method. | 43 | 35.0 | 53 | 43.1 | 27 | 22.0 |
| 9 | If preoperative hair removal is to be performed, using an electric shaver (clipper) is the best method. | 74 | 60.2 | 21 | 17.1 | 28 | 22.8 |
| 10 | Before surgery begins, the incision area should be wiped with a suitable antiseptic agent. | 119 | 96.7 | 3 | 2.4 | 1 | 0.8 |
| 11 | If the incision is closed primarily after surgery, the sterile wound dressing should be monitored and protected for 24–48 h in terms of bleeding and discharge. | 122 | 99.2 | 1 | 0.8 | 0 | 0.0 |
| 12 | During dressing change, hands should be washed before and after contact with the wound. | 122 | 99.2 | 1 | 0.8 | 0 | 0.0 |
| 13 | During dressing change, I wash my hands in accordance with the hygienic hand washing instructions before and after contact with the wound. | 120 | 97.6 | 3 | 2.4 | 0 | 0.0 |
| 14 | Dressing change in the postoperative period should be done using a sterile technique. | 112 | 91.1 | 10 | 8.1 | 1 | 0.8 |
| 15 | I use protective equipment (gowns, masks, glasses-face shields, and gloves) in case of contaminating blood and other infectious materials during dressing change. | 119 | 96.7 | 3 | 2.4 | 1 | 0.8 |
| 16 | When changing dressings, I use disposable sterile dressing materials and sterile gloves specific to each dressing. | 112 | 91.1 | 9 | 7.3 | 2 | 1.6 |
| 17 | I use an appropriate antiseptic solution to clean the surgical wound dressing. | 102 | 82.9 | 19 | 15.4 | 2 | 1.6 |
| 18 | I prioritize the non-infected area during dressing. | 120 | 97.6 | 2 | 1.6 | 1 | 0.8 |
| 19 | Gloves should be changed from the contaminated body area to a clean area while using gloves in the same patient. | 120 | 97.6 | 2 | 1.6 | 1 | 0.8 |
| 20 | SSI could present as fever, pain, discharge, redness, and tenderness in the patient. | 120 | 97.6 | 2 | 1.6 | 1 | 0.8 |
| 21 | At each shift, I monitor the surgical wound dressing for signs of infection. | 119 | 96.7 | 1 | 0.8 | 3 | 2.4 |
| 22 | I provide training on SSI starting from the patient’s hospitalization. | 116 | 94.3 | 4 | 3.3 | 3 | 2.4 |
| 23 | I inform the physician and take culture from the wound site under aseptic conditions when there is a discharge from the wound site. | 116 | 94.3 | 4 | 3.3 | 3 | 2.4 |
Note: SSI, surgical site infection.
In terms of the correct answers given by the nurses who thought that hair removal should be performed 2–4 h before surgery, it was found to be higher than the nurses who thought that it should be performed the night before surgery (Table 4). A chi-square independence test was performed to determine whether the nurses’ levels of knowledge regarding the relationship between preoperative hair removal and SSI differed according to their opinions on the timing of hair removal, which is a part of preoperative skin preparation, and the answers given to the questionnaire items were analyzed. Significant differences were found in the following items: “It is acceptable not to remove hair if it does not impede the visual field in the surgical incision area,” “If preoperative hair removal is to be performed, using depilatory cream is the best method,” and “If preoperative hair removal is to be performed, using an electric shaver (clipper) is the best method” (P < 0.01, Table 4).
Comparison of the differences between the optimal timing of preoperative hair removal variable and levels of knowledge.
| Item | Optimal timing | P | χ2 | |
|---|---|---|---|---|
| A, n (%) | B, n (%) | |||
| It is acceptable not to remove hair if it does not impede the visual field in the surgical incision area. | 0.001* | 13.749 | ||
| Yes | 35 (38.5) | 20 (62.5) | ||
| No | 54 (59.3) | 8 (25) | ||
| I do not know | 2 (2.2) | 4 (12.5) | ||
| If preoperative hair removal is to be performed, immediately before the incision is the optimal time. | 0.268 | 2.63 | ||
| Yes | 30 (33) | 11 (34.4) | ||
| No | 53 (58.2) | 15 (46.9) | ||
| I do not know | 8 (8.8) | 6 (18.8) | ||
| If preoperative hair removal is to be performed, using a razor is the best method. | 0.187 | 3.352 | ||
| Yes | 31 (34.1) | 6 (18.8) | ||
| No | 41 (45.1) | 20 (62.5) | ||
| I do not know | 19 (20.9) | 6 (18.8) | ||
| If preoperative hair removal is to be performed, using depilatory cream is the best method. | 0.003* | 11.383 | ||
| Yes | 24 (26.4) | 19 (59.4) | ||
| No | 44 (48.4) | 9 (28.1) | ||
| I do not know | 23 (25.3) | 4 (12.5) | ||
| If preoperative hair removal is to be performed, using an electric shaver (clipper) is the best method. | 0.000* | 20.677 | ||
| Yes | 44 (48.4) | 30 (93.8) | ||
| No | 21 (23.1) | 0 (0) | ||
| I do not know | 26 (28.6) | 2 (6.3) | ||
Note: A, One night before surgey; B, 2–4 h before surgery;
P < 0.01; chi-square independence test.
In terms of the correct answers given by the nurses about who should perform hair removal, a part of preoperative skin preparation, the number of nurses who thought that the patient/patient’s relative should do it was found to be higher (Table 5). A chi-square independence test was performed to determine whether the nurses’ levels of knowledge regarding the relationship between preoperative hair removal and SSI differed according to their opinions on who should perform hair removal, and the answers given to the questionnaire items were analyzed. Significant differences were found in the following items: “It is acceptable not to remove hair if it does not impede the visual field in the surgical incision area” and “If preoperative hair removal is to be performed, using an electric shaver (clipper) is the best method” (P < 0.05, Table 5).
Comparison of levels of knowledge with the variable of the person performing preoperative hair removal.
| Item | Person to perform preoperative hair removal | P | χ2 | |
|---|---|---|---|---|
| Nurse, n (%) | Patient/patient relative, n (%) | |||
| It is acceptable not to remove hair if it does not impede the visual field in the surgical incision area. | 0.032* | 6.882 | ||
| Yes | 22 (61.1) | 33 (37.9) | ||
| No | 14 (38.9) | 48 (55.2) | ||
| I do not know | 0 (0.0) | 6 (6.9) | ||
| If preoperative hair removal is to be performed, immediately before the incision is the optimal time. | 0.42 | 1.733 | ||
| Yes | 15 (41.7) | 26 (29.9) | ||
| No | 18 (50.0) | 50 (57.5) | ||
| I do not know | 3 (8.3) | 11 (12.6) | ||
| If preoperative hair removal is to be performed, using a razor is the best method. | 0.083 | 4.966 | ||
| Yes | 30.6 (22.0) | 29.9 (39.0) | ||
| No | 61.1 (3.0) | 44.8 (22.0) | ||
| I do not know | 8.3 (30.6) | 25.3 (29.9) | ||
| If preoperative hair removal is to be performed, using depilatory cream is the best method. | 0.1 | 4.599 | ||
| Yes | 12 (33.3) | 31 (35.6) | ||
| No | 20 (55.6) | 33 (37.9) | ||
| I do not know | 4 (11.1) | 23 (26.4) | ||
| If preoperative hair removal is to be performed, using an electric shaver (clipper) is the best method. | 0.040* | 6.46 | ||
| Yes | 22 (61.1) | 52 (59.8) | ||
| No | 10 (27.8) | 11 (12.6) | ||
| I do not know | 4 (11.1) | 24 (27.6) | ||
Note: P < 0.05; chi-square independence test.
The literature reports that SSIs are affected by preoperative hair removal methods.25 Shaving the hair in the surgical area with a razor abrades the skin surface, which consequently disrupts the microflora.26 Therefore, healthcare professionals have important responsibilities in patients’ preoperative skin preparation to reduce the risk of SSIs.27 Protection of skin integrity reduces the risk of SSI greatly. According to the guidelines published by Association of peri-Operative Registered Nurses (AORN), Centers for Disease Control and Prevention (CDC), National Institute for Health and Care Excellence (NICE), and World Health Organization (WHO) for the prevention of postoperative SSIs, the hair in the surgical area should be removed if it is necessary, and it should be removed only with a clipper immediately before surgery.16–18,20 In a similar vein, the Turkish Surgical and Operating Room Nurses Association’s national guideline for preoperative hair removal in the prevention of SSI recommends that “hair removal in the surgical area should be avoided unless it is necessary.”19
Clinical randomized controlled trials comparing preoperative hair removal methods were reviewed. Dakshinamoorthy28 compared razors and clippers and reported that among the patients who underwent hair removal with a razor, 51% developed superficial SSI and 9% developed deep SSI after surgery. Of the patients who underwent preoperative hair removal with a clipper, 16% developed superficial SSI and 2% developed deep SSI after surgery.28 Hence, the author argued that preoperative skin preparation with a clipper could cause a lower level of SSI incidence. Similarly, in their clinical randomized trial, Omoblake and Ozoila13 concluded that although razors provided more effective hair removal, SSI rates were statistically higher compared to the clipper, and the use of razors was associated with SSI by causing more surface abrasions. As a result, these studies reported that razors would cause skin injuries and indicated the importance of using clippers if hair removal is necessary. If hair removal is to be performed, it should be done using a clipper with a single-use head. In addition, the guidelines state that adhesive tape (plaster) should be used for cleaning after hair removal using a clipper.18
The majority of participating nurses think that hair removal methods are associated with SSI, but a significant majority also believe that the hair in the surgical site affects the development of SSI and should be removed. Similarly, in a study conducted by Güven et al.,29 50.5% of the participants responded to the statement “There is no need to shave the hair in the operation site unless it is necessary” correctly. Albishi et al.30 found that 46.2% of nurses stated that preoperative skin cleansing was associated with SSI. In the study conducted by Andsoy and Bozkurt Çetin,22 23.8% of the participants answered the statement “Removal of hair in the surgical intervention area increases the risk of SSI” correctly. In the study conducted by Alcan et al.,31 patients stated that the hair in the surgical area was routinely removed, and “this practice was related to the surgeon’s preference, and that they continued the traditional point of view.”
The majority of the participants thought that using a clipper was the optimal hair removal method, but a considerable number of participants did not know clipper-depilatory cream-razor methods. An analysis of the literature showed that Şahin24 found nurses’ correct response rate regarding the method to be used for preoperative hair removal as 33.7%. Albishi et al.30 found that only 22.7% of the participants stated that “clippers should be used for hair removal.” Qasem and Hweidi32 reported that 49% of the participants answered the question “hair removal should be done with a clipper” correctly.
In the present study, 74% of the nurses answered that preoperative hair removal should be performed the night before surgery, and 26% answered that it should be performed 2–4 h before surgery (Table 2). The literature reports that, besides the epilation method used in preoperative hair removal, the timing and the place of hair removal are risk factors for SSIs.27,33 The guidelines on the prevention of SSIs state that, as much as possible, hair removal should be performed in immediate temporal proximity to the operation and in a special area in the operating room.17,25,34 Similar to the present study, the study conducted by Güven et al.29 reported that 44.8% of the nurses stated that “Hair removal should not be done immediately before the operation” and 32.5% stated that “Hair removal should be done the night before the operation.” Yıldırım et al. found that 59.6% of the nurses answered the statement “Hair removal should not be done on the day of surgery” correctly.35 The study conducted by Şahin24 with nurses found that 10.9% of the nurses reported having no information about the “If preoperative hair removal needs to be done in the surgical site, this should be done in immediate temporal proximity to the surgery” question and 20.8% answered the question incorrectly.
Clinical researchers argue that leaving the hair would protect the skin flora and accelerate postoperative wound healing because stem cells in hair follicles play an important role in cell renewal and wound healing.13,15,25,28 An analysis of the results of our study indicates that nurses have misinformation or traditional beliefs about “hair removal and SSI.”
The majority of the nurses participating in this study thought that hair removal should be performed by the patient/patient’s relatives. A similar study by Ekici and Durna36 reported contrasting results in that the nurses’ views about who should perform preoperative hair removal were reported as the patient’s caregiver by 58.6%, the nurse by 40.2%, the patient’s relative by 13.8%, the patient himself/herself by 6.9%, and the barber by 3.4%. Usually, the patient/patient’s relatives are asked to perform hair removal, one of the responsibilities of the health professional in preoperative skin preparation. As a result, abrasions and cuts may occur and disrupt skin integrity at the surgical site. Protecting the integrity of the skin could significantly affect and reduce the postoperative SSI incidence rates.
Today, hair removal continues to be performed with a razor blade by the patient/patient’s relative in the ward or at home, the day before surgery. Due to some difficulties experienced, the issue of the patient who should be transferred to the operating room ready for surgery has still not been transformed into a fully realistic practice of hair removal by a healthcare professional with a clipper in the immediate temporal proximity to surgery. For this reason, the response rate of the statements about the timing and the person to perform hair removal is considered to remain at moderate levels.
Due to the single-center nature of the study, while some nurses seem to try to perform practices of preoperative hair removal according to evidence-based recommendations, others continue to use traditional methods in some practices. In this study, nurses were not given comprehensive training to update their knowledge and practices regarding preoperative hair removal and SSI prevention. Also, another limitation is that the form used is not a valid and reliable tool.
This study found that nurses generally had high rates of correct responses to the statements, but they did not have the desired level of knowledge about preoperative hair removal methods, the optimal timing of hair removal, and the person who should perform hair removal. Therefore, training booklets and algorithms can be created with a systematic and collaborative approach among nurses, surgeons, and hospital administration.