LAKEHEAD UNIVERSITY LIBRARY 
Nursing Knowledge and MRS A 
3 0012 01044648 1 
Running head: NURSING KNOWLEDGE AND MRSA 
Master of Public Health Project 
Nursing Knowledge and Methicillin-Resistant Staphylococcus aureus: 
Implications for Community Health Nursing in First Nations Communities 
Cheryl A. Chisholm 
Lakehead University 
MPH 
Supervisor: Dr. Lome McDougall 
March 19, 2009 
THESES 
M.P.H. 
2009 
C52 
ProQuest Number: 10611530 
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Nursing Knowledge and MRSA 2 
Abstract 
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a serious 
nosocomial and community-associated pathogen in aboriginal people in Canada 
(Canadian Pediatric Society, 2005). A recent survey with First Nations employed 
community health nurses (CHNs) in the Atlantic region found that nursing knowledge is 
lowest in the area of emerging infections such as MRSA (Mi’kmaq Confederacy of 
Prince Edward Island, 2009). The objective of this project is to review the nursing 
literature on this topic and to describe the factors that contribute to low nursing 
knowledge of MRSA. A search of the literature published during 2000-2008 using 
Medline, CINAHL with full text, DARE, and CD SR was conducted using the following 
search terms: “community-acquired MRSA”, “hospital-associated MRSA”, “hospital- 
acquired MRSA”, “community-associated MRSA”, “MRSA”, “community health 
nursing”, “nurse” “nursing”, “antibiotic resistant organisms”, “nosocomial infections” 
and “knowledge”. The search generated 48 papers for review. For each paper, 
information was obtained on the study population, health care setting (acute or 
community), geographic location of the research, and the study type. Publications were 
sorted by topic area MRSA (CA-MRSA, HA-MRSA or both) or nosocomial infections. 
The articles were also organized into key theme areas for further description. Sixty-two 
and one half percent (30) of the papers referred to healthcare workers as the study 
population (nurses, doctors, aides, dentists). Nurses were the primary study population in 
37.5% (18) of the papers, with only three of these papers focused on community health 
nurses. The research in this area has emerged from the United Kingdom (37.5%) and the 
United States (35%), with a paucity of research on this topic in Canada (15%) and the 
Nursing Knowledge and MRS A 3 
rest of the world. Sixty-two and one half percent of the papers focused on MRSA with 
two of the papers discussing CA-MRSA, Thirty-seven and one half percent of the papers 
focused on the broader topic of nosocomial infections. Acute care is the most common 
setting for research in this area (73%). Only five articles were found on this topic in a 
community setting. The majority of literature available addresses MRSA knowledge 
deficits and strategies to address them. There is limited literature published on the factors 
contributing to low nursing knowledge of MRSA. The review suggests that a gap exists 
in infection control content in nursing curriculum at the undergraduate level and between 
nurses’ reported knowledge and practice. The review also suggests that nurses’ personal 
way of knowing contributes to their knowledge of MRSA. Further research is required 
on these factors. Additional research on this topic is needed in Canada and in a variety of 
nursing practice settings. Nurses employed in First Nations communities warrant 
increased attention considering the implications of MRSA in aboriginal people. 
Nursing Knowledge and MRS A 4 
Nursing Knowledge and Methicillin-Resistant Staphylococcus aureus: 
Implications for Community Health Nursing in First Nations Communities 
The emergence of MRS A as a nosocomial and community-associated pathogen in 
Canada has resulted in a number of concerns (Canadian Pediatric Society, 2005), MRSA 
is associated with high morbidity and mortality, increased health care costs (First Nations 
and Inuit Health Branch, 2008) and is considered a key health issue affecting the health 
of Canadian aboriginal people (Canadian Pediatric Society). In 1990, Taylor, Kirkland 
and Kowalewska-Grochowska were the first to document cases in the aboriginal 
population in Canada after an outbreak of a multi-strain cluster of MRSA in a First 
Nations community in Alberta from 1986-1989 (Hawkes, Barton, Conly, Nicolle, Barry, 
& Ford-Jones, 2007). Since this outbreak, there has been increased attention to MRSA in 
Canadian aboriginals (Canadian Pediatric Society). One Canadian study found that 
aboriginals were six times more likely to have community-acquired MRSA than non- 
aboriginals (Ofner-Agostini, Simor, Bryce, Mcgeer, Kiss, & Paton, 2006). 
Much of the literature published in this area to date has focused on the 
epidemiology of the bacterium, risk factors, prevention and treatment. Recently, there 
has been more inquiry on the knowledge and practice of nurses in acute care settings. 
However, the literature in regards to the MRSA knowledge in community health nurses is 
limited. A recent survey conducted with First Nations employed community health 
nurses (CHNs) in the Atlantic region reports that nursing knowledge is lowest in the area 
of emerging infections such as MRSA (Mi’kmaq Confederacy of Prince Edward Island, 
2009). This is a significant finding considering the implications of this emerging 
pathogen in aboriginal people. 
Nursing Knowledge and MRS A 5 
It is important to understand the factors that contribute to low levels of nursing 
knowledge of MRSA. This project will provide an in-depth review of the nursing 
literature to explore the factors that contribute to low nursing knowledge levels of 
MRSA. The specific objectives guiding this project are: 
1. To provide an overview of the literature of MRSA in Canada 
2. To provide a description of the nursing theory of “multiple ways of knowing” in 
community health nursing 
3. To describe the published literature regarding nursing knowledge and MRSA 
4. To describe the factors contributing to nurses’ knowledge of MRSA 
5. To discuss the implications of these findings to community health nursing 
practice in First Nation communities 
6. To discuss questions for future research 
The following section will provide an overview of the literature of MRSA in Canada, 
followed by a review of the history and context of community health nursing in First 
Nations communities in Atlantic Canada and will conclude with the theoretical 
framework for community health nursing knowledge. 
MRSA: An Overview 
This section will include definitions, MRSA in Canada, risk factors, and 
transmission. 
Case definitions 
The rise of anti-biotic resistant organisms has resulted from the overuse of 
antibiotics (Yetman, 2006). After repeated exposure to antibiotics, bacteria mutate and 
Nursing Knowledge and MRS A 6 
become stronger and more resistant to antibiotic regimens (Yetman). In the case of 
MRSA, it is sometimes challenging for nurses to differentiate between the health-care 
associated and the community-associated strains of the bacteria. For the purposes of this 
discussion, the case definitions below are used: 
MRSA: “MRSA demonstrates resistance to the semi-synthetic penicillins 
(methicillin, oxacillin and cloxacillin). It is also resistant to cephalosporins, 
monobactams and carbapenems. Resistance to other antibiotic classes may occur, 
but it is strain dependent” (Barton, Hawkes, Moore, Conly, Nicolle, Allen, et al. 
2006, p.6C). 
Health Care-Associated MRSA (HA-MRSA): “Patients with infections that 
developed > 3 days after admission to hospital, or who stayed in a hospital or 
resided in a long-term care facility at any time during the 12 months before 
symptom onset” (Canadian Nosocomial Infection Surveillance Program, 2008). 
Community Associated-MRSA: “MRSA isolates obtained from individuals in the 
community who have not had recent exposure to the health care system, or from 
patients in health care facilities in whom the infection was present or incubating at 
the time of admission” (Barton et al., 2006, p. 6C). 
MRSA colonization: “The presence of MRSA without any clinical sign or 
symptoms of infection” (Canadian Nosocomial Infection Surveillance Program, 
2008). 
Nursing Knowledge and MRSA 
The case definitions and the other terms defined below are found in the Appendix. 
Aboriginal: “This is a collective name for all of the original peoples of Canada 
and their descendants. The Constitution Act of 1982 specifies that the Aboriginal 
Peoples in Canada consists of three groups - Indians, Inuit and Metis. Indians, 
Inuit and Metis peoples have unique heritages, languages, cultural practices and 
spiritual beliefs” (Indian & Northern Affairs Canada, 2001). 
Communicable Disease: “An illness due to a specific infectious agent or its toxic 
products that arises through transmission of that agent or its products from an 
infected person, animal, or reservoir to a susceptible host, either directly or 
indirectly through an intermediate plant or animal host, vector or the inanimate 
environment” (Last, 2001, p.35). 
Epidemiology: “The study of the distribution and determinants of health-related 
states or events in specified populations and the application of this study to 
control of health problems” (Last, 2001, p.62). 
First Nations: “A term that came into common usage in the 1970s to replace 
Indian. Although the term First Nation is widely used, no legal definition of it 
exists. Among its uses, the term “First Nations Peoples” refers generally to the 
Indian Peoples in Canada, both Status and non-Status” (Indian & Northern Affairs 
Canada, 2001). 
Nursing Knowledge and MRSA 8 
Inuit: “Inuit are the Aboriginal People of Arctic Canada who live primarily in 
Nunavut, the Northwest Territories and northern parts of Labrador and Quebec” 
(Indian & Northern Affairs Canada, 2001). 
Nosocomial Infection: “An infection originating in a medical facility, e.g. 
occurring in a patient in a hospital or other health care facility in whom the 
infection was not present or incubating at the time of admission. Includes 
infections acquired in the hospital but appearing after discharge; it also includes 
such infections among staff’ (Last, 2001, p.l25). 
Pathogen: “Organism capable of causing disease (literally causing a pathological 
process)” (Last, 2001, p.l32). 
MRSA in Canada 
MRSA is increasing in Canada (Public Health Agency of Canada, 2008). MRSA 
increased in Canadian hospitals from 0.46% to 9.1% per 1000 admissions from 1995 to 
2006 (Public Health Agency). This data is presented in Table 1. The Canadian 
Nosocomial Infection Surveillance Program (CNISP) reports a slight decrease of HA- 
MRSA in Canada in 2007, and that CA-MRSA increased by 8% (2008). 
There are many limitations in the collection and availability of data on MRSA in 
Canada. While there is a need for MRSA surveillance data, the burden of disease is not 
as significant as what is experienced in the United States (Allen, 2006). Thus, there have 
not been significant investments in surveillance systems to capture HA-MRSA and CA- 
MRSA rates regardless of setting. The only systematic data collection on MRSA is 
Nursing Knowledge and MRS A 9 
through the surveillance of hospital admissions (CNISP, 2008). Therefore, there are 
limitations to a broader public health interpretation of the data as the program falls within 
the domain of a nosocomial surveillance program (CNISP, 2008). 
Table 1 
MRS A in Canada 1995-2006 
PUBUC HEALTH AGENCY tf CANADA ACENCE DE SANTfi PUBUQUE dm CANADA 
MRSA in Canada from 1995 to 2006 
*Preliminary results for 2006 
(CNISP, 2008) 
Another factor for consideration is that MRSA is not a reportable disease in every 
jurisdiction in Canada (Nicolle, 2006). For example, consider two provinces in the 
Atlantic region: MRSA is reportable in Nova Scotia, and is not a reportable disease in 
the province of New Brunswick. Allen (2006) suggests, a “more structured and regulated 
approach to reporting and surveillance of MRSA at the provincial and national level” 
(p. 162). Systematic data collection, analysis and communication are integral elements of 
a robust public health system (Last, 2001). 
Nursing Knowledge and MRSA 10 
Risk Factors 
There are different risk factors for HA-MRSA and CA-MRSA. Those identified 
as being at risk for HA-MRSA include persons: currently or recently hospitalized, 
residing in a long-term care facility, having invasive procedures and those with recent or 
long-term antibiotic use (First Nations and Inuit Health, 2008). Those identified at risk 
for CA-MRSA include: children < two years of age, minority populations (Aboriginal, 
African), athletes who play contact sports, intravenous drugs users, men who have sex 
with men, military personnel, correctional inmates, veterinarians, pet owners and pig 
farmers (Gilbert, MacDonald, Gregson, Siushansian, Zhang, Elsayed et al., 2006; 
Hawkes et al., 2007; Ofner- Agostini et al., 2006; Yetman, 2006). Other environmental 
risk factors such as low socio-economic status and overcrowded housing are described in 
the literature as risk factors for both HA-MRSA and CA-MRSA (Allen, 2006). 
Transmission 
MRSA infections are spread by close skin to skin contact with a person with 
MRSA infection or colonization or by coming into direct contact with a surface or item 
contaminated with MRSA (such as wound dressings, towels or linens) (Allen, 2006; 
Heymann, 2004). Sub-optimal hygiene, crowding, frequent skin to skin contact, sexual 
activity and sharing personal items can increase the likelihood of transmission (Allen, 
2006; Barton et al., 2006; Gilbert et al., 2006). However, the main mode of transmission 
is via contaminated hands (Whitney, Marchant-Short & Yiu; cited in Leeseberg Stamler 
& Yiu, 2008). The outcomes of this infection can range from a mild abscess or cellulitis 
to invasive infections such as joint infections, necrotizing pneumonia or septicaemia 
(Adam, McGeer, & Simor, 2007; Kowalski, Berbari, & Osmon, 2005). 
Nursing Knowledge and MRSA 11 
The next section will review community health nursing in First Nations 
communities in Atlantic Canada. This will provide the nursing practice context that we 
will be discussing in relation to the research findings. 
The Landscape: First Nation Community Health Nursing in Atlantic Canada 
Mary Thomas, an elder from Neskonilth Band once said, “In order to move ahead 
and get on with our lives, we have to know where we came from; we have to look at 
where we’ve been to get to where we’re going. ” (Napoleon, 1992; cited in British 
Columbia First Nations Health Handbook, n.d., p.3) This section provides an overview 
of nursing practice in First Nations communities in Atlantic Canada including the 
following topics: demographics, First Nations managed health care, cultural competence 
and jurisdictional and legislative barriers. As there are limitations in published data 
regarding community health nursing in Atlantic Canada, some information contained in 
this section comes from my knowledge and experience as a community health nurse at 
First Nations and Inuit Health (FNIH), Atlantic Region. 
Demographics 
The Atlantic region of Canada includes the provinces of Nova Scotia, New 
Brunswick, Prince Edward Island, and Newfoundland and Labrador. This region is 
within the traditional territories of the Mi’kmaq, Maliseet, Innu and Inuit peoples. There 
are approximately 37,867 First Nations people comprising approximately 1% of the 
population of Atlantic Canada (Statistics Canada, 2008). The population has increased 
by 2% since 2004-2005. The average age of First Nations people in Canada is 30 years 
of age, with 69.7% of the population under the age of 40 (Statistics Canada). There are 
Nursing Knowledge and MRSA 12 
33 independent First Nations communities in Atlantic region ranging in size from 40 to 
3200 members with 13 communities in Nova Scotia, 15 in New Brunswick, two in Prince 
Edward Island and three in Newfoundland and Labrador. Public health programs for the 
seven Inuit communities in Labrador are self-managed by the Nunatsiavut Department of 
Health and Social Development and are not included in this discussion. 
There is a wealth of research on the poor health status of Canada’s First Nations 
people (Shah, 2003; Smylie, 2000). Atlantic Canada is not unique from the rest of 
Canada as health issues such as poverty, housing concerns, mental health, infectious 
disease. Type II diabetes, addictions, and obesity abound (First Nations Centre, 2005). 
First Nations Managed Health Care 
As a result of the Indian Health Policy of 1979, followed by the federal 
governments’ health transfer policy of 1989, there was a move to transfer control of 
health services to First Nations communities by the early 1990s (Kulig, MacLeod, & 
Lavoie, 2007). In Atlantic region, many First Nations communities chose to sign 
agreements for health transfer. This process was done in a bilateral way, without any 
involvement from the provincial governments (G. Bailey, personal communication, 
September, 2005). The process of health transfer was expedited in a swift manner with 
minimal planning and without the establishment of supportive environments. 
What does health transfer look like through a community health nursing lens? 
While CHNs practice within provincial legislation (including scope of practice and 
nursing standards), they are employed by the Chief and Council (with the exception of 2 
in Atlantic region), and are sometimes supervised by an individual with a limited health 
background (Kulig et al., 2007). Program policies and procedures were not considered at 
Nursing Knowledge and MRSA 13 
the time of transfer leaving most communities without adequate supports for nursing 
practice. Nursing policies and procedures are still a gap in most First Nations 
communities in Atlantic region. 
Cultural Competency 
The Mi’kmaq belief that “for every sickness on this Earth, there is a medicine 
under your feet” emphasizes the importance of culture in community health nursing 
practice (Cook, 2005, p. 96). Cultural competence reduces disparities in health services 
and impacts the health status of culturally diverse communities (College of Registered 
Nurses of Nova Scotia, 2006; Community Health Nurses Associations of Canada, 2003; 
Mahealani, Broad & Allison, 2002; Nova Scotia Department of Health, 2005; Wittig, 
2004). The First Nations perception of health differs from the traditional Western 
definition (First Nations Centre, 2005; Smylie & Anderson, 2006). The medicine wheel is 
a circular symbol that represents the wholeness of traditional First Nations life (First 
Nations Centre, 2005; Johnson, n.d.). Health and wellness are inseparable from the 
physical, spiritual, mental, economic, environmental, social and cultural wellness of the 
individual, family, and community (Johnson). It is a perfectly balanced shape without a 
top or bottom, length or width and represents constant movement and change (balance) 
(First Nations Centre). A healthy community is one with a lack of material scarcity and 
where its members are self-confident and participate in its political, economic and 
cultural life (First Nations Chiefs Health Committee and BC Ministry of Health, n.d.). 
While a large proportion of First Nations people in Atlantic Canada are Roman 
Catholic, many use traditional teachings, ceremonies and medicines as part of health and 
healing (Nova Scotia Department of Health, 2005). A survey done with Mi’kmaq clients 
Nursing Knowledge and MRSA 14 
at a First Nations community health center suggested that more than half of the clients 
(66%) use or have used traditional Mi’kmaq medicine and of this group a large number 
feel that traditional medicine is more effective than Western medicine (Cook, 2005). 
Furthermore, 92% of these participants do not discuss their use of traditional medicine 
with their physician (Cook). 
This evidence implies that community health nurses should be aware of and 
responsive to the needs of their First Nations clients by providing opportunities to 
integrate sweetgrass, sweat lodges, healing circles, spirit workshops, and medicine 
teachings into the nursing care plan (Dobblesteyn, 2006; Mahealani Broad and Allison, 
2002). 
Jurisdictional and Legislative Barriers 
The lack of clarity on roles and responsibilities of various stakeholders providing 
health care to First Nations peoples can be problematic (Nova Scotia Department of 
Health, 2005). Community health centers are funded to provide a range of public health 
services while primary, secondary and tertiary care is the responsibility of the provincial 
health system. The work within the community health center is public health oriented 
and this creates a need for inter-connectivity with respective public health partners. Each 
province has a unique public health structure as well as a unique history with the First 
Nations communities in their jurisdiction. 
While there is no federal Public Health Act, the Public Health Agency of Canada 
(PHAC) works collaboratively with many partners in the prevention and control of 
communicable diseases (PHAC, 2008). PHAC’s leadership role on MRSA surveillance 
through CNISP has already been described. The most recent national MRSA project is a 
Nursing Knowledge and MRSA 15 
new educational initiative titled, Safer Healthcare Now (SHN), that has been developed 
by PHAC, the Community Healthcare Infection Control Association of Canada and the 
Canadian Patient Safety Authority (PHAC, 2008). The objective of this project is to 
provide health staff across Canada with the knowledge and tools needed to address 
MRSA in their workplace (PHAC, 2008) 
Authority for communicable disease control lies within the domain of the 
provincial government. Therefore, issues such as provincial surveillance, diagnosis, 
notification of communicable diseases and outbreak identification are managed at a local 
public health unit level. Furthermore, the provincial public health systems do not have 
the capacity for First Nations people to self-identify their ethnicity (Smylie & Anderson, 
2006). Thus, local public health units are unable to identify a First Nations client as living 
on reserve until contact tracing is started. As noted previously, the unique structure and 
history of the local public health unit impacts how communicable disease management 
plays out at the community level. Some First Nations communities may be contacted to 
proceed with communicable disease case follow-up, while other CHNs may never be 
informed of the disease in their community. CHNs require community level data that 
reflects First Nations ethnicity and geographic location (Smylie & Anderson). While this 
is the current reality there are many options for integration of services involving the 
federal government, provincial government and First Nations being explored (e.g. 
Panorama project)(NS Department of Health, 2005; First Nations and Inuit Health 
Branch, 2006). 
There are many complexities in the day to day practice of First Nations employed 
CHNs that affects the acquisition and implementation of new knowledge. As discussed. 
Nursing Knowledge and MRSA 16 
the multitude of health issues in the First Nations population, the move towards self- 
determination in health programs and understanding the aboriginal traditions and ways of 
knowing impact community health nursing knowledge. The overlay of the jurisdictional 
web adds further complexity to the CHNs nursing knowledge especially in the area of 
communicable disease prevention and control. 
The following section will introduce the theoretical framework that outlines the 
foundation of knowledge patterns in nursing. 
Multiple Ways of Knowing: A Theoretical Framework 
Simply defined, knowledge is an “awareness or familiarity gained by experience 
(of a person, fact or thing)” (Barber, 1998, p. 787). This field of study emerged from the 
work of early theorists like Descartes who proposed that all knowledge can be explained 
by cause and effect (Streubert Speziale, 2003). This viewpoint was challenged in later 
years by theorists such as Kant, Husserl and the German school of philosophy (Streubert 
Speziale). They proposed that not all of reality can be explained by cause and effect and 
this development provided an opportunity for exploration of the lived experience and the 
meaning of this in social science (Streubert Speziale). 
Multiple ways of knowing, first described in the nursing literature by Carper 
(1978; cited in Fawcett, 2004), are four knowledge patterns in nursing: empirics, ethics, 
esthetics, and personal. Carper proposed that positive care outcomes result only from the 
integration of the four knowledge patterns (1978). Subsequent authors (Jacobs-Kramer & 
Chinn, 1988; White, 1995; cited in Fawcett) have built upon Carper’s work and this 
theory has been incorporated into the Canadian Community Health Nursing Practice 
Nursing Knowledge and MRSA 17 
Model (Canadian Community Health Nurses Association (CHNAC), 2003). The 
multiple ways of knowing framework is outlined in Table 2. 
Table 2 
Multiple Ways of Knowing Framework  
Way Of Knowing Definition  
Aesthetics The art of nursing, means adapting knowledge and practice 
to particular rather than universal circumstances. It 
encourages nurses to explore possibilities, promotes 
individual creativity and style, and contributes to the 
transformative power of community health nursing. 
Example: The way a nurse would provide care differently 
for two elderly women based on the nurse’s knowledge of 
each woman’s particular life circumstances 
Empirics Empirics, the science of community health nursing, includes 
research, epidemiology and theories and models 
(incorporating publicly verifiable, factual descriptions, 
explanations and predictions based on subjective and 
objective data). Empirical knowledge is generated and tested 
by scientific research (Fawcett, Watson, Neuman & Hinton, 
2001). 
Example: Treatment regimens for diabetes mellitus. 
Nursing Knowledge and MRSA 18 
Way Of Knowing Definition  
Personal Knowledge The most fundamental way of knowing, comes from 
discovery of self, values and morals and lived experience. It 
involves continuous learning through reflective practice. 
Reflective practice in community health nursing combines 
critical examination of practice, interpersonal relationships 
and intuition to evaluate, adapt and enhance practice. 
Example: Understanding of one’s beliefs and the capacity 
for change. 
Ethics Ethics or moral knowledge, describes the moral obligations, 
values and goals of community health nursing. It is guided 
by moral principles and ethical standards set by the Canadian 
Nurses Association (2002). Ethical inquiry clarifies values 
and beliefs and uses dialogue to examine the social and 
political impact of community health nursing on the health 
environment (Fawcett et al., 2001). 
Example: This type of knowing is important when decisions 
of right and wrong are blurred by differences in values and 
beliefs. 
Nursing Knowledge and MRS A 19 
Way Of Knowing Definition  
Socio-political Socio-political knowledge or emancipatory knowing, goes 
knowledge beyond personal knowing and nurse-client introspection. It 
places nursing within the broader social, political and 
economic context where nursing and health care happen. It 
equips the nurse to question the status quo and structures of 
domination in society that affect the health of individuals and 
communities. 
Example: The effect of social determinants on health. 
(CHNAC, 2003, pg.7; Streubert Speziale, 2002, pg 4-6). 
Knowing is defined as “the state of being aware or informed of anything” (Barber, 
1998, p.787). This framework of knowing describes nurses as active participants in the 
acquisition of new knowledge (CHNAC, 2003). The ideology of this framework is 
supported by the findings of Belenky, Clinchy and Tarule (1986; cited in Streubert 
Speziale, 2003). They suggest that “when presented with received knowledge from 
authority figures (teachers, adults); the receiver should ask themselves about their own 
perceptions of this knowledge” (p.3). 
An understanding of the evolution of knowledge theory and the multiple ways of 
knowing framework is an important consideration for this review. Multiple ways of 
knowing recognizes that knowledge is more complex than what is learned through 
empirical inquiry (CHNAC, 2003). “By recognizing diverse evidence for practice. 
Nursing Knowledge and MRS A 20 
community health nursing is able to question and move beyond the status quo, evolve and 
create relevant and effective action for community health” (Community Health Nurses 
Association of Canada, 2003, p.7). 
Method 
A search of the literature using Medline, CINAHL with full text, DARE, and 
CD SR was conducted using the following medical subject heading (MeSH) and text 
words used alone or in combination: “community-acquired MRSA”, “hospital-associated 
MRSA”, “hospital-acquired MRSA”, “community-associated MRSA”, “MRSA”, 
“community health nursing”, “nurse” “nursing”, “antibiotic resistant organisms”, 
“nosocomial infections” and “knowledge”. Journal articles published during 2000-2008 
were included. Further articles were acquired after review of the initial reference list. 
Table 3 outlines the inclusion and exclusion criteria for the search. 
Table 3 
Search Criteria  
Category Inclusion Criteria Exclusion Criteria 
Language English Non-English 
Study Population Registered Nurses (All Countries) 
Topic Of Interest Community Associated MRSA 
Hospital Care Associated MRSA 
Nosocomial Infections 
Study Type Systematic Reviews Letters 
Meta-Analyses Editorial 
Prospective/Retrospective Studies News reports 
Practice Guidelines 
Narrative Reviews, Grey Literature 
Nursing Knowledge and MRSA 21 
It became evident early in the search that the MRSA literature in the community 
setting is very limited. Accordingly, there was a lack of published literature on the 
knowledge of community health nurses in regards to MRSA. A decision was made to 
include literature regarding infection control and nosocomial infections. 
For each article, information was obtained on the study population, health care 
setting (acute or community), geographic location of the research, and the study type. 
Publications were also categorized as dealing with specifically with MRSA (CA-MRSA, 
HA-MRSA or both) or the broader category of nosocomial infections. Comparisons of 
practice areas in the acute care setting have not been attempted in this review. 
Results 
The search was completed in October 2008 and generated more than 100 articles. 
48 papers were selected for review after eliminating articles that did not meet the 
inclusion criteria. Further articles were acquired on review of the reference list of the 
articles found in the initial review. 
Sixty-two and one half percent (30) of the papers referred to healthcare workers 
as the study population (nurses, doctors, aides, dentists). Nurses were the primary study 
population in 37.5% (18) of the papers, with only three of these papers focused on 
community health nurses. The research in this area has emerged from the United 
Kingdom (37.5%) and the United States (35%), with a paucity of research on this topic in 
Canada (15%) and the rest of the world. Sixty-two and one half percent of the papers 
focused on MRSA with three of the papers discussing CA-MRSA. Thirty-seven and one 
half percent of the papers focused on the broader topic of nosocomial infections. Acute 
care is the most common setting for research in this area (73%). Seventeen percent of the 
Nursing Knowledge and MRSA 22 
papers were set in both acute and community settings. Only five articles were set in a 
community setting. 
Eight articles were found that addressed the project objective of describing the 
factors contributing to nurses’ knowledge of MRSA. There were no studies found on 
MRSA knowledge in First Nations employed CHNs nurses in Canada. A summary of 
these findings are found in Table 4. The section following the summary table describes 
the themes that emerged in this review. 
tN 
Nursing Knowledge and MRSA 
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Nursing Knowledge and MRSA 
Nursing Knowledge and MRSA 28 
Knowledge needs and strategies to improve knowledge and practice will be 
reviewed first. This will be followed by a more detailed review of the studies exploring 
the factors contributing to nursing knowledge. 
Knowledge Deficits and Strategies 
The literature on this topic is largely empiric, with an emphasis on increasing 
knowledge in the areas of hand hygiene (Fairclough, 2005; Maskerine & Loeb, 2006; 
Pittet, Hugonnet, Harbarth, Mouraga, Sauvan, Touveneau, et al., 2005; Trampuz & 
Widmer, 2004), standard precautions (Banning, 2005; Easton, 2005; Gould, 2004; 
Ghabrah, 2007; Prieto & Clark, 2005), disease transmission (Banning, 2005; Lugg & 
Ahmed, 2008; Stirling, Littlejohn, & Willbond, 2008; Tisinger, 2008) and antibiotic 
stewardship (Conly, 2002; Plonczynski & Plonczynski, 2005). Raising awareness among 
health care workers about MRSA and the implications on practice in various settings is a 
key message throughout the literature (Alex & Letizia, 2007; Anderson, 2003; Farley, 
2007; Nazarko, 2007). 
Strategies to address MRSA knowledge deficits were abundant in the literature. 
Infection control policies and procedures were mentioned the most frequently (Antoniak, 
2004; Conly, 2002; Gould, 2004; Larson, Quiros, Giblin, & Lin, 2007; Lines, 2006; 
Lopez-Alcalde, Contemo, Mateos-Mazon, Guevara-Eslava, Job-Neto, & Sola, 2008; 
Plonczynski & Plonczynski, 2005; Trigg, 2008; Wilcox, 2005; Wills, 2005). Other 
strategies frequently mentioned include: education on surveillance of infection incidence 
and treatment (Conly, 2002; Plonczynski & Plonczynski, 2005; Tisinger, 2008), broad 
health care system campaigns (Larson, Early, Cloonan, Sugrue, & Parides, 2000; Larson 
et ah, 2007; Pittet et al., 2000; Wilcox, 2005; Wills, 2005), education regarding alcohol 
Nursing Knowledge and MRSA 29 
based sanitizer (Dragon, 2006; Hussein, Khakoo, & Hobbs, 2006; Pittet et al., 2000; 
Trampuz & Widmer; 2004;) and the implementation of MRSA standards and guidelines 
(Alberta Health and Wellness, 2007; Alberta Health and Wellness, 2008; Barton et al., 
2006; Boyce & Pittet, 2002; Holcombe, 2006). 
There are other strategies mentioned less frequently in the review but are worth 
noting. They include: reduction of inappropriate prescribing (Conly; 2002; Lines, 2006; 
Plonczynski & Plonczynski, 2005; Wills, 2005), improved environmental conditions (ie. 
access to hand washing facilities, alcohol hand sanitizer at the bedside) (Pittet et al., 
2000; Rollins, 2008; Trampuz & Widmer, 2004), education of patients to advocate for 
hand hygiene (Dragon, 2006; Rollins, 2008), organizational leadership (Antoniak, 2004; 
Trampuz & Widmer, 2004), performance feedback and audits (Gould, 2004; Maskerine 
& Loeb, 2006; Preston, 2005; Trigg, 2008) and a positive deviance approach (Forsha & 
Richmond, 2007; Hospital Infection Control, 2008). Positive deviance is a participatory 
approach where staff identifies the issues and work collaboratively to identify solutions 
(Hospital Infection Control) 
The following section will provide a review of the eight papers that specifically 
address the objective of describing the factors contributing to nurses’ knowledge of 
MRSA. These factors can be grouped into three areas: nursing education 
(basic/continuing), a gap between reported knowledge and practice and nurses’ personal 
ways of knowing. 
Nursing Education 
Nursing knowledge is integral for relevant and effective action for community 
health (CHNAC, 2003). However, nurses are not knowledgeable of MRSA despite the 
Nursing Knowledge and MRSA 30 
introduction of guidelines for various health care settings in both Canada and the United 
States (Barton et ah, 2006; Easton, 2005; Prieto & Clark, 2005). The literature suggests 
that the lack of knowledge of MRSA and other anti-biotic resistant organisms can stem 
from lack of content in nursing curriculum (Andersen, 2003; Gill, Kumar, Todd & 
Wiskin, 2005; Hallett, 2000). Nurses consider their basic education to be an important 
source of knowledge (Gill et ah, 2005), but there is a recognition that infection control is 
not often a subject that is covered well within core nursing curriculum (Anderson, 2003). 
A study by Hallett (2000), identified a “fatalistic approach” (p.l07) by community health 
nurses in infection control as “practitioners appear to emerge from the educational 
process unsure what they think and unsure what to do” (p.l07). 
While there were no published studies regarding nursing students' knowledge of 
MRSA, one study investigated MRSA awareness and knowledge in new nursing staff in 
a tertiary care hospital in Saudi Arabia (Navaneeth, 2003). The nurses had difficulty in 
detecting an outbreak of MRSA in the hospital and they were not familiar with the proper 
treatment regime (Navaneeth). These findings were consistent with the hypothesis that 
basic nursing education does not provide adequate knowledge of MRSA or infection 
control measures. 
The Gap between Nursing Knowledge and Practice 
The literature also suggests that the lack of knowledge of MRSA and other 
nosocomial infections can stem from limitations in continuing education provided by the 
employer (Andersen, 2003; Gill et al., 2005; Ott, Shen & Sherwood, 2005). Registered 
nurses have entry level competencies from their professional licensing body (College of 
Registered Nurses, 2006). However, the need for continuing education for nurses in 
Nursing Knowledge and MRSA 31 
MRSA goes beyond basic education and has been noted in both published studies and 
various clinical guidelines (Gill et ah, 2005). One study assessed the learning needs of 
CHNs in First Nations communities (Silverman, Goodline, Ladouceur & Quinn, 2001). 
While the survey questions did not address MRSA or nosocomial infections, 64.5% of 
those surveyed requested public health and programming planning initiatives (including 
communicable disease control) to be included in their learning program (Silverman et al). 
As previously mentioned, a regional communicable disease program survey conducted in 
2008, found that Atlantic First Nations employed CHNs’ level of knowledge was lowest 
for emerging infectious diseases such as MRSA (Mi’kmaq Confederacy of Prince 
Edward Island, 2009). The nurses identified MRSA as a priority for future training 
sessions (Mi’kmaq Confederacy of Prince Edward Island, 2009). 
Numerous studies and clinical guidelines have emphasized the importance of 
adherence to workplace MRSA policies and procedures in order to provide a safe 
environment for both nurses and clients (Barton et ah, 2006). Easton, Sarma, Williams, 
Marwick, Phillips and Nathwani found that 70% of nurses were able to correctly identify 
S. Aureus as a gram positive organism (2005). They also found knowledge deficits as 
only 14% of nurses correctly identified the risk factors for MRSA colonization and 
infection (Easton et ah). Furthermore, the majority of nurses in this study failed to 
identify the most common sites for MRSA infection as well as common complications of 
MRSA infection (Easton et ah). 
Prieto and Clark (2005) conducted a study with 100 nurses and 18 health care 
assistants on the implementation of contact precautions with MRSA and Clostridium 
difficile. They found low knowledge levels of MRSA and contact precautions in the 
Nursing Knowledge and MRSA 32 
study population. Lugg and Ahmed (2008) also reported low knowledge levels of MRSA 
in a group of adult and pediatric nurses. A difference was found, however, in the adult 
nurses as they reported higher knowledge and self-reported practice than the pediatric 
nurses (Lugg & Ahmed). 
Trigg conducted a hospital audit on MRSA knowledge levels and found that 71% 
of staff felt MRSA was a serious issue and that most nurses had read the MRSA policy 
(2008). Different results were found in a qualitative study done by Lines (2006). A 
group of 10 experienced registered nurses reported that MRSA was uncontrollable and 
they did not feel that the management of MRSA was a priority in their nursing care 
(Lines). 
van Gemert-Pijnen, Hendrix, van der Palen and Schellens conducted a study in 
Dutch hospitals where they reviewed the performance of MRSA protocols with a variety 
of health care workers using a questionnaire and a practical test (2005). The results of the 
questionnaire were positive in relation to the knowledge, attitude and self-reported 
behaviour related to MRSA protocols. Ninety-seven percent of nurses reported 
familiarity with the protocol and subsequently reported 91% compliance with the 
protocol (van Gemert-Pijnen et al.). The results of the practical test demonstrated that 
staff overestimated their knowledge of MRSA protocols because they were only able to 
carry out the practical test scenarios less than 50% of the time (van Gemert-Pijnen et al.). 
These results are consistent with a study done by Berhe, Edmond, and Bearman (2005) 
and Ghabrah, Madani, Albarrak, Alhazmi, Alazraqi, Alhudaithi, et al. (2007), where the 
health care worker’s self-reported high knowledge of infection control and compliance 
with infection control measures is better than their actual demonstrated practice. 
Nursing Knowledge and MRSA 33 
Multiple Ways of Knowing: Personal Knowledge 
Four articles explored nurses’ personal way of knowing, or the ability of the nurse 
to know oneself (Cole, 2008; Hallett, 2000; Prieto & Clark, 2005; van Gemert-Pijnen et 
ah, 2005). van Gemert-Pijnen et al.’s study (2005), as discussed previously, describes 
nurses’ personal way of knowing. The completion of the practical test demonstrated that 
some nurses had challenges with the MRSA protocols because the protocols interfered 
with client care and they were not consistent with their practice needs (van Gemert-Pijnen 
et al.). 
Prieto and Clark (2005) also provided insight to the participants’ decision making 
in relation to their infection control practice. The authors found that nurses (100) and 
assistants (18) held personal beliefs and perceptions of risk (to themselves and to the 
client) that the authors stated to be irrational (Prieto & Clark). These results were similar 
to Hallet’s findings (2000). Using a qualitative interview method, Hallet found the seven 
nurses interviewed appeared ambivalent towards infection control and what could 
realistically be achieved through policy (2000). 
Cole (2008) authored the final paper reviewed for this section. His narrative 
review provides an overview of the concept of compliance. The author discussed the 
reality of low knowledge levels of policies and procedures regardless of availability 
(Cole). The author challenges the concept that increasing knowledge will result in 
improved policy adherence and concludes that incorporation of the personal, lived 
experience is integral to decision making in practice (Cole). 
“Infection control education is fundamental to the ongoing development of 
practice. However, it needs to include more than microbiology, epidemiology and 
universal precautions. Compliance is a social construct and infection 
control nursing, this author would argue, is a social science” (Cole, 2008, p. 703). 
Nursing Knowledge and MRSA 34 
Discussion 
The purpose of this review is two-fold. The first objective is to describe the 
published literature regarding nursing knowledge and MRSA and secondly to describe 
the factors contributing to nurses’ knowledge of MRSA. The results of this review have 
demonstrated that the research on this topic is largely empiric and has increased between 
2000 and 2008. While MRSA affects health care practitioners in all settings, research is 
limited to acute care settings. The review also demonstrates that nurses are less likely to 
be the primary study population as compared to the broad category of health care 
workers. 
The research on this topic area is more common in the United States and the 
United Kingdom. Canadian research on this topic was surprisingly low given the media 
attention to outbreaks of nosocomial infections in health care facilities over the past few 
years. The majority of the papers in the review were focused on MRSA or the broader 
topic of nosocomial infections. Only four papers focused on CA-MRSA. This was an 
unexpected finding considering increasing rates of CA-MRSA in Canada (CNSIP, 2008). 
Only one paper was found that reviewed nursing knowledge needs in First Nations 
employed CHNs in Canada. No papers were found looking specifically at MRSA in First 
Nations employed CFINs. This was not an unexpected finding, yet it highlights a 
research gap considering the trends of MRSA in Canadian aboriginals. 
The majority of papers in this review emphasize areas of knowledge deficits in 
MRSA and various approaches to mitigate these deficits. The identification of 
knowledge deficits is a key component of the knowledge cycle and is integral to effective 
Nursing Knowledge and MRSA 35 
nursing practice (CHNAC, 2003). Nursing knowledge of MRSA was consistently 
reported as low in this review (Barton et al., 2005; Easton, 2005; Lugg & Ahmed, 2008; 
Navaneeth, 2003; Prieto & Clark, 2005; Trigg, 2008). Knowledge deficits identified 
include (in descending order of frequency): hand hygiene, standard precautions, disease 
transmission, antibiotic stewardship, the difference between CA-MRSA and HA-MRSA, 
and epidemiology. There were several narrative reviews that focused on raising 
awareness among nurses in other settings (school, occupational health, nurse 
practitioners, and community). Deficits found in fundamental concepts such as hand 
hygiene and disease transmission were unexpected findings. These findings have a 
broader application than just the acute care setting. The areas that have been identified as 
deficits are fundamental concepts in infection control and are a cornerstone of nursing 
practice, regardless of setting. 
The largest number of papers in this review focused on strategies for improving 
practitioner knowledge and practice. The strategies identified include (in descending 
order of frequency): infection control policies and procedures, education on surveillance 
of infection incidence and treatment, broad health care system campaigns, education 
regarding alcohol based sanitizer, implementation of MRSA standards and guidelines, 
reduction of inappropriate prescribing, improved environmental conditions (ie. access to 
hand washing facilities, alcohol hand sanitizer at the bedside), education of patients to 
advocate for hand hygiene, organizational leadership, performance feedback and audits. 
The review also revealed three different approaches in improving health care 
worker knowledge and practice. The papers were targeted at the individual practitioner. 
Nursing Knowledge and MRSA 36 
hospital units or wards or the organizational level. There were no papers found in the 
review that compare outcomes of strategies directed at individuals, units or organizational 
level. There were no papers that report on the outcome of multiple intervention strategies 
(individuals, units and organizational). 
There is more attention to the improvement of practice of individual practitioners 
in this review. The positive deviance approach was discussed in two papers and is 
suggested as an organizational strategy for improving MRSA knowledge. This was a 
new finding and appears to be an approach that is consistent with the principles found in 
successful participatory action projects in First Nations communities (Smith & Davies, 
2006). A participatory approach involves participants coming together, understanding 
each other’s goals, influencing each other’s work, building partnerships and the self- 
identification of solutions (Smith & Davies). 
The review also focused on a closer examination of the nursing literature on 
possible factors contributing to nursing knowledge of MRSA. The results of this 
examination were limited to only eight papers that address this objective. These factors 
can be grouped into three areas: nursing education (basic/continuing), a gap between 
reported knowledge and practice and nurses’ personal ways of knowing. The limited 
amount of research is of particular significance in the results of this review. The findings 
suggest that the answers are in part related to the lack of content in undergraduate nursing 
curriculum and the gap between nurses’ perceived infection control knowledge and 
practice. 
Nursing Knowledge and MRSA 37 
Perhaps the answer can be found in further exploration of nurses’ personal way of 
knowing. The papers reviewed provided evidence of the reflective nature of nursing 
practice that “combines critical examination of practice, interpersonal relationships and 
intuition to evaluate, adapt and enhance practice” (CHNAC, 2003, p.7). These findings 
have identified that the traditional empirical approach to this area of study needs to be 
broadened to encompass critical inquiry on the other areas of nursing knowledge. These 
findings are consistent with the CHNAC multiple ways of knowing framework. 
Limitations 
In conducting this research, articles found in Medline, CINAHL with full text, 
DARE, and CDSR were reviewed. It is possible that some articles published in journals 
not indexed in these databases were missed. There are several limitations in this review. 
The majority of the papers on this topic are narrative reviews and are generally set in 
acute care settings. A smaller number of papers used either a quantitative, qualitative or 
mixed method. However, sample sizes in all of these studies are small. Only one 
proposal for a systematic review was found (Lopez-Alcade et al., 2008). Papers 
investigating the factors contributing to nursing knowledge are also limited. While the 
findings are useful to inform an educational program design, they are not generalizable to 
nurses in other settings. 
Significance of Findings to Public Health Policy and Practice 
There were many themes that emerged in this review that have implications for 
First Nations community health nursing in Atlantic Canada. It is known that MRSA 
knowledge levels are low in this population of nurses. This is consistent with the 
findings of this review. The findings have suggested many areas that will inform an 
Nursing Knowledge and MRSA 38 
education strategy for First Nations employed CHNs. This strategy should be 
participatory in nature, where nurses self-identify their learning needs and how to address 
them (CHNAC, 2003). The strategy needs to consider the themes that emerged in the 
review. Topics that could be considered include: MRSA incidence in aboriginal people, 
transmission, treatment, the difference between HA-MRSA and CA-MRSA, social 
determinants of MRSA, cultural competence, hand hygiene, standard precautions and the 
reduction of inappropriate prescribing. The findings also suggest that a strategy include 
interventions at the workplace and community level. Activities that could be considered 
are: education and leadership of Chief, council and community, education of all 
healthcare providers, education of community members to be informed about hand 
hygiene and appropriate antibiotic use, development and implementation of appropriate 
infection control policies and procedures (e.g. MRSA, hand hygiene), and monitoring and 
feedback on infection control performance. 
Significance of Findings to Public Health Research 
The need for attention to First Nations employed CHNs knowledge of MRSA is 
immediate. The review of the trends of MRSA in Canadian aboriginals, the implications 
of this pathogen on the health of Canada’s First Nations people, and the absence of 
current research on this topic identify this as a potential area for future research. 
The literature reviewed on nursing knowledge and MRSA is complex and raises 
many challenges for nursing educators, practitioners and managers. MRSA first emerged 
in the acute care setting and is now a reality in all areas of nursing practice in Canada. 
However, there is silence of this topic within the nursing research community in Canada. 
Nursing Knowledge and MRSA 39 
Furthermore, this review has identified a need for further study on nursing knowledge of 
MRSA in settings outside of acute care. 
Lastly, these findings support the theoretical framework of multiple ways of 
knowing. Nurses develop “their own unique pathway to knowledge construction and 
problem solving, which is dependent on their previous experiences” (Cole, 2008, p.702). 
Further exploration of the integration of knowledge patterns will improve our collective 
understanding of how the nurse “co-creates nursing knowledge” (CHNAC, 2003, p.7) 
which leads to improved knowledge and practice. 
Nursing Knowledge and MRSA 40 
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Nursing Knowledge and MRSA 54 
Appendix 
Definition of Terms 
Aboriginal: “This is a collective name for all of the original peoples of Canada 
and their descendants. The Constitution Act of 1982 specifies that the Aboriginal 
Peoples in Canada consists of three groups - Indians, Inuit and Metis. Indians, 
Inuit and Metis peoples have unique heritages, languages, cultural practices and 
spiritual beliefs” (Indian & Northern Affairs Canada, 2001). 
Communicable Disease: “An illness due to a specific infectious agent or its toxic 
products that arises through transmission of that agent or its products from an 
infected person, animal, or reservoir to a susceptible host, either directly or 
indirectly through an intermediate plant or animal host, vector or the inanimate 
environment” (Last, 2001, p.35). 
Community Associated-MRSA: “MRSA isolates obtained from individuals in the 
community who have not had recent exposure to the health care system, or from 
patients in health care facilities in whom the infection was present or incubating at 
the time of admission” (Barton, Hawkes, Moore, Conly, Nicolle, Allen, et al., 
2006, p. 6C). 
Epidemiology: “The study of the distribution and determinants of health-related 
states or events in specified populations and the application of this study to 
control of health problems” (Last, 2001, p.62). 
Nursing Knowledge and MRSA 55 
First Nations: “A term that came into common usage in the 1970s to replace 
Indian. Although the term First Nation is widely used, no legal definition of it 
exists. Among its uses, the term “First Nations Peoples” refers generally to the 
Indian Peoples in Canada, both Status and non-Status” (Indian & Northern Affairs 
Canada, 2001). 
Inuit: “Inuit are the Aboriginal People of Arctic Canada who live primarily in 
Nunavut, the Northwest Territories and northern parts of Labrador and Quebec” 
(Indian & Northern Affairs Canada, 2001). 
Health Care-Associated MRSA (HA-MRSA): “Patients with infections that 
developed > 3 days after admission to hospital, or who stayed in a hospital or 
resided in a long-term care facility at any time during the 12 months before 
symptom onset” (Canadian Nosocomial Infection Surveillance Program, 2008). 
MRSA: “MRSA demonstrates resistance to the semi-synthetic penicillins 
(methicillin, oxacillin and cloxacillin). It is also resistant to cephalosporins, 
monobactams and carbapenems. Resistance to other antibiotic classes may occur, 
but it is strain dependent” (Barton et al., 2006, p.6C). 
MRSA colonization: “The presence of MRSA without any clinical sign or 
symptoms of infection” (Canadian Nosocomial Infection Surveillance Program, 
2008). 
Nursing Knowledge and MRSA 56 
Nosocomial Infection: “An infection originating in a medical facility, e.g. 
occurring in a patient in a hospital or other health care facility in whom the 
infection was not present or incubating at the time of admission. Includes 
infections acquired in the hospital but appearing after discharge; it also includes 
such infections among staff’ (Last, 2001, p.l25). 
Pathogen: “Organism capable of causing disease (literally causing a pathological 
process)” (Last, 2001, p.l32).