shampoo after craniotomy: a pilot study · shampoo after craniotomy: ......

14 Volume 29, Issue 1, 2007 • Canadian Journal of Neuroscience Nursing

AbstractObjectives: The primary goal of this study was to assess theeffect of postoperative hair-washing on incision infection andhealth-related quality of life (HRQOL) in craniotomy patients.The objectives of this study were to 1) determine the effect ofpostoperative hair-washing on incision infection and HRQOL,2) provide evidence to support postoperative patient hygieniccare, and 3) develop neurosurgical nursing research capacity.

Research question: Does hair-washing 72 hours after cran-iotomy and before suture or clip removal influence postopera-tive incision infection and postoperative HRQOL?

Methods: A prospective cohort of 100 adult patients was ran-domized to hair-washing 72-hours postoperatively (n = 48), orno hair washing until suture or clip removal (n = 52). At five to-10 days postoperatively, sutures or clips were removed, inci-sions were assessed using the ASEPSIS Scale (n = 85) and par-ticipants were administered the SF-12 Health Survey (n = 71).At 30 days postoperatively, incisions (n = 70) were reassessed.

Results: No differences were found between hair-washing andno hair-washing groups for ASEPSIS scores at five to 10 daysand 30 days, and total SF-12 scores at five to 10 days postop-eratively (p ≥ 0.05).

Conclusions: Postoperative hair-washing resulted in noincrease in incision infection scores or decrease in HRQOLscores when compared to no hair-washing in patients experi-encing craniotomy.

IntroductionThe aim of clinical nursing research is to “generate knowledgeto guide nursing practice and to improve the health and qual-ity of life of nurses’ clients” (Polit & Beck, 2004, p. 3).Although research-based practice and evidence-based healthcare has received a great deal of emphasis in recent years, arelatively small proportion of frontline clinical nurses reportthe use of research as a basis for their practice (Mulhall, 1998).

Lawler (1991, 1997) described nursing as a profession notmerely concerned with just the physical body, but one thattakes a more holistic perspective. From Lawler’s perspective,nurses assess and intervene to meet not only the physicalneeds of patients, but also their more immediate and person-al concerns. In so doing, nurses are provided with opportuni-ties to identify unique and innovative ways to assist patients toendure and surpass the illness experience. This professionalvantage point provides staff nurses with opportunities toidentify research questions and evaluate the impact of inter-ventions designed to meet the concerns of patients on careoutcomes. However, in our experience, frontline staff nursesrarely have the opportunity to participate fully in researchprojects that would put these innovations to the test. A recentsurvey confirmed this understanding.

Using the Barriers Scale (Funk, Champagne, Wiese, &Tornquist, 1991), a survey of approximately 1,000 nurses wasconducted by the Hamilton Health Sciences Nursing ResearchCommittee to identify barriers to the utilization of research innursing practice. The top three barriers were identified as 1)not enough time to read research evidence, 2) not enoughauthority to change patient care procedures, and 3) insuffi-cient time to implement new ideas (Lee, Blatz, Dore, Ireland,

Shampoo after craniotomy: A pilot studyBy Sandra Ireland, Karen Carlino, Linda Gould, Fran Frazier, Patricia Haycock, Suzin Ilton, Rachel Deptuck, Brenda Bousfield,Donna Verge, Karen Antoni, Louise MacRae, Heather Renshaw, Ann Bialachowski, Carol Chagnon and Kesava Reddy

Étude sur les effets du lavage descheveux (shampooing) à la suited’une craniotomie récente

RésuméObjectifs : Le but principal de cette étude était d’évaluer leseffets, en phase post-opératoire, d’un shampoing surl’incision et sur la qualité de vie (HRQOL) des patientsayant subi une craniotomie. Les objectifs de cette étudeétaient de : 1. déterminer l’effet du lavage des cheveux(shampoing), en phase post-opératoire, au niveau del’incision et l’effet sur la qualité de vie des patients ayantsubi une craniotomie. 2. promouvoir une meilleure hygièneen phase post-opératoire. 3. contribuer au développementde la recherche en nursing neurochirurgical.

Question à étudier : Est-ce que le fait de laver les cheveuxdu patient dans un délai de 72 heures après une cran-iotomie et, avant l’excision des sutures ou agrafes, aug-mente le risque d’infection au site de l’incision? Et, est-ceque cela affecte la qualité de vie du patient (HRQOL)?

Méthode : Au cours d’une analyse prospective d’un groupede 100 patients adultes, certains ont été assignés, au hasard,à recevoir un shampoing 72 heures après la chirurgie (n=48)et un autre groupe (n=52) a du attendre que les sutures oules agrafes soient enlevées pour recevoir un shampoing.Après 5 à 10 jours, en période post-opératoire, les sutures ouagrafes furent enlevées. La condition des incisions a été éval-uée à l’aide de l’« ASEPSIS Scale » (n=85) et les partici-pants furent administrés le « SF-12 Health Survey » (n=71).Après 30 jours, en phase post-opératoire, toutes les incisionsont été examinées à nouveau.

Résultats : Nous n’avons pas observé de différence entre legroupe qui a eu un shampoing et celui qui n’en pas eu enutilisant la méthode « ASEPSIS Score » entre 5 à 10 jourset à 30 jours. De même, le calcul du total « SF-12 HealthSurvey » n’a pas changé entre 5 et 10 jours en phase post-opératoire. (p ≥ 0.05).

Conclusion : Administrer un shampoing, tôt en phase post-opératoire, aux patients ayant subi une craniotomie,n’augmente pas le risque d’infection au niveau de l ‘inci-sion. De plus, il ne semblaient pas avoir une diminution dela qualité de vie (HRQOL) en comparant les deux groupes

Canadian Journal of Neuroscience Nursing • Volume 29, Issue 1, 2007 15

& Zychla, 2004). Over the past three years, this evidence hasbeen used to develop strategies to increase the utilization ofevidence in nursing practice and to support frontline staffnurse participation in research projects such as this study.

This research project gave a group of frontline staff nurses ona busy neurosurgical unit the opportunity to put an idea toimprove patient care to the test. They were not only involvedin the creation of a research question that specifically relatedto their patient population, but also they were given the oppor-tunity to be involved in designing, implementing, and evaluat-ing a clinical nursing research study from beginning to end.

BackgroundAnnually at Hamilton Health Sciences, approximately 400patients require a craniotomy for a variety of neurosurgicalproblems. These include 1) brain tumour, 2) subarachnoidhemorrhage, 3) aneurysm, 4) arteriovenous malformation,and 5) traumatic head injury. Surgical site infections (SSI) arealways a concern for these patients and preventative measuresare in place to minimize this risk. Historically, one such meas-ure that has been reported by nurses to be based on physicianpreference is the order that patients refrain from hair-washinguntil sutures or clips are removed at approximately five to 10days postoperatively. When the proposed study was discussedwith neurosurgeons, they agreed with the nursing staff thatevidence was needed to identify best practice to inform clini-cal decision-making and patient health teaching in this area.

In the development of this study, frontline neurosurgical nurs-es reported anecdotal evidence that patients perceived hair-washing after cranial surgery to be important to their self-esteem and feelings of well-being. They also reported that theunclean appearance of their hair after surgery frequentlycaused patients to be concerned about wound infection andself-care after discharge. Nurses questioned whether the simpleact of postsurgical hair-washing had potential to help patients“endure” and “surpass” a major neurosurgical illness experi-ence. In order to evaluate the impact of hair-washing on patientperceptions of well-being and incision infections and informhygiene health teaching, a research study was proposed.

Research questionDoes hair-washing 72 hours after craniotomy and before sutureor clip removal influence 1) postoperative incision infection asmeasured by a wound assessment scale at five to 10 days and 30days, and/or 2) postoperative HRQOL at five to 10 days?

Literature reviewA literature review identified several studies that reported theinfluence of a variety of risk factors on surgical site infectionsin neurosurgical patient populations. Findings from a meta-analysis conducted by Barker (1994) and a prospective multi-centred trial conducted by Korinek, Golmard, Elcheick,Bismuth, Effenterre, Coriat, et al. (2005) supported the effica-cy of using prophylactic antibiotic therapy in reducing woundinfection rates in patients undergoing craniotomy. The resultsof two other studies supported that cranial surgery withouthair removal did not increase the rate of post-surgical siteinfections (Kumar & Thomas, 2002; Bekar, Korfali, Dogan,Yilmazlar, Baskan, & Aksoy, 2001). A similar study conducted

by Miller, Weber, Patel, and Ramey (2001) confirmed theseresults and also suggested that lack of hair removal improvedpatients’ feelings of confidence and self-esteem during theirpostoperative recovery. Korinek (1997) identified other riskfactors for infection in 2,944 patients with craniotomy: 1)emergency versus elective surgery, 2) clean-contaminated anddirty surgery, 3) operative time greater than four hours, and 4)recent neurosurgery.

Two additional studies reported the effect of early hair-wash-ing or bathing on the development of surgical site infectionsin spinal and cranial surgical populations. Carragee andVittum (1996) studied the effect of early bathing on woundinfections in 100 patients undergoing lumbar microdiscecto-my surgery. An intervention group was allowed to shower twodays postoperatively. A control group followed the traditionalprotocol of no bathing until sutures or clips were removed. Asingle infection occurred in the control group; no infectionwas reported in the intervention group.

Goldberg et al. (1981) studied 200 outpatients with clean headand neck lacerations that were surgically repaired in officeoperating rooms or emergency rooms. All wounds were keptdry overnight (eight to 24 hours) postoperatively. The follow-ing day, a randomly selected group of 100 patients wasallowed to use any soap available and water to rinse all aboutand over the incised or lacerated area. Shampooing hair wasallowed, but patients were instructed 1) not to scrub over theincision, 2) to let the soap and water run across it, and 3) toapply an antibiotic topical ointment to the incision post-cleansing. The control group was instructed to keep the inci-sion dry until the sutures were removed. No wound infectionoccurred in any of the 200 patients studied.

Although the evidence reviewed suggested that early cleans-ing of surgical incisions might not pose additional infectionrisk in similar patient populations, it was inadequate toanswer the research question identified in this study. A pilotresearch study was designed to provide preliminary evidenceto inform clinical decision-making and patient educationregarding the effect of hair-washing on craniotomy incisioninfection rates and HRQOL. The study was approved by theHamilton Health Sciences Research Ethics Board.

MethodsPhase oneFour neurosurgical nurses and one infection control practi-tioner, all with greater than five years experience, participatedin three craniotomy wound assessment sessions prior to theinitiation of the study to establish rater reliability in assessingcraniotomy incision using the ASEPSIS Scale (Wilson,Webster, Gruneberg, Treasure, & Sturridge, 1986).

Phase twoUsing a randomized controlled trial study design, 100 adultpatients were enrolled in the study over a 16-month period atthe Hamilton General Hospital site. Included were patientsgreater than 18 years of age who were scheduled for electiveor urgent craniotomy and recruited in a pre-operative clinic,or within 72 hours postoperatively in an intensive care unit ora neurosurgical unit. Exclusion criteria included 1) severely


immunocompromised patients related to recent chemothera-py or radiation treatment, 2) patients who were cognitivelyimpaired without a supportive caregiver or substitute deci-sion-maker, 3) presence of an open head wound or ventricu-lar drain, and/or 4) presence of active infection.

Eligible patients were identified through a daily nursingreview of clinic lists and operating room schedules. Once con-sent was obtained, participants were randomly assigned to the“hair-washing group” after 72 hours (intervention group) orthe “no hair-washing group” before suture removal at five to10 days postoperatively (control group). The nurse assigned tocare provided participants in the intervention group or theirsupportive caregiver with health teaching outlining carefulhair-washing technique to be initiated at 72 hours postopera-tively. They were also provided with a “shampoo record form’”to record the number of times they had washed their hair. Allreceived a supply of a gentle shampoo. Participants in thecontrol group were instructed to keep the incision dry untilsutures or clips were removed.

MeasuresASEPSIS Scale. The Additional treatment, Serous discharge,Erythema, Purulent discharge, Separation of deep tissue,Isolation of bacteria, and Stay as an inpatient (ASEPSIS) Scalewas used for wound assessment (Wilson et al., 1986). Thisscale was developed for the purpose of accurately grading sur-gical wound infections. Wound assessments were conductedusing the ASEPSIS Scale at five to 10 days postoperatively, atthe time of suture or clip removal and at 30 days postopera-tively. Part A of the ASEPSIS Scale provides criteria to gradethe incision from 0 to 5 depending on the percentage of thewound that demonstrates characteristics of 1) serous exudate,2) erythema, 3) purulent discharge, and 4) separation of deeptissues. Grading levels include a) absent, b) < 20%, c) 20-39%,d) 40-59%, e) 60-79%, and f) ≥ 80%. The scoring range is from0 to 30. Characteristics of purulent exudate and separation ofdeep tissue are assigned twice the value assigned to serousexudate and erythema at each level.

Part B of the ASEPSIS scale provides for the assignment ofpoints for complications related to wound infection: 1) pre-scription of antibiotics (10), 2) surgical drainage (5), 3) wounddebridement (10), 4) positive wound culture (10), and 5) pro-longed stay over 14 days (5). The scoring range is from 0 to 40.

The ASEPSIS Scale was originally created for use in a cardiacpatient population, but has since been utilized in a variety ofsurgical patient populations. Wilson et al. (1986) reported arepeatability coefficient of 4.2 in a sample of 51 sternalwounds and 3.2 in a sample of 34 leg wounds. Wilson, Weavill,Burridge, and Kelsey (1990) compared the ASEPSIS definitionof wound infection (score more than 20 points) with otherdefinitions in a sample of 1,029 surgical patients. ASEPSISscores of > 20 were more sensitive and as specific as the pres-ence of pus in indicating changes in management as an indi-cator of medical diagnosis of infection.

SF-12 Health Survey. The short form of the MOS SF-36 HealthSurvey, the SF-12, provided a summary measure of quality oflife domains of 1) general health, 2) limitations to activities ofdaily living, 3) physical health and daily activities, 4) emotions

and daily activities, 5) the degree to which pain interfered withwork activities, 6) general health perceptions, and 7) socialfunctioning (Ware & Sherbourne, 1992; McHorney, Ware, &Raczek, 1993). Participants were asked to rate their perceptionsbased on a scale ranking scores from least to most. Each SF-12item has an individualized rating scale and some items arereverse ordered. For the purpose of this study, reverse-ordereditems were reordered to ensure that all lower scores denotedpoorer perception and higher scores denoted higher percep-tions of quality of life. Using this method, the possible scoringrange was from 12 (lowest) to 47 (highest). The SF-12 provideda high degree of correspondence between summary physicaland mental health measures when compared to the widely usedSF-36 in a European study of 1,483 people (Gandek, Ware,Aaronson, Apolone, Bjorner, Brazier, et al., 1998).

Suture removal and wound assessment using the ASEPSISScale Part A, the postoperative administration of the SF-12Health Survey at five to 10 days, and the 30-day postoperativewound assessment using ASEPSIS Part A and Part B were con-ducted by the study wound assessment nurses on the inpatientunit or in an outpatient clinic after discharge. In some cases, aphysician in another hospital or a family practitioner complet-ed the ASEPSIS Scales. Wound assessment nurses and physi-cians were blinded to the group assignment of participants.

ResultsPhase oneFive craniotomy incision assessments using the ASEPSIS Scalewere conducted at each of three testing sessions resulting in atotal of 15 assessments performed by each of four nurses andone infection control practitioner acting as a control. Percentinterrater reliability was established as a function of agreementsat 89.72% (reliability coefficient 0.89) (Polit & Beck, 2004).

Phase twoDescriptive statistics. The mean age of participants was 52.68years (SD = 14.24 years). Fifty-seven per cent were female and43% were male. Sixty-three per cent of surgeries were per-formed for brain tumour, 18% for cerebrovascular problems,and 29% for other neurosurgical problems. Fifty-three per centhad an ICU stay immediately postoperatively. Mean length ofICU stay was 2.54 days (SD = 4.28). Mean length of hospitalstay, including on-site rehabilitation for some participants, was10.13 days (SD = 8.83; range one to 40 days). Of those partici-pants (n = 68) who completed the full 30-day wound assess-ment (Part A and Part B), three (4%) had total scores of > 20indicating presence of infection based on ASEPSIS criteria(Wilson et al., 1990).

Of the 100 participants recruited to the study, 48 were ran-domized to the “hair-washing group” and 52 to the “no hair-washing group”. The ASEPSIS Part A wound assessment atfive to 10 days was completed for 85 participants. The SF-12at five to 10 days was completed for 70 participants. Fourteenparticipants were unable to complete the SF-12 at five to 10days due to decreased level of consciousness and/or cognitiveor sensory deficits, and one survey was incomplete.

At 30 days postoperatively, the ASEPSIS Part A was completedfor 70 participants and Part B was completed for 68 partici-


pants. Difficulties occurred in obtaining complete ASEPSISPart A and Part B data for eight participants who were trans-ferred to other facilities. Eleven participants withdrew from thestudy for the following reasons: 1) deteriorating health (threeparticipants), and 2) undefined reasons (eight participants).Protocol errors occurred for four participants who were eithernot provided with instructions appropriate to their study group(three participants) or did not follow the prescribed hair-wash-ing routine (one participant). Four participants were deceasedbefore follow-up. Five operations were cancelled.

Group comparisons. A student’s t test demonstrated no differ-ences between the “hair-washing group” and the “no hair-wash-ing group” means on ASEPSIS Part A scores at five to 10 days (n= 85), total SF-12 scores at five to 10 days (n = 70), ASEPSIS PartA scores at 30 days (n = 70), and ASEPSIS Part B Scores at 30days (n = 68) (p = > 0.05). Means on only one of the seven SF-12subscales demonstrated significant differences between thegroups (p = < 0.05). Higher mean scores on the single-item bod-ily pain subscale in the “no hair-washing group” indicated thatpain had interfered to a lesser degree with their normal work(including both work outside the home and housework) in thepast week when compared with the “hair-washing group” (p =0.031). Table one summarizes these results.

Developing capacity inneurosurgical nursing researchA total of 14 neurosurgical nurses participated in the researchprocess. Included were those in the following practice roles:staff nurses (five) advanced practice (two), operating roomfirst assistant (one), preoperative clinician (one), managers(two), infection control practitioner (one), post-diploma stu-dent (one), and data analyst (one). Research roles assumed bythese nurses included 1) study design, 2) the development ofpatient education tools, 3) staff education, 4) identification ofeligible patients, 5) consent-taking, 6) wound assessment, 7)survey administration, 8) data collection, 9) data input, 10)data analysis, and 11) reporting of results.

Although the overall research experience was reported byfrontline staff nurse researchers to be a positive one, barriersto their participation included difficulty in ensuring continu-ity of coverage for the study associated with shift work and the

competing priorities of patient assignments and other duties.Although study funding provided backfill for study nurses,and management provided unlimited support, staffing chal-lenges frequently made their full participation difficult.Additionally, it was identified that pre-study training includ-ing a review of basic research methods and data managementwould have enriched the research experience for nurses andimproved protocol efficiency.

DiscussionGiven the reported low prevalence of incision infection ratesof 4% for neurosurgical procedures reported by Korinek(1997) and confirmed by the findings reported here, thesmall sample size utilized limits the generalizability of theresults of this study. Replication of this study in other neuro-surgical patient populations is recommended to validatethese results. However, the findings of this study are consis-tent with evidence previously described that supported thecleansing of surgical wounds in superficial cranial and otherthan cranial locations.

Although the number of participants who were lost to five- to10-day follow-up was less than 20%, the study team experi-enced significant challenges in ensuring that participantswere followed up at 30 days. This resulted in only 68% of par-ticipants completing all steps in the study process and a lost-to-full-follow-up rate of 32%.

The study team has suggested that several measures toimprove follow-up be implemented in future neurosurgicalnursing research to include: 1) limiting recruitment topatients living within the immediate hospital area, 2) random-ization in the perioperative or immediate postoperative phaseof care, 3) routine telephone contact by the study nurses dur-ing the course of the study, and 4) investigating the possibilityof obtaining follow-up data from neurosurgeons at thepatient’s post-discharge appointment at six weeks. However,in a patient population where postoperative morbidity andmortality, and multiple care provider management are thenorm, it is suggested that follow-up challenges may be diffi-cult to avoid.

Although all participants in the intervention group washedtheir hair at least once in the period between their operation

Table One. Comparison of “hair-washing” and “no hair-washing” groups

Hair Washing Group No Hair Washing Group Sig.

N M (SD) N M (SD) p

ASEPSIS Part A 5-10 daysa 39 1.28 (1.07) 46 1.35 (1.61) 0.82

ASEPSIS Part A 30 daysa 33 .52 (1.09) 37 .68 (1.45) 0.60

ASEPSIS Part B 30 daysa 31 2.10 (6.80) 37 1.38 (4.80) 0.62

SF-12 Total 5-10 daysb 36 31.33 (6.41) 34 34.06 (7.30) 0.10

SF-12 Subscaleb 36 3.19 (1.33) 34 3.91 (1.40) *0.03Pain Limitations to Daily Activities

* p = < 0.05 a higher scores indicate greater % of wound characteristics meet definition of infectionb higher scores indicate higher SF-12 ratings of HRQOL


and suture or clip removal at five to 10 days postoperatively,the shampoo records providing a measure of frequency werenot consistently completed and many were not returned.Unfortunately, these data were inadequate to provide reliableresults and were excluded from the analysis. Full data wouldhave provided a measure of how the frequency of hair-wash-ing influenced scores on the ASEPSIS and SF-12 measures. Itis recommended that future studies include measures toensure the collection of hair-washing frequency data.

A strength of this study was the resultant close monitoringand consistent reporting of wound assessment and infec-tion data over time. This resulted in improved woundassessment skills and a heightened awareness of the needfor diligent wound surveillance on the part of all membersof the interdisciplinary team. The increased awarenessextended to the standardization of health teaching materi-als and procedures related to patient hygienic self-carebefore and after hospital discharge, and increased follow-upmonitoring.

The 30-day follow-up visit provided staff nurses with anopportunity to ensure that pre- and post-discharge care metpatient and family needs. At the 30-day visit, study nursesreported that many participants required interventions rang-ing from monitoring medication levels and assessing for uri-nary tract infections to arranging semi-urgent appointmentsfor attendance at the neurosurgeon’s office or the regionalcancer centre to address outstanding concerns. Since thesefindings were communicated to the neurosurgical staff, theirreferrals of patients to the nurse-led follow-up clinic haveincreased.

It is a concern that those participants in the “hair-washinggroup” reported significantly more pain-related limitationsto their work (including work outside the home and house-work) activities in the past week (p = 0.03), as measured byscores on the single-item SF-12 pain subscale. It is recog-nized that the SF-12 Health Survey measures pain indirectlythrough its effect on work and other normal activities ratherthan directly. It is recommended that future research supple-ment the single-item SF-12 bodily pain measure with a directmeasure of self-reported pain in order to validate this result.Additionally, it would be important to collect these self-report data at regular intervals during the postoperative peri-od and before suture or clip removal in the “hair-washing” or“no hair-washing” groups. Evidence-based management ofpostoperative pain while the patient is in hospital and duringthe early discharge period is a priority concern for neurosur-gical nurses.

ConclusionsIt can be concluded from the results of this pilot study, that ina group of 100 participants undergoing craniotomy, hair-washing at 72 hours postoperatively resulted in no increase inwound infection rating scores when compared with no hair-washing. Additionally, postoperative hair-washing did notaffect total scores on a health-related quality of life measure.Further study is indicated to replicate the results of this studyin other neurosurgical patient populations.

AcknowledgementsFunded by the Hamilton Health Sciences Foundation and theCanadian Nurses Foundation.

Supported by Neurosciences and Trauma Program Staff, Dr.Kesava Reddy, Dr. Mark Loeb, and Johnson and Johnson.

ApprovalsThis study was approved by the Hamilton Health SciencesResearch Ethics Board.

Permission to use the SF-12 Health Survey was purchasedfrom Medtronics.

About the authorsSandra Ireland, RN, PhD, Chief of Nursing Practice,Hamilton Health Sciences, Hamilton General Hospital,Hamilton, ON. Correspondence regarding this article shouldbe addressed to Dr. Sandra Ireland by e-mail: [email protected]

Karen Carlino, RN, BScN, Nurse Clinician, NeuroscienceAmbulatory Clinic, Hamilton Health Sciences.

Linda Gould, RPN, Stroke Data and Evaluation Specialist,Neuroscience Ambulatory Centre, Hamilton Health Sciences.

Fran Frazier, RN, Staff Nurse, Neuroscience Unit, HamiltonHealth Sciences.

Patricia Haycock, RN, BScN, former Clinical Educator,Neuroscience Unit, Hamilton Health Sciences, sessionalInstructor for Mohawk-McMaster Nursing Program.

Suzin Ilton, RN, RNFA, Operating Room, Hamilton HealthSciences.

Rachel Deptuck, RN, Staff Nurse, Neuroscience Unit,Hamilton Health Sciences.

Brenda Bousfield, RN, Staff Nurse, Neuroscience Unit,Hamilton Health Sciences.

Donna Verge, RN, Staff Nurse, Neuroscience Unit, HamiltonHealth Sciences.

Karen Antoni, RN, BSc, MSc, ACNP, former ACNP in theIntensive Care Unit at Hamilton Health Sciences, currentlyACNP for the Acute Pain Service.

Louise MacRae, RN, BScN, MBA, former Manager of theNeuroscience Unit, Hamilton Health Sciences.

Heather Renshaw, RN, Clinical Manager, Neuroscience Unit,Hamilton Health Sciences.

Ann Bialachowski, RN, BScN, former Infection ControlPractitioner Hamilton Health Sciences, currently RegionalInfection Control Coordinator.

Carol Chagnon, RN, BScN, Clinical Manager of the CardiacCare Unit Hamilton Health Sciences, BScN student who con-tributed to the study.

Dr. Kesava Reddy, MD, FRCS(C), Head of ServiceNeurosurgery, Hamilton Health Sciences.


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References

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