|Year : 2020 | Volume
| Issue : 4 | Page : 272-279
Knowledge and attitudes toward preventing hospital-acquired infections among nurses and residents at a university hospital
Mazin Barry, Ghada Alhadlaq, Reem Alsergani, Rana Almana, Nora Alshabib, Najd Altheeb
Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||06-Mar-2020|
|Date of Decision||10-May-2020|
|Date of Acceptance||10-May-2020|
|Date of Web Publication||25-Jul-2020|
Department of Internal Medicine, Division of Infectious Disease, College of Medicine, King Saud University, P.O. Box: 2925, Riyadh 11461
Source of Support: None, Conflict of Interest: None
Introduction: Survey questionnaire hospital-acquired infections (HAIs) can be prevented through correct prevention and control measures. We assessed knowledge and attitudes of nurses and postgraduate residents in a developing country, by comparing knowledge on HAI and its prevention between internal medicine and surgery residents and between nurses in outpatient departments, wards, and intensive care units (ICUs) to assess need on more focused training. Methodology: This was a cross-sectional study measuring the knowledge and attitudes on HAI among 261 health-care workers. A questionnaire was adapted from the Centers for Disease Control and Prevention and World Health Organization. The association between knowledge score percentage and demographic and work-related factors was assessed using independent samples t-test or one-way analysis of variance when appropriate. The Chi-square test (Fisher's exact test when appropriate) was used to compare the percentage of correct answers between residents and nurses. Results: Nurses and residents did not meet the accepted level of knowledge, with mean scores of 71.2% among 160 nurses and 66% among 101 residents. Nurses' knowledge score was significantly associated with their department (P < 0.001). Nurses working in ICUs had a higher mean knowledge score (81.68%) than nurses working in outpatient (56.77%) or inpatient (72.5%) settings. Whereas, no significant difference is found among residents' mean knowledge score according to their departments. Conclusions: Residents and nurses had insufficient knowledge regarding HAI prevention varying by department. Corrective measures through increased education and training intensively targeting specified areas would be helpful in improving knowledge and preventing infections.
Keywords: Hospital-acquired infections, knowledge, nurses, residents
|How to cite this article:|
Barry M, Alhadlaq G, Alsergani R, Almana R, Alshabib N, Altheeb N. Knowledge and attitudes toward preventing hospital-acquired infections among nurses and residents at a university hospital. J Nat Sci Med 2020;3:272-9
|How to cite this URL:|
Barry M, Alhadlaq G, Alsergani R, Almana R, Alshabib N, Altheeb N. Knowledge and attitudes toward preventing hospital-acquired infections among nurses and residents at a university hospital. J Nat Sci Med [serial online] 2020 [cited 2020 Oct 20];3:272-9. Available from: https://www.jnsmonline.org/text.asp?2020/3/4/272/291091
| Introduction|| |
Hospital-acquired infections (HAIs) occur uniformly in both developed and more frequently developing countries. Despite being widely distributed, a 1-day point-prevalence survey at a tertiary hospital in Riyadh, Saudi Arabia, showed that 8% of the patients developed HAI, of whom 46.7% developed HAI in intensive care units (ICU).
Proper infection prevention and control with education and training are essential in addressing HAI and its prevention. A recent report by the Centers for Disease Control and Prevention (CDC) examined the United States' progress toward eliminating common types of HIA. Accordingly, a 19% decrease in central line-associated bloodstream infections (CLABSIs), 12% decrease in catheter-associated urinary tract infections (CAUTIs) in acute care hospital wards, and a 11% decrease in surgical site infections (SSIs) had been observed between 2015 and 2017.
No previous studies have assessed health-care workers' level of knowledge regarding HAI in our target population in Saudi Arabia (i.e., internal medicine and surgery residents and nurses from outpatient departments, wards, and ICUs). Our hypothesis is that health care workers who are more exposed to HAI would have superior knowledge on their prevention which would result in future educational focus on health care workers who are less exposed to such events.
| Methodology|| |
This quantitative, observational, questionnaire-based, cross-sectional study was approved by our hospital's institutional review board (IRB No. E-19-4055). Informed consent was obtained from all participants before the study. Accordingly, participants filled out a survey containing multiple-choice questions (MCQs) based on the CDC and World Health Organization (WHO) guidelines. Data were collected from January 6, 2019, to February 25, 2019. This study included nurses from outpatient clinics, inpatient wards, and ICUs settings. In addition, postgraduate medical doctors in residency training programs in both Departments of Internal Medicine and Surgery were included. External rotating residents were excluded from this study.
Knowledge regarding HAI and its prevention at institute name masked for peer review, an academic center serving the largest college of medicine in the country, was assessed using an 18-item survey divided into seven main sections. The first section was about demographic characteristics of the study participants which consisted of six items. The second section was about attitude and knowledge regarding hand hygiene. Attitude was assessed using two items (each having several subitems), and knowledge was assessed using two MCQs., The third section was about personal protective equipment (PPE). Attitude was assessed using one item, which included several subitems, each inquiring about protective equipment that would be used by the participant in a specific scenario. Knowledge was assessed using two questions. The fourth section was about SSI., This section included two MCQs that assessed participants' knowledge. The fifth section was about CLABSI. Knowledge was assessed using two MCQs., The sixth section was about CAUTI. Knowledge was assessed using three MCQs. The seventh section was about ventilator-associated pneumonia, and two MCQs were used to assess knowledge.,,,
Categorical variables, such as sociodemographic characteristics, and responses to various knowledge and attitude questions were expressed using numbers and percentages. Knowledge scores were presented using means and standard deviations. Bar plots were used to visualize responses to various questions related to knowledge of HAI.
For MCQ related to knowledge, participants were awarded 1 point for each correct answer and no points for wrong answers. The percentage of correctly answered questions for each participant was then calculated by dividing the total number of correctly answered questions by total number of questions (n = 13).
Factor associated with knowledge regarding hospital-acquired infections
Statistical analysis was performed to identify demographic and work-related factors associated with knowledge score among nurses and residents. The association between knowledge score and demographic and work-related factors was assessed using independent samples t-test or one-way analysis of variance (ANOVA) when appropriate. Both statistical tests were chosen due to the continuous and approximately normal nature of the dependent variable (knowledge score percentage). Independent samples t-test was used for independent variables with only two levels (e.g., gender), whereas one-way ANOVA was used for independent variables with more than two levels (e.g., education). The Chi-square test (or Fisher's exact test when appropriate) was used to compare the percentage of correct answers (for individual knowledge questions) between internal medicine and surgery residents, with P < 0.05 being considered statistically significant.
Knowledge and attitude among residents and nurses
The independent samples t-test was used to assess differences in the mean knowledge score between nurses and residents. The Chi-square test for independence (or Fisher's exact test when appropriate) was used to compare the distribution of responses to individual attitude and knowledge questions between nurses and residents. The Chi-square test aimed to determine whether the distribution of responses among the two groups differed significantly from that expected under the hypothesis of no association, with P < 0.05 being considered statistically significant.
| Results|| |
The study sample comprised 261 participants who completed the survey, with female predominance (74.3% vs. 25.7%, respectively). Residents represented 38.7% (n = 101) of the study sample, of whom 49.5% (n = 50) were surgical residents and 50.5% (n = 51) were internal medicine residents, whereas nurses represented the remaining 61.3% (n = 160). Most nurses had either 5–10 years (n = 56, 35%) or >10 years (n = 73, 45.6%) of experience. Included nurses worked in ICU (38.1%), outpatient (31.3%), and inpatient (30.6%) setting. [Table 1] shows the demographic characteristics of the study sample, whereas [Table 2] stratifies them by occupation.
|Table 2: Demographic characteristics of the study sample (stratified by occupation)|
Click here to view
A significant difference in gender was observed between nurses and residents (P < 0.001), with a female predominance of nurses (n = 151, 94.4%) compared with residents (n = 43, 42.6%).
Attitude toward hospital-acquired infections
Attitude toward the importance of hand hygiene
Attitude toward hand hygiene was similar among residents and nurses, except regarding the importance of hand hygiene for patients' visitors, where only 87% of the residents selected “very important” or “important” and 99% of the nurses selected “very important.” Attitude toward the importance of hand hygiene for colleagues and residents/nurses was similar among both the groups [Figure 1].
Frequency of handwashing at specific situations
Differences in the frequency of handwashing at various occasions were observed between residents and nurses. One main difference between the groups was the frequency of handwashing after opening the door, with only 62% of the residents selecting “always” or “sometimes,” while 98% of the nurses did. Another difference between both the groups was the frequency of handwashing after using the stethoscope, with only 75% of the residents selecting “always” or “sometimes,” while 96% of the nurses did. The third notable difference was the frequency of handwashing before wearing gloves, with only 64% of the residents responding with “always” or “sometimes,” while 98% of the nurses responding did [Figure 2].
Moreover, more nurses than residents selected “always” or “sometimes” for the following situations: before touching a patient (100% vs. 88%, respectively), after touching a patient's surroundings (100% vs. 91%, respectively), and after taking off gloves (100% vs. 92%). Nonetheless, percentages were similar for the following situations: after body fluid exposure, after touching a patient, and before aseptic procedures [Table 3].
|Table 3: Attitudes toward and frequency of handwashing among residents and nurses|
Click here to view
A significant difference in the attitude toward the importance of handwashing was observed between nurses and residents (P < 0.05 for all comparisons). Similarly, nurses had a higher reported frequency of handwashing in the various proposed scenarios than residents (P < 0.05 for all scenarios). More nurses than residents selected responses indicating higher frequency. These results indicate that nurses displayed a better attitude toward handwashing than residents.
Attitude toward personal protective equipment
Some differences in the use of PPE were observed between nurses and residents. For contact precautions, almost 43% of both nurses and residents believed a mask is necessary. For droplet precautions, more nurses selected a surgical mask than residents (89.4% vs. 62.4%). For airborne precautions, nearly 65% of both the groups believed both gown and gloves are necessary [Figure 3].
|Figure 3: Attitude toward personal protective equipment among nurses and residents|
Click here to view
Knowledge regarding HAI prevention
Knowledge regarding HAI prevention
Significantly more nurses than residents identified correct answers for the sequence for donning PPE (95.6% vs. 83.2%, respectively; P < 0.05) and precautions for preventing SSIs in the presence of hair (73.8% vs. 52.5%, respectively; P < 0.05). However, more residents than nurses identified the correct time to administer prophylactic antibiotics (54.5% vs. 40.6%, respectively; P < 0.05). Moreover, 44.6% of the residents and 31.2% of the nurses provided a correct response regarding the management of asymptomatic patients with an indwelling catheter and a positive urine culture (P < 0.05).
More nurses than residents correctly answered the question related to the oral hygiene of patients on mechanical ventilation (72.5% vs. 43.6%, respectively; P < 0.001), a question in which the greatest difference between nurses and residents was observed. Moreover, 80.6% of the nurses and 62.4% of the residents correctly answered the question related to the prevention of aspiration (P < 0.05) [Table 4].
Knowledge score percentage among nurses and residents
Nurses had a significantly higher average knowledge score than residents, although the difference between both the groups was ~5%. Nurses and residents correctly answered 71.2% and 66% of the questions, respectively (P < 0.05 using independent samples t-test) [Table 5].
Factors associated with knowledge regarding HAI
Factors associated with knowledge among nurses
A significant association was observed between knowledge score and department (P < 0.001). Accordingly, nurses working in the ICU had a significantly higher mean knowledge score (81.68%) than those working in outpatient (56.77%) or inpatient (72.5%) settings, supporting the association between department and knowledge regarding HAIs [Table 6].
|Table 6: Association between demographic and work-related characteristics and knowledge score among nurses|
Click here to view
Factors associated with knowledge among residents
No significant association was observed between overall knowledge score and age, gender, residency year, and department (P > 0.05) [Table 7]. A detailed analysis was performed to assess whether responses to certain questions differed significantly between internal medicine and surgical residents [Table 8].
|Table 7: Association between demographic and work-related characteristics and knowledge score among residents|
Click here to view
|Table 8: Association between department and responses to knowledge questions|
Click here to view
Examining the responses to knowledge questions among internal medicine and surgery residents showed that surgery residents had significantly higher knowledge on SSI than internal medicine residents. On the contrary, internal medicine residents were more knowledgeable on CLABSI than surgery residents.
| Discussion|| |
This study measured nurses' and postgraduate residents' knowledge and attitudes regarding HAI and how to prevent them, while also comparing levels of knowledge between different departments to determine whether exposure to certain HAI affects knowledge thereof. Our results showed that residents, both surgical and medical, scored below the accepted threshold of knowledge set by the WHO and CDC guidelines regarding precautions used against HAI, with means of 66.97% and 64.92%, respectively. No significant difference in knowledge was observed between medical or surgical subspecialties. However, regarding knowledge on SSI, 80% of the surgical residents correctly answered the question regarding the appropriate time to administer prophylactic antibiotics, whereas only 29.4% of the medical residents did. Moreover, 68% of the surgery residents correctly answered the question regarding precaution toward hair removal at operating site, whereas only 39.2% of the medical residents did. On the contrary, 88.2% of the medical residents correctly answered the question regarding appropriate management for CLABSI, whereas only 68% of the surgery residents did. As for nurses, all three departments scored below the optimal score. However, a significant difference was observed between knowledge and rate of exposure. Accordingly, ICU nurses, who had the highest exposure to HAI, had the highest mean score of 81.68%, whereas OPD nurses, who had the least rate of exposure to HAI, had a mean score of 56.77%. Meanwhile, inpatient nurses had a mean score of 72%.
With residents and nurses being the frontline of patient care, optimal knowledge levels are imperative for preventing HAI. The study concludes that there is a gap in knowledge between different departments which should be breached through effective training programs. Training programs for different levels of health care workers should be implemented, with scoring surveys before and after such programs to monitor acquisition of required knowledge. The results highlight the importance of adequate knowledge regarding HAI, as it would play a major role in prevention. When looking specifically at nurses alone, previous studies has shown that their knowledge regarding HAI was 90%, attitudes were 84.4% and preventive practice were 76.2%, these scores are higher than what we have found in our study population which highlights different institutions training programs and exposure to HAI; however, no previous study has looked at postgraduate residents per se. As for the limitation of the study, there was no organized method of sending out our survey to all health-care workers in the hospital.
| Conclusions|| |
This study suggests that nurses have a higher overall knowledge regarding HAI than residents, although the absolute difference in knowledge score was only 5%. Moreover, our results suggest that both nurses and residents exhibit a good level of knowledge regarding HAI.
Our results also supported the association between department and knowledge score among nurses, considering that ICU nurses exhibited higher knowledge than inpatient or outpatient nurses. The overall knowledge score did not significantly differ between internal medicine and surgery residents. This study highlights the necessity for more education and formal training regarding HAI prevention and precautions among nurses and in particular postgraduate residents.
Financial support and sponsorship
The authors extend their appreciation to the Deanship of Scientific Research at King Saud University for funding this work through the Undergraduate Research Support Program Project.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Revelas A. Healthcare - Associated infections: A public health problem. Niger Med J 2012;53:59-64. [Full text]
Balkhy HH, Cunningham G, Chew FK, Francis C, Al Nakhli DJ, Almuneef MA, et al
. Hospital- and community-acquired infections: A point prevalence and risk factors survey in a tertiary care center in Saudi Arabia. Int J Infect Dis 2006;10:326-33.
Moolenaar RL, Crutcher JM, San Joaquin VH, Sewell LV, Hutwagner LC, Carson LA, et al
. A prolonged outbreak of Pseudomonas aeruginosa
in a neonatal intensive care unit: Did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol 2000;21:80-5.
Boyce JM. Scientific basis for handwashing with alcohol and other waterless antiseptic agents. In: Rutala WA, editor. Disinfection, Sterilization and Antisepsis: Principles and Practices in Healthcare Facilities. Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc.; 2001. p. 140-51.
Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35 10 Suppl 2:S65-164.
Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, et al
. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:605-27.
Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N
Engl J Med 1992;326:281-6.
Haddadin Y, Regunath H. Central Line Associated Blood Stream Infections (CLABSI). Treasure Island (FL): StatPearls Publishing; 2019.
Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: Effect of site of placement and catheter type. Infect Control Hosp Epidemiol 1998;19:842-5.
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010;31:319-26.
Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med 2006;32:230-6.
Pearson LS, Hutton JL. A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. J Adv Nurs 2002;39:480-9.
Torres A, Serra-Batlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, et al
. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: The effect of body position. Ann Intern Med 1992;116:540-3.
Orozco-Levi M, Torres A, Ferrer M, Piera C, el-Ebiary M, de la Bellacasa JP, et al
. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med 1995;152:1387-90.
Gruda A, Sopjani I. The knowledge, attitudes and practices of nurses toward management of hospital-acquired infections in the university clinical center of Kosovo. Mater Sociomed 2017;29:84-7.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]