End-stage renal failure requires a variety of treatment options including dialysis and transplantation, which are procedures in which infection control is of paramount importance . Infection is potentially preventable; yet, it remains the second most common cause of death in hemodialysis .
To prevent transmission of infections in dialysis units, the Centers for Disease Control and Prevention (CDC, 2001) set out guidelines to protect against the spread of infections, especially hepatitis B and C . As identification of patients infected with blood-borne pathogens such as HIV, hepatitis B, and hepatitis C viruses cannot be reliably made by medical history and physical examination, universal precautions were recommended by the CDC to be used on all patients .
Standard precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. The term ‘standard precautions’ is replacing ‘universal precautions’ as it expands the coverage of universal precautions by recognizing that any body fluid may contain contagious and harmful microorganisms . Standard precautions include hand hygiene, use of appropriate personal protective equipment (PPE), use of aseptic technique to reduce patient exposure to microorganisms, and management of sharps, blood spills, linen, and waste to maintain a safe environment [4,6].
Compliance on the part of health-care workers including nursing staff with standard precautions has been recognized as being an efficient means to prevent and control health-care-associated infections. Such measures protect not only the patient but also the health-care workers and the environment .
It was observed that overall hand washing adherence was often less than 50% in studies carried out during the last 20 years . The risk of irritating the hands, distance from washing facilities, and a lack of time are the reasons usually presented to explain poor adherence .
Statistics of the dialysis unit in the hospital under study for the year 2009 showed an infection rate of 20% in arteriovenous fistula, 27% in prosthetic graft, and 50% in central venous catheters [Infection control committee of the dialysis unit of the Student University hospital, 2009]. This study was conducted to determine the degree to which standard precautions are applied by nurses in the dialysis unit of the Student University Hospital in terms of hand hygiene and use of PPE. Furthermore, it aimed to assess nurses' knowledge and attitudes toward standard precautions.
Materials and methods
Study design and setting
A descriptive, cross-sectional study was conducted in the dialysis unit of one of Alexandria University Hospitals. The hospital has one dialysis unit (18 beds), which serves 51 patients. The unit consists of two rooms for patients who are hepatitis B and C negative and two rooms for patients who are hepatitis B and/or C positive. There are three shifts; morning, evening, and night shifts. The morning and evening shifts are for the scheduled patients. The study covered morning and evening shifts only.
The target population included all nurses who were involved in direct patient care in the dialysis unit under study. The total number of nurses was 17 nurses (14 professional and three technical nurses).
Assuming noncompliance with standard precautions of 50%, 95% confidence level, and 0.06 precision, 1067 opportunities are required. In this study, 1082 opportunities were recorded (992 for different renal dialysis activities and 190 for changing gloves between patients).
Data collection methods
Two data collection methods were used: direct observation and self-administered questionnaire. Three checklists were used to collect observed data; one checklist was used to assess the availability of cleaning facilities, and two checklists were used to record the observed activities that should be performed by nursing staff and that required the implementation of hand hygiene, use of sterile gloves, and the use of PPE. The self-administered questionnaire was used to assess knowledge and attitude on standard precautions. Both the questionnaire and the observation checklists were drafted in a structured format and were used in a pilot test before being applied to the nurses enrolled in the study.
An observation checklist for recording the performance of nurses during dialysis sessions was prepared by the researchers after reviewing studies [2,3,10–14]. Opportunities for hand hygiene (often previously referred to as hand washing) are all situations in which hand hygiene is indicated according to published guidelines [2,3,10–14]. The hands should be washed with soap and water or be disinfected before and after patient contact, after contact with a source of microorganisms (body fluids and substances, mucous membranes, broken skin, or inanimate objects that are likely to be contaminated), and after removing gloves. With regard to opportunities for glove use, glove use is required when contact with mucous membranes, broken skin, or any moist body substance is anticipated [10–12].
Compliance with hand hygiene was defined as either washing the hands with water or plain soap or rubbing the hands with an antiseptic solution. Departure from the room after patient care without hand washing was regarded as noncompliance. Hand washing was required regardless of whether gloves were used or changed. Failure to remove gloves after patient contact or contact between a dirty and a clean body site on the same patient was considered noncompliance [10–14].
With regard to other PPE, eyewear/goggles, masks, and face shields are required to protect the mucous membranes of the eyes, nose, and mouth when performing procedures that may generate splashes or sprays of blood or body fluids (e.g. during initiation and termination of dialysis), whereas plastic aprons are indicated to prevent contamination of the nurses' clothing with blood, body fluids, and other potentially infectious material. PPE should be changed at the earliest opportunity if it becomes splashed with blood or body fluids [10–12].
After literature review [2,3,13,14] and for the purpose of our study, the activities that should be performed by nursing staff and that required the implementation of hand hygiene, the use of sterile gloves, and the use of PPE are summarized as follows:
The observer recorded the total number of potential opportunities to implement standard precautions and the number of occasions when they were actually implemented. The observer works in the unit under study; therefore, the nurses did not recognize observation.
The second observation checklist of hand-washing steps and alcohol rub was prepared after reviewing the studies [10,11]. As during conduction of the study, the nurses did not wash their hand; therefore, they were only observed for steps of alcohol rubs. Defect or absence of any step was considered to be incorrect.
Adherence to hand hygiene, use of gloves, or use of other PPE, was quantified as percentage adherence [the denominator (expected) was the total number of potential situations calling for standard precautions, and the nominator (observed) the actual number of times precautionary measures were implemented]. The availability of cleaning facilities in the dialysis unit under study was assessed by using a checklist designed for this purpose.
Immediately after nurses were observed 19 times on different work shifts, they were given a self-administered questionnaire (semi-structured). The response rate was 100% as all the nurses accepted to share in the study. The questionnaire was designed according to literature review [15,16] and included questions regarding respondents' characteristics (two questions) including age and years of experience, knowledge of standard precautions (11 questions), and attitudes toward standard precautions (nine questions).
Degree of knowledge was ascertained by means of yes–no questions on certain items, whereas the others were multiple-choice questions. Attitude questions were used to collect data about attitude toward application of standard precautions in different renal dialysis activities (previously mentioned). A 3-point scale was used indicating important, do not know, and not important. Data were analyzed using the SPSS program, version 13.0 (Chicago, IL). The data were summarized using simple frequency tables and pie charts.
A total of 17 nurses represented bedside nurses; 14 (82.4%) of them were bachelor degree nurses and three (17.6%) were secondary diploma nurses. Their mean years of experience was 5.7±5.74 years. None of the nurses received training in infection control. Out of 51 shifts, 40 were morning shifts and 11 were evening shifts. In the morning shifts, the nurse-to-patient ratios were one to one, one to two, and one to three in four (10%), 22 (55%), and 14 (35%) shifts, respectively. In the evening shifts, one nurse was assigned to three patients in 9.1%, to four patients in 27.3%, and to five patients in 63.6% shifts (Table 1).
During the study period, the observer recorded 992 opportunities for applying standard precautions (hand hygiene and use of appropriate PPE). None of the nurses (0%) washed hands before and after the different activities that required hand washing or used plastic aprons or face protection. In contrast, all of them (100%) wore nonsterile gloves before or after the different activities that required wearing of gloves (Table 2). In more than half of the opportunities (55.3%) that required changing gloves, nurses removed the nonsterile gloves only and did not change the polyurethane gloves, which they wore under the nonsterile gloves (Fig. 1). In 3.7% of opportunities that required the use of hand washing or alcohol rub after removing gloves (seven of 190 opportunities), nurses used alcohol rub in correct steps after removal of gloves, whereas in 6.3% (12 out of 190 opportunities) they used alcohol rub but by following incorrect steps (Fig. 2).
With regard to the availability of cleaning facilities, it was observed during the study period that the sinks were inconveniently located outside the dialysis rooms and hand-washing sinks were with hand taps. No elbow, wrist, sensor, mixer, or foot-operated taps were available. There were no soap pump dispensers, wall-mounted paper towels, or foot-operated waste bins with lids in the hand-washing area. There were bars of soap. Alcohol rub was available in a dispenser at the bedside in the dialysis rooms. Posters depicting good hand-washing technique were not distributed to all dialysis rooms or hung over clinical hand basins (result not shown).
With regard to nurses' attitude toward hand hygiene and use of gloves in renal dialysis, all the nurses (100%) reported that it is important to wear gloves for all dialysis activities, except for preparation of dialysis material and machine. All the nurses (100%) answered that it is important to wash hands before and after connection and disconnection. Only 29.4% of them reported that hand hygiene is important after removal of gloves (Table 3).
With regard to the knowledge of standard precautions, nearly half (47.1%) of the nurses had heard about standard precautions, only 17.6% of them correctly answered that hands are the most important vehicle of transmission of infectious agent, 100% of nurses chose latex gloves as the first choice to reduce transmission of infectious agents most efficiently, 94.1% of them had conviction that isolation of all infected patients is the main method for prevention against transmission of infectious agents, and 82.4% of them mentioned that splashing of a patient's body fluids in a health-care-worker's eye represents a risk for systemic infection only if the patient has a known infection (Table 4). Nearly half (47.1%) of the nurses knew that they had to wash their hands before and after caring for a patient, the remaining (52.9%) knew that they had to wash their hands after caring for a patient only, and 70.6% mentioned that hand hygiene and wearing gloves are indicated to protect health workers, and none of them mentioned that hand hygiene is important to protect the patient (Table 5).
Among the reported barriers for not applying standard precautions, inaccessibility of sinks, high work load or lack of appropriate staffing, and interference with the practice of care were cited as the most important barriers (100%), followed by an absence of role model from colleagues or superiors (94.1%), whereas a preference for the use of gloves was the reason given by 82.4% of nurses and skin irritation and lack of time were the reported reasons of 70.6% of nurses (Table 5).
Health-care-associated infection is one of the major challenges in providing high-quality health care . It is the duty of all health-care workers in the dialysis and renal transplant settings to actively take steps to protect themselves and their patients from disease . One of the most important routes of patient-to-patient transmission of microorganism in health-care settings is through the contaminated hands of health workers . Exposure to blood and potentially contaminated fluids can be anticipated in dialysis settings; hence, it is important to wear gloves and wash hands before and after caring for patients and before and after touching patient's equipments. In this study, standard precautions were not well adhered to by all nurses in all occasions. This is in agreement with other studies [13,14,17,19,20].
The sinks were present in another area separated from the patient station by a door. This inaccessibility to sink represented one of the barriers of compliance according to the nurses' answers for reasons of poor compliance (Table 5). Donabedian's quality paradigm of structure, process, and outcome provides a useful framework for considering efforts to improve hand-hygiene compliance. Clearly, if sinks and alcohol dispensers are not readily accessible (faulty structure) and hand hygiene is not performed (inadequate process), the risk of infection and its attendant morbidity, mortality, and cost (outcomes) will increase .
Lack of enough knowledge about hand hygiene is one of the major risks of spread of infection in hospitals and the attitude of staff toward proper hand hygiene also influences the way they adhere to hand washing and wearing of gloves . The results of this study showed inconsistency between nurses' knowledge, attitude, and practice. Even though less than half (47.1%) of the nurses were aware that they had to wash their hands before and after caring for a patient, practice of this among them was less than desired. Similar findings were shown by studies conducted in teaching hospitals. They explained this situation by a reflection of the existing dichotomy between the theory and the practice that is observed in the teaching–learning process being adopted currently [15,16].
More than half (52.9%) of the nurses knew that they had to wash their hands after caring for a patient and 70.6% mentioned that hand hygiene and wearing gloves are indicated to protect health workers, whereas none of them mentioned that hand hygiene is important to protect the patient (Table 5). This is probably associated with the providers' concern for the possible transmission of pathogenic viruses by patients. In contrast, health workers tend to disregard their own role in transmitting infections to patients. This is in agreement with other studies [13,16,18,22], which showed that nurses and physicians reported a low rate of hand hygiene before direct patient contact and suggested that hand hygiene is more likely to be performed when self-protection is the goal.
In contrast, there was no contradiction between nurses' knowledge, attitude, and practice regarding glove use before patient care as gloves were their first choice to reduce transmission of infectious agents most efficiently (Table 5) and preference for the use of gloves was among the reported barriers for not applying hand hygiene (82.4%, Table 5). This is in contrast to a study conducted in Ain Shams university, Egypt, which showed that, although nurses' attitude about the importance of gloves was generally good, their corresponding performance was unsatisfactory .
Since October 2002, the CDC  has changed the concept of hand washing to hand hygiene, and the Centers provide specific recommendations that are designed to promote improved hand hygiene. For generations, hand washing with soap and water has been considered a measure of personal hygiene, but now and according to WHO guidelines (2006), if hands are not visibly soiled, the routine use of an alcohol-based hand rub to decontaminate hands is regarded as sufficient  An observational study carried out in two hospital intensive care units in the USA (2001) concluded that introduction of the alcohol gel for the hygienic friction of the hands increased the nurses' compliance as it requires less time; cleanses more effectively than standard hand washing with soap, and is more accessible than alcohol rub. Despite these benefits of alcohol rub , the findings of this study illustrated a low rate of adherence to alcohol rub; although it was available in a dispenser at the bedside, the nurses used it after patient care in only 19 (10%) opportunities of 190 and they performed correct steps in seven (3.7%) opportunities and performed incorrect steps in 17 (6.3%) opportunities (Fig. 2).
Many studies have investigated the reasons preventing health-care providers to comply with standard precaution measures. In addition to the negative influence on the part of the professional serving as role models, some investigators highlight that the origin of the low compliance, especially regarding hand hygiene, lies in the academic training [24,25]. In this study, none of the nurses received training about standard precautions (Table 1). Hence, much work needs to be carried out to educate health-care workers on the need for standard precautions and to ensure that adherence to standard precautions is monitored. Perceived barriers to adherence with hand hygiene practice recommendations reported by nurses in this study (Table 5) were similar to those reported in other studies [15,21,22].
The observation showed poor compliance to hand hygiene whether the nurse-to-patient ratio was low or high or the shift was the morning or evening (Table 1). The degree of compliance with some basic standard precautions (hand washing or hand hygiene and wearing of gloves) by health workers was monitored in nine Spanish hemodialysis units in the study by Arenas et al. . They observed that hand washing was significantly lower when the number of patients attended by nurses was higher, and when there were more shifts per day. The researchers concluded that one of the factors that can contribute to noncompliance is time limitation — staff having to work in a hurry because shifts follow each other closely and because the timetable has to be strictly adhered to . Another multicenter study conducted in 58 units in Italy (2001) suggested that the combination of understaffing and a high level of infected patients in the dialysis setting increases the risk for HCV nosocomial transmission. This is likely related to an increased likelihood for breaks in infection control measures . The issue that needs further research is in good working conditions; because if good working conditions are guaranteed, the actual and perceived individual control over hand hygiene might improve, with a positive subsequent effect on hand hygiene behavior.
Evidence from the medical and lay literature suggests that the role model could play a pivotal role in changing human behavior . In contrast, negative role models could also be influential; poor practice can also be learned at the bedside [28,29]. Junior staff and students who were taught to hand wash abandoned their habit when others, especially more senior staff, did not bother. If the older nurses or tutor nurses do not wash or disinfect hands before and after attending to a patient, the new nurses or the student nurses will follow in their footsteps as well . In this study, lack of role models was cited as a reason not to perform hand hygiene as senior nurses did not wash their hands, thereby, acting as negative role models (Table 5).
A multicentric survey of the practice of hand hygiene in hemodialysis units (2005) showed that the gloves are the individual protection equipment of larger adherence on the part of the professionals . It was found that health-care workers who wore gloves were less likely to cleanse their hands on leaving a patient's room . Guidelines recommend that health-care workers should be informed that gloves do not provide complete protection against hand contamination and the use of gloves does not replace the need for hand cleansing by either hand rubbing or hand washing as contamination may occur during glove removal . Although all the nurses under study wore gloves, their practice was insufficient to ensure safe practice. The nurses did not wear sterile gloves as there were only few and for economic reasons they were used only in catheter insertion. Nurses wore polyurethane gloves and they wore nonsterile gloves (double gloving) on it. They explained this by allergy from nonsterile gloves and in their opinion this practice gives them overprotection. Between caring for different patients, they removed only the nonsterile gloves leaving polyurethane gloves and wore new nonsterile gloves (polyurethane gloves were removed only if they were damaged). If polyurethane gloves were not available, they wore only nonsterile gloves and used alcohol rub after it (this was the only situation in which they used alcohol rub). Nurses did sometimes care for patients and did touch patients' equipment and machines at the dialysis station with contaminated gloves. Health-care workers should be reminded that the failure to remove gloves between patients or between different body sites of the same patient might contribute to the transmission of organisms . In addition, polyurethane/polythene gloves do not act as a barrier to infection. These gloves do not meet the Health and Safety Commission regulations (2005–2006) and they do not have a place in clinical application. They should not be used. Sensitivity to natural rubber latex in health-care personnel must be documented. Alternatives to natural rubber latex gloves must be available and there should be access to latex-free gloves for health-care personnel who are sensitive to latex or who are caring for patients with latex hypersensitivity .
There was no availability of plastic aprons or face protection in the dialysis unit under study. It was observed during the study that splashes or sprays of blood during initiation and termination of dialysis had occurred (five times). There should be adequate supplies of PPE available at the point of use.
Strengths and limitations of the study
A strong point of this study is the assessment of practice of universal precautions by observation, avoiding the Hawthorne effect, which often threatens the validity of results in many studies. Self-reports of compliance do not correlate well with the compliance actually measured by direct observation, and self-assessment tends to overestimate compliance with hand hygiene.
An important limitation is that whether our findings can be generalized to other groups of health-care workers and other dialysis units. It remains to be tested, considering that infrastructure, past experience, and social and institutional backgrounds influence behavior.
Conclusion and recommendations
Although there is a clear requirement and an obligation to adhere to standard precautions, these measures were poorly practiced by nurses. Our investigation shows a poor degree of adherence to the recommended practices of hand hygiene. Although all the nurses under study wore gloves, their practices were insufficient to ensure safe practice. There was poor knowledge regarding standard precautions. There was an absence of a written policy for precautions regarding infection control and a lack of continuous and efficient inservice training.
Findings of this study indicate the following recommendations
Performance feedback on hand hygiene behavior is critical to improve compliance with hand hygiene among health-care workers. This is through strict observation of nurses during work and through continuous evaluation of their practice and correction of poor practices.
A protocol for universal blood precautions, needle-stick injuries, and infection control should be used in the unit, e.g. as wall charts and handouts. The infection control committee should develop and update annually all relevant protocols as new information becomes available on the best practice. Training health-care workers (preservice and inservice) about blood-borne infections and universal blood precautions through regular scientific meetings and training courses should be conducted. Training programs and information sessions should be provided on initial employment and at appropriate intervals thereafter. There should be availability of all facilities and equipment that are required for applying standard precautions.
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