The specialty in pediatric critical care medicine was developed as an offshoot of neonatology, pediatric general and cardiac surgery, and pediatric anesthesiology. Although the first pediatric intensive care unit (PICU) emerged in the late 1950s and early 1960s, pediatric critical care medicine was not formally recognized as a specialty until 1987, when the American Board of Pediatrics first offered a certifying examination, paving the way for hospital credentialing of pediatric intensives 1.
The PICU is a section of hospital that provides sick children with the highest level of medical care. The PICU provides intensive nursing care by monitoring parameters such as heart rate, breathing, and blood pressure. It also allows the medical staff to provide therapies that might not be available in other parts of the hospital such as ventilators and certain medications that can be given only under close medical supervision 2.
A nosocomial infection, also called healthcare-associated infection (HCAI), is a prominent problem among most patients in the PICU due to the nature of infants and children as well as the nature of the modern critical care environment. Young patients are in disadvantage because of their immature immune system, lack of exposure to antigens, and their relatively porous physical barriers to microbial invaders 3. The majority of HCAIs become evident 48 hours or more after admission; however, HCAIs may not become clinically evident until after discharge 4. HCAIs result in significant morbidity, prolonged hospitalization, increase in healthcare costs, and contribute to patient deaths 5. Efforts to reduce the rate of HCAIs in children are often hampered by the lack of pediatric-specific research, lack of national pediatric-specific quality measures to guide prevention of HCAIs, and the implementation of infection-prevention practices validated only in adult populations 6.
HCAIs are generally related to multiple factors such as the knowledge and attitude of healthcare personnel regarding infection control 7, environmental factors such as those related to cleanliness of instruments, floors, and walls 8, and antimicrobial resistance 9. Prevention of these infections depends on daily implementation and monitoring of infection-prevention and control practices, which should aim at breaking the chain of infection at all possible sites 10.
Infection control has a particular important role in PICUs which must take into account the specificity of needs and environment of pediatric patients. The role of nurses is extremely important in preventing the hazards and sequela of HCAIs and protecting patients, themselves, and other healthcare personnel from acquiring infection 11. Many studies have reinforced the fact that compliance of nurses to infection-control guidelines could be improved by educational interventions that address their knowledge, attitude, and practice (KAP) 12.
The role of nurses in infection control has been addressed in many studies 13,14; however, to the researchers’ best knowledge, no data have been reported regarding nurses’ KAP of infection control in PICUs at Cairo University hospitals. By assessing the nursing staff’s KAP, we have baseline data to start with for monitoring and consequently improving their KAP regarding infection control.
Aim of the work
This study was conducted to assess the effect of a health education program regarding infection-control measures on nursing staff’s KAP in PICUs at Cairo University hospitals. This would be accomplished by:
- assessing nursing staff’s KAP regarding infection-control measures in PICUs,
- providing health education sessions addressing proper infection-control measures, and
- reassessing the nursing staff’s knowledge and attitudes after providing the educational program.
Participants and methods
A pre–post interventional study to test the effect of health education regarding infection-control measures on nurses’ knowledge and attitudes in PICUs at Cairo University hospitals.
Study site and study period
The current study was conducted in PICUs at Cairo University Hospital. The included units were (a) the neonatal intensive care units at Monira, Japanese, and Kasr El-Ainy hospitals and (b) PICUs at Monira and Japanese hospitals including cardiothoracic and emergency departments. The study took place over 3 months duration from 15 September 2012 to 15 December 2012 and included three phases. The first phase tested the nursing staff’s KAP regarding infection-control measures. The second phase included health education sessions to all nurses who participated in the first phase. The third phase reassessed the nurses’ knowledge and attitudes regarding infection-control policies (each phase took nearly 1 month’s duration). Practice was not assessed in the postintervention phase because it is usually standardized and also due to work overload in PICUs.
A convenient sample of 125 nurses was selected from the nursing staff working in different PICUs at Cairo University hospital who accepted to participate.
Study tools and data collection technique
- A self-administered pretested questionnaire was designed to collect and record data. It included three sections. The first section included demographic data and job characteristics such as nurses’ age, qualification and years of experience, pre-employment examination, and previous infection-control courses. The second section included data to assess the nurses’ knowledge regarding infection-control measures and precautions. The third section assessed the nurses’ attitudes regarding infection-control policies and precautions 12,14.
- An observation checklist was used for the assessment of nurses’ practices regarding infection-control procedures including environmental control (13 items), hand hygiene (13 items), personal protective equipment (PPE) (14 items), injection safety (8 items), handling and disposal of sharps (5 items), waste management (6 items), decontamination of patient care equipment (13 items), specimen handling (3 items), and personal hygiene (2 items). The total practice score (out of 77 items) was computed for different units in which correct answers scored 1 and incorrect or not done scored 0 5,15.
- Health education materials included powerpoint presentations regarding infection-control principles and guidelines and video showing proper hand hygiene.
Data processing and analysis
Data were entered and analyzed using the statistical package for social sciences (SPSS, version 16; SPSS Inc., Chicago, Illinois, USA). Descriptive statistics such as frequency, percentage, arithmetic mean, and SD were used. Comparison between preassessment and postassessment data was performed using the McNemar test for qualitative data variables and paired t-test for quantitative variables.
Ethical and administrative issues
Verbal consents were obtained from all participants in the study according to Helsinki decelerations of biomedical ethics 16. Also, all required permissions were obtained from the Chairman of the Pediatric Hospital and from the Chair of the infection-control units.
The study group comprised 125 nurses working in different PICUs at Cairo University hospitals. Table 1 shows that nearly half (48.8%) of the study sample was less than 30 years old, with a mean age of 30.76±7.58 years. Most of the study participants (98%) were female. Nearly 61% of the nurses were married. About 59% of the nurses had a diploma in nursing and the mean years of experience was 11.25±7.35 years. More than 50% of the nurses have attended infection-control courses. Nearly three-fourth of the study group has received pre-employment examination (clinical and laboratory examination).
The respondents were asked a few questions to assess their knowledge regarding nosocomial infections, components of an infectious cycle, and hand washing (Table 2). In the postintervention phase, nurses had significantly more knowledge as compared with the preintervention phase regarding the types of nosocomial infections (94.4 vs. 76.8%, P<0.001), the at-risk groups for acquiring nosocomial infections (95.2 vs. 86.4%, P=0.035), and the measures applied to control nosocomial infections (89.6 vs. 68%, P<0.001). Moreover, nurses in the postintervention phase had significantly more knowledge compared with that in the preintervention phase regarding all items related to infectious cycle.
The respondents were asked to identify some precautions to prevent acquiring nosocomial infections. Regarding the required vaccinations for nursing staff, nurses in the postintervention phase had significantly more knowledge compared with that in the preintervention phase (92 vs. 16%, P<0.001). Similarly, the nurses’ knowledge about the precautions applied when dealing with hepatitis A patients was significantly higher in the postintervention phase when compared with the preintervention phase (92 vs. 56%, P<0.001). Nearly 97% of the nurses in the postintervention phase identified correctly that they have to wash their eyes and mouth with running water if they were exposed to accidental splashes of blood or body fluids, compared with 89.6% of those in the preintervention phase (P=0.035). As for hand washing, nearly all (99.2%) nurses in the postintervention phase knew that the types of hand washing include plain, antiseptic, and surgical, compared with 91.2% of those in the preintervention phase. This difference was statistically significant at a P-value of 0.006. Moreover, the nurses’ knowledge in the postintervention phase was significantly higher when compared with the preintervention phase concerning the conditions in which plain hand washing is not enough (87.2 vs. 51.2%, P<0.001) and when to use disinfectants (84.8 vs. 42.4%, P<0.001). Regarding the spectrum of activity of alcohol, 68 and 98.4% of nurses in the preintervention and postintervention phases, respectively, knew that alcohol was effective against bacteria, viruses, and fungi but not against spores (P<0.001) (Table 2).
The nurses’ knowledge in the postintervention phase was significantly higher as compared with that in the preintervention phase regarding all items related to PPE except their importance. A significantly higher percent of nurses in the postintervention phase knew the importance of avoiding recapping syringes as a universal precaution in reducing the risk of transmission of blood-borne pathogens (72.8 vs. 34.4%, P<0.001) and correctly identified that the sharp box should be emptied when half-full only to minimize the risk of infection (85.6 vs. 43.2%, P<0.001). Similarly, in the postintervention phase, nurses had significantly more knowledge regarding the precautions to be taken when they were exposed to accidental needle-stick injury (NSI); they knew that they have to wash the injured site with water and soap and take the postexposure prophylaxis (66.4 vs. 32.8%, P<0.001). The knowledge regarding the modes of transmission of hepatitis B and C virus was significantly higher among nurses in the postintervention phase when compared with that in the preintervention phase (96.8 vs. 64%, P<0.001). Only 34 (27.2%) nurses in the preintervention phase correctly knew the definition of decontamination, compared with 85 (68%) nurses in the postintervention phase (P<0.001). At the postintervention phase, nurses had significantly more knowledge compared with that in the preintervention phase regarding the correct definition of sterilization (71.2 vs. 54.4%, P=0.009). Thirty-six percent of nurses in the preintervention phase knew the proper way for disposal of infected items compared with 86.4% of those in the postintervention phase (P<0.001) (Table 3).
In the present study, no statistically significant differences were observed between the preintervention and postintervention phases regarding their attitudes towards hand washing, whether before or after using gloves and towards frequent hand washing. A significantly higher percent of nurses in the postintervention phase compared with those in the preintervention phase believed that infection-control measures could protect them completely from acquiring infection (79.2 vs. 65.6%, P=0.033). There was also a statistically significant difference (P=0.002) between nurses’ attitudes in both phases regarding antibiotic abuse: 65.6% of nurses in the postintervention phase believed that they should not use antibiotics when suspecting any infection compared with 44% in the preintervention phase. The respondents were also asked to state their attitude towards the importance of certain aspects of standard precautions. The nurses’ attitude regarding the importance of avoiding recapping was uniformly poor in the preintervention phase, being only 40.8%, whereas it was 91.2% among nurses in the postintervention phase. This difference was highly significant at P-value less than 0.001. A significantly higher percent of nurses in the postintervention phase compared with those in the preintervention phase thought that they should not avoid infectious patients as long as they follow the required precautions (92 vs. 75.2%, P<0.001) and also believed that they should not avoid using disinfectants as long as they are used properly (96.8 vs. 87.2%, P=0.008) (Table 4).
Table 5 shows statistically significant higher knowledge and attitude scores in the postintervention phase with a mean of 37.176±3.494 and 13.264±1.666, respectively, compared with 28.672±4.499 and 12.248±1.615 in the preintervention phase.
Figure 1 shows the evaluation of nursing practices regarding infection-control measures in different PICUs using an observational checklist that included the following items: environmental control, hand hygiene, PPE, injection safety, handling and disposal of sharps, waste management, decontamination of patient care equipment, specimen handling, and personal hygiene. Analysis of results revealed that the percentage practice score of the observed units was the highest in the neonatal intensive care unit at the Japanese hospital (88%), whereas the lowest score was observed in the emergency pediatric unit (65%).
HCAIs continue to be one of the most important public health problems in many countries throughout the world as they represent one of the most common complications affecting hospitalized patients. These infections result in morbidity, mortality, increased length of hospital stay, and consequently additional medical costs 17. Infection control through appropriate standardized prevention procedures is thus a key component of practice for all healthcare professionals, not only for their health but also to reduce nosocomial infections and thus improve patient safety 18. However, it has been documented that the level of compliance with the use of infection-control guidelines by healthcare workers (HCWs) has been low 19, despite the fact that evidence-based procedures enhancing appropriate practices in healthcare facilities have been published 20.
In the current study, the nurses’ knowledge in the postintervention phase was significantly higher as compared with that in the preintervention phase regarding the types of nosocomial infections, the at-risk groups for acquiring nosocomial infections, and the measures applied to control nosocomial infections. Regarding the vaccinations required for the nursing staff, nurses in the postintervention phase had significantly more knowledge compared with those in the preintervention phase (P<0.001). Similarly, in a study conducted by Yamini et al.21 on the perception and practice regarding infection-control measures among nurses, most of the respondents (88.3%) were of the opinion that HCWs should be immunized against hepatitis B (P=0.024).
Hand hygiene is the first initial step towards successful infection control in any healthcare facility 22 because HCWs’ hands are the main source of HCAI transmission 21. In the current study, it was found that a significantly higher percent of nurses in the postintervention phase as compared with those in the preintervention phase knew the types of hand washing (P=0.006) and the conditions for using disinfectants (P<0.001). In another study conducted by Jain et al. 14 to assess infection-control practices among doctors and nurses in a tertiary care hospital, it was found that knowledge regarding hand hygiene was 86.8%. Moreover, a positive attitude towards hand washing was observed in the current study in both the preintervention and postintervention phases, whether before using gloves (95.2 and 99.2%, respectively, P=0.125) or after using gloves (94.4 and 92%, P=0.607) and towards frequent hand washing (88.8 and 87.2%, P=0.851). The positive attitude towards hand washing was also associated with a high compliance score (range 70–100%) among the study participants (untabulated data). However, it has been stated in a study conducted by Whitby et al.23 that although standard precautions and guidelines for hand washing have been established to decrease the transmission of HCAIs, adherence to such policies was uncommon.
Whereas exposure to biologic agents and subsequent infection is not the only occupational hazard faced by HCWs, infections present the greatest risk, especially those caused by blood-borne organisms 24. Although there is a growing awareness of the seriousness of HIV and hepatitis B and C and how these viruses are transmitted, many HCWs do not perceive themselves to be at risk 25. Universal precautions are good hygiene habits that reduce acquiring HCAIs due to exposure to blood and body fluids; they include barrier precautions (BPs) (e.g. gloves, mask, gown, goggles, etc.), hand washing, correct handling and disposal of sharps, and aseptic techniques 26. In the present study, significant differences were observed between the pretest and post-test phases regarding most of the items related to universal precautions. In accordance with the previous finding, a study conducted by Mohamed and Wafa 27 found statistically significant differences between knowledge about universal precautions related to blood and body fluids in the pre-education and posteducation phases. BPs reduce the risk of infection among HCWs as they decrease the direct contact of body fluids and pathogens and thus reduce the chance of infectivity 24. In the current study, almost all the nurses knew the importance of BPs, whereas the nurses’ knowledge in the postintervention phase was significantly higher regarding all the other items of BPs. Moreover, it was found that nurses adhered to the use of BPs in the present study with a score ranging from 71.5 to 100%. However, in a study conducted in Pakistan to determine the practice of BPs among HCWs, it was observed that HCWs did not consistently use BPs. Wearing gloves (69%) was the most common means of BPs in that study, followed by goggles (27%), gown (21%), and mask (13%) 24. Moreover, suboptimal compliance with BPs was reported by other studies 14.
As NSIs are a major source of hospital-acquired infections to HCWs, proper handling and disposal of needles is mandatory so that this preventable source of infection is no more a cause of nosocomial infections 28. In the current study, nurses in the postintervention phase had significantly more knowledge when compared with those in the preintervention phase regarding the importance of avoiding recapping syringes as a universal precaution to reduce the risk of transmission of blood-borne pathogens (72.8 vs. 34.4%, P<0.001). In accordance with the present study, a considerable percent (76%) of HCWs at Kasturba Medical College in India knew that used needles and syringes are not to be recapped after use 21. Similarly, in a study conducted in Turkey, it was found that 73% of HCWs did not recap the needles after use 29. In the current study, a significantly higher percent of nurses in the postintervention group knew the precautions that should be taken when exposed to accidental NSI (66.4 vs. 32.8%, P<0.001) and the proper method of disposal of syringes (94.4 vs. 84.8%, P=0.029). However, in a study conducted by Yamini et al.21, 88.3% of HCWs were aware of the appropriate sequence of events to be followed if they were exposed to accidental NSI and also of the importance of its notification to the appropriate authority. In that study also, the majority of HCWs (86%) were aware of the fact that used syringes and needles are to be disposed in puncture-resistant containers.
Hepatitis C virus infection is an emerging health problem worldwide; awareness about the disease is necessary for its prevention and control particularly among nursing staff 30. In the current study, the nurses’ knowledge in the postintervention phase regarding the mode of transmission of hepatitis B and C virus had significantly improved after the educational intervention (P=0.029). Similar results were concluded from a study conducted by Mohamed and Wafa 27, who observed that the knowledge of nurses about hepatitis C virus infection and the use of preventive measures had been inadequate before an educational program was provided to them and improved after their participation in the program. These results were also consistent with the findings of a study conducted in Egypt, where there was an increase in staff’s knowledge about viral hepatitis and their compliance with preventive precautions from pretest to post-test 31.
It has been found in a study conducted by Suchitra and Devi 32 that a yearly education program on nosocomial infections and their prevention helps in the retention of KAP among HCWs and also in better adherence to BPs. In the current study, it was found that nearly half (48%) the study group has not undergone any training program for infection control. It was also observed that the percentage practice score related to infection-control measures in different PICUs was the lowest among nurses in the emergency pediatric department (65%), which could be attributed to work overload and time factor.
The current study found that health education was successful in improving the knowledge and attitudes of nurses regarding infection-control measures in different PICUs at Cairo University hospitals. Thus, application of health education and training programs is mandatory for nurses to continuously upgrade their KAP and subsequently minimize nosocomial infections and reduce the duration and the cost of stay of pediatric patients.
- Educational training programs should be multidisciplinary in the era of quality control to help HCWs realize the importance of basic infection-control policies in reducing morbidity and mortality and improving the quality of care.
- Encouraging the adherence to recommended universal precautions and safety practices should be an integral part of providing high-quality care.
- Providing sufficient resources to conduct training programs that are both educational and motivational.
The authors are thankful to the Chairman of the Pediatric Department at Cairo University Hospital for his kind permission to conduct this study. The authors also thank all the nursing staff in different pediatric intensive care units at Cairo University Hospital for their participation in the study. The research team thanks Dr Shaymaa Baher, Assistant Professor of Public Health, Faculty of Medicine, Cairo University, for her guidance and valuable assistance in managing and analyzing data.
Conflicts of interest
There are no conflicts of interest.
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