The Nurses' Knowledge and Compliance with Standard Precautions to prevent Healthcare-associated Infections
Ayat Da'seh1, Ibtisam M. Al-Zaru2, Audai A Hayajneh2, *, Osama Obaid3
Identifiers and Pagination:Year: 2023
E-location ID: e187443462306231
Publisher ID: e187443462306231
Article History:Received Date: 06/01/2023
Revision Received Date: 27/05/2023
Acceptance Date: 07/06/2023
Electronic publication date: 11/09/2023
Collection year: 2023
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Nursing knowledge and compliance with standard precautions are important for preventing healthcare-associated infections (HAIs) and protecting nursing personnel and patients from exposure to infectious microorganisms.
The study aimed to assess the nurses’ knowledge of and compliance with standard precautions.
This study used :a cross-sectional design. A total of 302 nurses were recruited from three Jordanian hospitals. Data were collected through two structured questionnaires: Standard Precautions Knowledge Questionnaire and Compliance with Standard Precautions Scale. Pearson’s correlation test was used to assess the correlation between nurses' knowledge and compliance with standard precautions.
The average knowledge score was 14.09 (SD=2.97), indicating a good level of knowledge regarding standard precautions. The average compliance score was 14.46. A significant positive and strong relationship was found between nurses’ knowledge and compliance with standard precautions (r=0.77, p <0.001).
Continuous monitoring and evaluation of standard precautions are required to maintain and enhance compliance among nurses.
Healthcare environments are considered to be one of the most hazardous occupational settings [1, 2]. Healthcare professionals regularly encounter biological hazards during their clinical practice, which exposes them to various microorganisms that can cause fatal infections . Nurses, in particular, are extremely vulnerable to biological hazards as they deliver direct care to their patients .
Biological hazards in hospital environments include exposure to blood-borne infections, such as human immunodeficiency virus (HIV), hepatitis B (HBV) and C (HCV) viruses, and cytomegalovirus from sharp objects and direct contact with body fluids [5-7]. Prüss-Ustün et al.  estimated that approximately 66,000 HBV, 16,000 HCV, and 1,000 (200-5,000) HIV infections are detected among millions of healthcare workers annually because of injuries that occur during the course of performing their duties . The risk of contracting HIV, HBV, or HCV infection from needle stick injuries is estimated to be approximately 0.3%, 2-40%, and 2.7-10%, respectively .
HBV and HCV infections account for 40–65% of the infections in developing countries, while in developed countries, HCV accounts for 8–27%, and HBV accounts for <10% of infections due to immunization and personal protective equipment (PPE) . These infections are also accompanied by serious consequences, including illness, disability, and even death [7, 9].
In order to prevent hospital-acquired infections, a set of standard precautions are recommended by the Centers for Disease Control and Prevention (CDC) that should be applied to each patient based on their diagnosis and infection status [10, 11]. The standard precautions are comprehensive and evidence-based guidelines for infection control, including hand hygiene, protective barrier usage, such as gloves and gowns, appropriate waste product handling and discarding, patient isolation based on the source of infection transmission, and proper discarding of sharp instruments, such as needles and plaids [12, 13].
Among these standards, hand hygiene is considered the most important [14, 15]. Nursing knowledge and compliance with standard precautions are important for the prevention of healthcare-associated infections (HAIs) and the protection of nurses and patients from exposure to infectious microorganisms. HAI is a new concept being used instead of hospital-acquired infections because many infections are associated with healthcare delivery, either during hospital admissions or in outpatient clinics . The strict implementation and compliance with standard precautions effectively reduce occupational hazards [17, 18]. In particular, hand hygiene reduces infections by approximately 50% . In contrast, poor compliance with standard precautions increases the risk of sharp injuries twice as much as when all precautions are followed .
Several studies have indicated that nurses lack knowledge regarding standard precautions [21-23]. Knowledge about standard precautions has been reported as a significant predictor for better compliance [24, 25]. Several studies have also reported a lack of or poor compliance with standard precautions among nurses [25-27]. Powers et al. reported less than one in five nurses to comply with standard precautions . A study conducted among 247 nurses in Jordan showed that although most nurses (90%) had good knowledge about standard precautions, it was not enough to improve their compliance . The current study aimed to investigate the nurses’ knowledge and degree of compliance with standard precautions.
2. MATERIALS AND METHODS
This study adopted a descriptive, cross-sectional design. A simple random sample of 302 registered nurses who were willing to participate in the investigation and had at least one year-experience were included. The study was conducted at three military hospitals at Royal Medical Services. The study used data provided by the administration at the three hospitals. Then, an anonymized list of all registered nurses was created using computer software. The target population comprised all nurses working at Royal Medical Services. The study sample represented approximately ten percent of the target population. Data were collected through the following three structured questionnaires: the socio-demographic data questionnaire, the standard precautions knowledge questionnaire , and the compliance with standard precautions scale (CSPS) . The data questionnaires package was handed out to the participants. The researchers requested the contact numbers of eligible nurses from the head nurses, and then the participants were contacted to participate in the study after explaining the aims of the study. Theparticipants filled out the questionnaires at the end of their shifts. Data were collected over a period of 1 month from December 15, 2018, to January 15, 2019.
The socio-demographic data questionnaire was developed by the authors and included the following: age, gender, educational level, hospital, working department, working experience, and previous infection control training course.
The Standard Precautions Knowledge Questionnaire is a 19-item scale, with requires ‘yes’ and ‘no’ responses. The correct answer was awarded one point, and an incorrect answer was awarded 0; the maximum possible score was 19. The higher the score, the greater was the nurses’ assumed knowledge about standard precautions. The test results were interpreted as follows: 16 – 19 was “very good knowledge,” 12 – 15 was “good knowledge,” 8 – 11 was “fair knowledge,” and 0 – 7 was “poor knowledge”. In a previous validation study, the Standard Precaution Knowledge Questionnaire exhibited an interclass correlation coefficient of 0.91 and a satisfactory Kappa index .
The CSPS is a 20-question tool evaluating compliance with PPE use, disposal of sharp objects and other biological waste, decontamination of spills and used articles, and prevention of cross-infection. The response was set on a 4-point Likert scale, which consisted of “never,” “seldom,” “sometimes,” and “always.” “Always” was assigned a score of one, whereas the other responses were assigned a score of zero. The total score ranged from 0 to 20, with higher scores indicating better compliance with the standard precautions. Items 2, 4, 6, and 15 were reverse-coded. A pilot study with 10 nurses was conducted to assess the clarity and readability of the instruments, the reliability and validity of the instruments, and the time required to complete the questionnaires. All questions in both questionnaires were clear and did not require any changes. The investigators determined that 20 minutes would be sufficient to complete both the questionnaires. The pilot study revealed Cronbach’s α of 0.88 for knowledge and 0.85 for compliance. Valim et al. , Cruz et al. , and Pereira et al.  established that CSPS exhibits good reliability with Cronbach’s α ranging from 0.61 to 0.89, which validates it.
2.2. Statistical Analysis
Assumptions of normality and linearity were checked for violations. Quantitative data are expressed as means, medians, and standard deviations (SD), whereas qualitative data are expressed as frequencies and percentages. Pearson’s correlation test was used to assess the correlation between nurses' knowledge and compliance with standard precautions. The level of significance was set at p ≤ 0.05. Data were analyzed using SPSS (version 25; Armonk, NY: IBM Corp.).
2.3. Ethical Consideration
Ethical approval for this study was obtained from theRoyal Medical Services (Ref. # 1112019) on December 13, 2018, and the study was conducted according to the principles of the Helsinki Declaration of 1975, as revised in 2013. Each participant selected for this study was provided a written informed consent. The aim, risks, and benefits of the study were explained to the participants. The identifying information was kept strictly confidential in a password-protected computer. The right to participate in or quit the study at any time was guaranteed to the participants.
The average age of the participants was 30.9 (SD=4.24) years and the majority of them (196, 49%) were between the ages of 24 and 30. Of the 302 nurses, 166 (55%) were females, and the rest (45%) were males. The majority of the nurses (88%) had a bachelor’s degree, 10.3% had a master’s degree, and only 1.7% had a PhD. The average clinical experience was 7.28 years (SD=3.47). Furthermore, 73 nurses (24.2%) had attended an infection control training course (Table 1).
The mean knowledge score was 14.09 in the Standard Precautions Knowledge Questionnaire, while the mean compliance score was 14.46 in the CSPS. The cumulative scores and distribution of the study participants' knowledge of the standard precaution knowledge questionnaire were estimated. A total of 127 participants (42.1%) scored within the range of 12 to 15 indicating “good knowledge,” while 36.1% of the participants scored within the range of 16 to 19 indicating “very good knowledge.” None of the study participants had a poor level of knowledge (Table 2).
The majority of the participants (75.2%) answered that invasive procedures increase the risk of nosocomial infection. Additionally, 69.3% answered that age (either advanced or young age) increases the risk of nosocomial infections. Around two-thirds (73.6%) of the participants answered that standard precautions aim to protect patients and healthcare workers. Around two-thirds (71.6%) answered that standard precautions should be applied to all patients. Approximately, 80% of the participants answered that hand hygiene should be performed before and after contact with a patient and between patient contacts. Most of the participants (80.2%) answered that gloves should be used when there is a risk of being cut, whereas 75.2% of the participants answered that gloves should be used when there is a risk of contact with blood or bodily fluids. Furthermore, 71.6% of the participants answered that masks, goggles, and gowns should be worn when there is a risk of splashes or spraying of blood and body fluids (Table 3).
Age (mean=30.9, SD=4.24)
Years of experience (mean=7.28, SD=3.47)
Previous infection control training course
|-||N (%)||Mean (SD)|
|Knowledge of standard precaution||-||14.09 (2.97)|
|Compliance with standard precautions||-||14.46 (3.02)|
|Categories of nurses' knowledge regarding standard precautions
Very good knowledge
|Statements||Correct Answer||N (%)|
1. Nosocomial infection
a. The environment (air, water, inert surfaces) is the major source of bacteria responsible for nosocomial infection.
|b. Advanced age or very young age increases the risk of nosocomial infection.||Yes||210 (69.3)|
|c. Invasive procedures increase the risk of nosocomial infection.||Yes||228 (75.2)|
2. Precaution standards
a. Include the recommendations to protect only the patients.
|b. Include the recommendations to protect the patients and the healthcare workers.||Yes||223 (73.6)|
|c. Apply for all the patients.||Yes||217 (71.6)|
|d. Apply for only healthcare workers who have contact with body fluid.||No||245 (80.6)|
3. When is hand hygiene recommended?
a. Before or after contact with (or care of) a patient.
|b. Before and after contact with (or care of) a patient.||Yes||241 (79.5)|
|c. Between patient contacts.||Yes||244 (80.5)|
|d. After the removal of gloves.||Yes||223 (73.6)|
4. The standard precautions recommend the use of gloves
a. For each procedure.
|b. When there is a risk of contact with the blood or body fluid.||Yes||228 (75.2)|
|c. When there is a risk of a cut.||Yes||243 (80.2)|
|d. When healthcare workers have a cutaneous lesion.||Yes||200 (66)|
5. When there is a risk of splashes or spray of blood and body fluids, the healthcare workers must wear
a. Only mask
|b. Only eye protection||No||205 (67.7)|
|c. Only a gown||No||228 (75.2)|
|d. Mask, goggles, and gown||Yes||217 (71.6)|
|Knowledge of standard precautions||0.77||<0.001|
|Compliance with standard precautions||-||-|
There was a significant positive correlation between the nurses’ knowledge and compliance with standard precautions (r=.77, p=.000) (Table 4).
The current study aimed to assess nurses’ knowledge of and compliance with standard precautions. Currently, HAI remains a common issue encountered in healthcare settings worldwide. A nurses’ up-to-date knowledge about standard precautions plays an important role in managing this issue. Moreover, compliance with these standards on a daily basis could decrease the infection rate among patients and healthcare workers. This study was conducted in three hospitals in Jordan, and it revealed nurses to have a good level of knowledge about standard precautions, which is in agreement with another study conducted in Jordan . These findings emphasize the importance given to these standards in the healthcare systems in Jordan.
The good level of knowledge was found to be consistent with compliance with standard precautions, which may be due to the strict monitoring by infection control personnel and nurses-in-charge. These findings contradict those of Suliman et al. ; they indicated that a good level of knowledge alone was not enough to ensure compliance. In our study, approximately a quarter of the study sample had attended a training course on infection control, which may have improved their knowledge and compliance with standard precautions. Chan et al.  and Luo et al.  reported knowledge about standard precautions to be a significant predictor for better compliance. Some studies have identified a lack of knowledge about standard precautions among the nurses [23, 35-37].
In the present study, 79.9% of the nurses believed that the goal of standard precautions was to protect the patients, and 73.6% believed that they also protected healthcare workers. Approximately, 71.6% reported that standard precautions should be applied to all patients. A study conducted among 82 nurses in Brazil showed that 75.6% of nurses understood that standard precautions are protective measures; 11% believed that they protected professionals only, and 52.4% believed that they protected both patients and professionals. Furthermore, 9.8% believed that it was for protection against patients diagnosed with infectious diseases . Siegel et al.  reported that standard precautions should be applied to all patients because the infective status of a patient is not always known.
Although nurses had a good level of knowledge about standard precautions, only 65% of the participants answered that the environment is not the only source of bacteria responsible for nosocomial infections. Therefore, knowledge about microorganisms requires more attention. Approximately, 79.5% of the participants answered that hand hygiene should be performed before and after contact with patients. This finding implies that standard precautions for hand hygiene are well-established in clinical practice. In contrast, Hessels et al.  reported that hand hygiene was performed only half of the times when indicated and was more often missed before contact with a patient than after.
Approximately, 71.6% of the participants answered that they should use masks, goggles, and gowns when there is a risk of splashes or spraying of blood and bodily fluids. This implies that PPE is well-recognized as an effective means for controlling infection and protecting patients and healthcare workers. In contrast, a study conducted by Jain et al.  revealed that less than half of the participants used PPEs for maximal protection, which put the healthcare workers at risk for blood-borne infections, such as hepatitis and HIV, through splashes or spraying of blood and bodily fluids.
Finally, our study showed a strong positive correlation between knowledge of and compliance with standard precautions (r=.77, p=.000). This implies that infection control training courses and continuous education may improve knowledge of standard precautions and positively affect compliance. Knowledge about standard precautions and the availability of PPE have been determined as the main factors for compliance with standard precautions [25, 40].
5. IMPLICATIONS FOR NURSING
Infection control training courses and continuous education may improve knowledge of standard precautions and positively affect the compliance of nurses.
6. STRENGTH AND LIMITATIONS OF THE STUDY
The strength of this study was using random sampling of the participants to avoid selection bias. Whereas, the limitations of this study are that the recruitment of military nurses only and using self-reported questionnaires rather than actual observation of the compliance of nurses limited the generalization of the findings. The self-reported questionnaires might have led to recall bias.
In conclusion, the nurses’ knowledge of standard precautions was good in this study, and it translated into appropriate compliance in clinical practice. There was a positive relationship found between nurses’ knowledge and compliance with standard precautions. Continuous monitoring and evaluation of the implementation of standard precautions are needed to maintain and enhance compliance among the nurses.
LIST OF ABBREVIATIONS
|HAIs||= Healthcare-associated Infections|
|HIV||= Human Immunodeficiency Virus|
|HBV||= Hepatitis B|
|PPE||= Personal Protective Equipment|
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Ethical approval for this study was obtained from the Royal Medical Services (Ref. # 1112019) on December 13, 2018.
HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the 1975 Declaration of Helsinki, as revised in 2013.
CONSENT FOR PUBLICATION
A written informed consent was provided by each participant selected for this study.
AVAILABILITY OF DATA AND MATERIAL
The data and supportive information are available within the article.
|||Moore RM Jr, Kaczmarek RG. Occupational hazards to health care workers: Diverse, ill-defined, and not fully appreciated. Am J Infect Control 1990; 18(5): 316-27.
|||Ndejjo R, Musinguzi GYuX, et al. Occupational health hazards among healthcare workers in Kampala, Uganda. J Environ Public Health 2015; 2015: 913741.|
|||Twitchell KT, Wachs JE. Bloodborne pathogens. AAOHN J 2003; 51(1): 38-47.
|||Vieira M, Padilha MI, Pinheiro RDC. Analysis of accidents with organic material in health workers. Rev Lat Am Enfermagem 2011; 19(2): 332-9.
|||Gerberding JL. Incidence and prevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and cytomegalovirus among health care personnel at risk for blood exposure: Final report from a longitudinal study. J Infect Dis 1994; 170(6): 1410-7.
|||Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev 2000; 13(3): 385-407.
|||Prüss-Üstün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005; 48(6): 482-90.
|||Centers for Disease Control and prevention. Guidelines for infection control in health care personnel. Infect Control Hosp Epidemiol 1998; 19(6): 445.|
|||Prüss-Üstün A, Rapiti A, Hutin Y. Sharps injuries: Global burden of disease from sharps injuries to health-care workers. Geneva: World Health Organization 2003.|
|||Centers for Disease Control (CDC). Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR Morb Mortal Wkly Rep 1988; 37(24): 377-382, 387-388.
|||Centers for Disease Control and prevention (CDC). Universal precautions for prevention of transmission of HIV and Other bloodborne infections 1996. Available From: https://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html|
|||Garner JS. The Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17(1): 53-80.
|||Center for Disease Control and Prevention. Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. 2007. Available From: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf (Accessed on August 01, 2018).|
|||Gould DJ, Hewitt-Taylor J, Drey NS, Gammon J, Chudleigh J, Weinberg JR. The CleanYourHandsCampaign: Critiquing policy and evidence base. J Hosp Infect 2007; 65(2): 95-101.
|||Luangasanatip N, Hongsuwan M, Limmathurotsakul D, et al. Comparative efficacy of interventions to promote hand hygiene in hospital: Systematic review and network meta-analysis. BMJ 2015; 351: h3728.
|||Magill A, Ryan E, Hill D, Solomon T. Hunter’s Tropical Medicine and Emerging Infectious Disease. 9th edition. Saunders 2012.|
|||Siegel JD. Controversies in isolation and general infection control practices in pediatrics. Semin Pediatr Infect Dis 2002; 13(1): 48-54.
|||Siegel JD, Rhinehart E, et al. The health care infection control practices: Guidelines for isolation precautions. J Infect Prev 2007; 41: 274-82.|
|||Martín-Madrazo C, Cañada-Dorado A, Salinero- Fort MA, et al. Effectiveness of a training programme to improve hand hygiene compliance in primary healthcare. BMC Public Health 2009; 9(1): 469.
|||Jacob A, Newson-Smith M, Murphy E, Steiner M, Dick F. Sharps injuries among health care workers in the United Arab Emirates. Occup Med 2010; 60(5): 395-7.
|||Ahmed SMS, Hassan SAA, Abd Allah ES. Compliance with universal precautions among nurses and laboratory technicians in mansoura international specialized hospital. Egypt J Hosp Med 2008; 30(1): 151-64.
|||Ogoina D, Pondei K, Adetunji B, Chima G, Isichei C, Gidado S. Knowledge, attitude and practice of standard precautions of infection control by hospital workers in two tertiary hospitals in Nigeria. J Infect Prev 2015; 16(1): 16-22.
|||Ayed A, Eqtait M, Fashafsheh I. Knowledge & compliance of nursing staff towards standard precautions in the Palestinian hospitals. Adv Life Sci Technol 2015; 36: 21-30.|
|||Chan MF, Ho A, Day MC. Investigating the knowledge, attitudes and practice patterns of operating room staff towards standard and transmission-based precautions: Results of a cluster analysis. J Clin Nurs 2008; 17(8): 1051-62.
|||Luo Y, He G-P, Zhou J-W, Luo Y. Factors impacting compliance with standard precaution in nursing, China. Int J Infect Dis 2010; 14(12): e1106-14.
|||Gammon J, Morgen H. A review of the evidence for suboptimal compliance of health care practitioners to infection control precautions. J Clin Nurs 2007; 17(2): 157-67.
|||El-Greeb H, Ahmed A, Atia H, et al. Assessment of nurses’ compliance with infection control standard precautions at outpatient clinics of urology and nephrology center - Mansur University. Nurs Health Sci 2018; 7(3): 54-9.|
|||Powers D, Armellino D, Dolansky M, Fitzpatrick J. Factors influencing nurse compliance with Standard Precautions. Am J Infect Control 2016; 44(1): 4-7.
|||Suliman M, Aloush S, Aljezawi M, AlBashtawy M. Knowledge and practices of isolation precautions among nurses in Jordan. Am J Infect Control 2018; 46(6): 680-4.
|||Tavolacci MP, Ladner J, Bailly L, Merle V, Pitrou I, Czernichow P. Prevention of nosocomial infection and standard precautions: Knowledge and source of information among healthcare students. Infect Control Hosp Epidemiol 2008; 29(7): 642-7.
|||Valim MD, Pinto PA, Marziale MHP. Questionnaire on standard precaution knowledge: Validation study for brazilian nurses use. Texto Contexto Enferm 2017; 26(3): e1190016.|
|||Valim MD, Marziale MHP, Hayashida M, Rocha FLR, Santos JLF. Validity and reliability of the questionnaire for compliance with standard precauction. Rev Saude Publica 2015; 49(0): 87.
|||Cruz JP, Colet PC, AL-otaibi JH, et al. Validity and 369 reliability assessment of the compliance with standard precaution scale. arabic version in Saudi nursing students. J Infect Public Health 2016; 9(5): 645-371.
|||Pereira FMV, Lam SC, Gir E. Cultural adaptation and reliability of the compliance with standard precaution scale (CSPS) for nurses in Brazil. Rev Lat Am Enfermagem 2017; 25: e2850.|
|||Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford SM. Compliance with Universal/Standard Precautions among health care workers in rural north India. Am J Infect Control 2005; 33(1): 27-33.
|||López C, Limón E, Castillo E, et al. Standard precautions: Are these known? Are they applied?. Rev Enferm 2006; 29(1): 16-20.
|||Melo DS, Souza ACS, Tipple AFV, Neves ZCP, Pereira MS. Nurses’ understanding of standard precautions at a public hospital in Goiania - GO, Brazil. Rev Lat Am Enfermagem 2006; 14(5): 720-7.
|||Hessels AJ, Genovese-Schek V, Agarwal M, Wurmser T, Larson EL. Relationship between patient safety climate and adherence to standard precautions. Am J Infect Control 2016; 44(10): 1128-32.
|||Jain M, Dogra V, Mishra B, Thakur A, Loomba PS. Infection control practices among doctors and nurses in a tertiary care hospital. Ann Trop Med Public Health 2012; 5(1): 29-33.
|||Ferrer LM, Cianelli R, Norr KF, et al. Observed use of standard precautions in Chilean community clinics. Public Health Nurs 2009; 26(5): 440-8.