ABSTRACT
Health care workers, particularly nurses are at risk of infection because they constantly come into contact with infected tissues, fluid, blood and blood products. By complying with infection control measures a lot of infections can be prevented. Some survey studies have been conducted in Nigeria on knowledge, perception attitude and practice of infection control and they concluded that there was inadequate adherence to infection control practices and this could be addressed by organizing training and retraining programmes. This study therefore examined the effects of a training programme in promoting infection control in two teaching hospitals in Ogun State.
The study adopted a pretest-posttest quasi experimental design. The sample consisted of 87 participants. They were made up of experimental group which consisted of 42 registered nurses from Babcock University Teaching Hospital (BUTH). Ilishan-Remo, Ogun State. The control group was 45 nurses from Olabisi Onabanjo University Teaching Hospital. The training programme consisted of 4 modules on infection control. The programme lasted 4 weeks. The instruments used for data collection were Knowledge about Infection Control Questionnaire (r = 0.79); Perceptions about Infection Control Questionnaire (r = 0.80); Attitudes towards Components of Infection Control Questionnaire (r = 0.62); Practice of Infection Control Questionnaire (both self-reported and observation checklist) (r =0.62). Four research questions were answered and three hypotheses were tested at 0.05 alpha level. Data were analysed using descriptive statistics and Students’ T-test.
Findings showed that the mean age in the experimental group was 34.92 and SD 8.99 while the control group was 47.43 and SD 6.60. The mean for years of experience in the experimental group was 10.42 and SD 9.95 while in the control group was 21.89 and SD 8.72. On attitude, 30 participants (69.0%) had positive attitude in the experimental group compared to 21 participants (46.7%) in the control group. The mean difference was 4.02. On perception, 32 participants (76.0%) in the post intervention had good perception compared to nonein the control group. The mean difference was 8.36. On knowledge, 26 participants (62.9%) in the post intervention had high knowledge compared to none participant in the pre intervention. The mean difference was 7.24. On infection risk reduction in the intervention group, 28 participants (66.7%) have experienced sharp injury pre intervention and none post intervention. Significant differences were found between mean practice score of participants in the experimental and control (p = 0.001) and between self reported and observed practices (p = 0.000) but there was no significant difference between the mean knowledge score in the experimental and control group (p = 0.149).
The training programme was effective in improving the level of knowledge, attitude, perception and practice of infection control. Based on these findings, it is recommended that there should be adequate provision of facilities for infection control. Training and retraining should be organized for all nurses and other categories of healthcare workers to promote adherence to infection control.
Keywords: Training, Knowledge, Attitude, Perception, and Practice
Word Count: 479
TABLE OF CONTENTS
Content Page
Title Page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract v
Table of Contents vi
List of Tables ix
List of Figures x
Appendices xi
List of Abbreviations xii
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study 1
1.2 Statement of the Problem 4
1.3 Objective of the Study 5
1.4 Research Questions 5
1.5 Hypotheses 6
1.6 Scope of the Study 6
1.7 Significance of the Study 6
1.8 Justification for the Study 7
1.9 Operational Definition of Terms 7
Content Page
CHAPTER TWO: REVIEW OF LITERATURE
2.0 Introduction 9
2.1 Overview of infection prevention and control 9
2.2 Knowledge Attitude and Practice of Infection Control 13
2.3 Standard Precautions 17
2.4 Empirical Studies on Infection Control Measures 22
2.5 Theoretical/Conceptual Framework Precede Model 31
2.6 Appraisal of Literature Review 34
CHAPTER THREE: METHODOLOGY
3.0 Introduction 36
3.1 Research Design 36
3.2 Population 37
3.3 Sample size and sampling Technique 38
3.4 Instrumentation 42
3.5 Validity and Reliability of the Instrument 43
3.6 Data Collection Procedure 44
3.7 Method of Data Analysis 46
3.8 Ethical Consideration 46
CHAPTER FOUR: DATA ANALYSIS, RESULTS AND DISCUSSION
OF FINDINGS
4.0: Introduction 47
4.1: Demographic Data of Participants 54
4.2: Discussionof Effects of Training Programme on Perception of Participants 55
Content Page
4.3: Discussion of Hypotheses 57
CHAPTER FIVE: SUMMARY, CONCLUSION AND
RECOMMENDATIONS
5.1: Summary 61
5.2: Conclusion 63
5.3: Recommendations 63
5.4: Limitation of Study 64
5.5: Suggestion for Further Studies 64
REFERENCES 65
APPENDICES 75
LIST OF TABLES
Table Page
3.1: Sampling Distribution for Intervention Group 40
3.2: Sampling Distribution for Control Group 41
4.1: Demographic Data of Participants 48
4.2: Descriptive statistics showing Effect of Training on Participants’ Attitudes in
the Experimental Group 49
4.3: Descriptive statistics showing Effects of Training on Participants’ perceptions
in the Experimental Group 50
4.4: Descriptive statistics showing Effects of Training on Participants’ knowledge in
the Experimental group 51
4.5: Pre Intervention Responses of Participants on Exposure or Injury Experience in Experimental Group and Control Group 51
4.6:Post Intervention Responses of Participants on Exposure or Injury Experience in
Experimental and Control Group 52
4.7: T-test Showing Differences between the Mean Knowledge Score of Participants in
Experimental group and Control Group 53
4.8: T-test Showing Differences between the Mean Practice Score of Participants in
Experimental Group and Control Group 53
4.9:T-test Showing Differences between Self-reported and Observed Practices of
Infection Control in the Experimental Group 54
LIST OF FIGURES
2.1: The Chain of Infection 11
2.2: Precede Framework Adapted to Nursing Intervention to promote
Infection Control 33
APPENDICES
- Informed Consent
- Questionnaire
III. Reliability of Instruments
- BUHREC Approval Letter
- Letter of Introduction to the Teaching Hospitals
- Letter of Approval from OOUTH
VII. Training Programme for Participants
VIII-XI Intervention Packages
XII. Pictures from Field Work
XIII Similarity Index (Turnitin)
LIST OF ABBREVIATIONS
BUTH- Babcock University Teaching Hospital
CDC- Center for Disease Control and prevention
CEU- Continuous Education Unit
CHER- Children Emergency
CMPC- Community Medical Primary Care
COPD- Casualty Outpatient Department
CSSD- Central Sterile Supply Department
CVC- Central Venous Catheter
HBV- Hepatitis B Virus
HCV- Hepatitis C Virus
HCW- Healthcare Waste Management
HIV- Human Immunodeficiency Virus
ICU- Intensive Care Unit
NSIs- Needle Stick Injuries
OOUTH- Olabisi Onabanjo University Teaching Hospital
PEP- Post Exposure Prophylaxis
PMTCT- Prevention of Mother-to-Child Transmission
PRECEDE- Predisposing, Reinforcing, Enabling, Constructs in
Educational Diagnosis and Evaluation
PPE- Personal Protective Equipment
SP- Standard Precautions
WHO- World Health Organisation
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Infection control is an aspect of healthcare delivery that deals with the curtailment of the spread of infection within the healthcare set-up, be it from patient-to-patient, patient-to-staff, staff-to-patients or staff to staff. According to World Health Organisation (WHO, 2011) the components of infection prevention and control are as follows: organisation, technical guidelines, human resources, surveillance, microbiology laboratory support, environment, evaluation and links with public health and other services. Organisation involves setting up a programme, formation of the infection control committee and inter-professional team, which should include physicians, nurses, microbiologists, epidemiologists, infection control specialists, information specialists and others. The committee must have a good working relationship with one another, because their work entails collaboration with other departments, staff and programmes. Technical guidelines involve developing, disseminating and implementing technical evidence-based information in preventing the risks of infection. Human resources involve training and re-training of health care personnel in preventing infections and the training of infection control professionals. It guarantees a pool of adequate staff responsible for infection prevention and control activities.
Surveillance is the tracking of demonstrated or suspected spread of infection. It involves the collection of data on epidemic and detection of outbreaks as well as the assessment of level of compliance with infection control practices, response to outbreaks and documentation of the situation of healthcare associated infection. Surveillance is important in that it causes early detection, identification, isolation and intervention, and results in effective infection prevention. Microbiology laboratory supports generate data, standardised laboratory techniques and promotes interaction between infection control activities. The environment refers to the minimum requirements for infection control. It includes water, ventilation, hand-hygiene equipment, placement of patient as well as isolation facilities, sterile supply storage, building conditions and renovation activities. Evaluation has to do with monitoring, assessment and report of infection prevention and control outcomes, processing and strategizing at national level and in healthcare facilities. It mirrors the impact of the infection control programmes. Links with public health and other services ensures proper coordination and collaboration between staff and departments in the events of mandatory reporting and activities such as waste management and sanitation, bio-safety, occupational health, patients and consumer’s care and the quality of health care (Hebden, 2015; Stempliuk & Eremin, 2015; WHO, 2011).
There are various sources of infections. Healthcare associated infections (HAI) are infections that develop in the course of healthcare and results in aggravating illnesses and may lead to deaths, extends the duration of hospital stay, and calls for more interventions at an added cost to the one already expended by the patient’s initial disease. Its occurrence is an indicator of the quality of patient care, adverse event and an issue of patient safety. The sources includes adverse drug events, surgical complications, microorganism isolates, antimicrobial resistance, decreasing trends in intensive care units, exogenous microorganisms such as bacteria, fungi, viruses, protozoan from other patients, endogenous flora of the patients- residual bacteria residing on the patient’s skin, mucous membrane, gastro intestinal tract, respiratory tract, inanimate environmental surfaces, contaminated objects, patient room touch, surfaces, equipment, medication, individual patient, medical equipment, devices, hospital environment, contaminated drugs and foods and hospital flora in the healthcare environment. Other sources include doctors’ white coats, nurses’ uniform, hospital garments, privacy drapes, stethoscopes, bed rails, common hospital surfaces, contaminated water, compromised immune system, negligence or poor attitude of hospital staff, hands of health care workers. It could be from patient to patient, patient to environment, staff to patient, renovation works in the hospital (Hans, 2012; Stubblefield, 2014; WHO, 2011).
Healthcare workers generally are at risk of infection, because they constantly come into contact with infected materials such as tissues, fluid, blood and blood products. There are several infection control measures aimed at controlling the spread of infectious diseases, such as hepatitis B and C, Human immunodeficiency virus (HIV) and other life threatening infections. Moreover, the hospital waste itself is a potential source of infection hence the need for proper infection control measures. It has been found that healthcare workers do not adhere strictly to the various infection control measures, probably because they do not recognise such, or they lack adequate knowledge, or could be due to poor attitude towards infection control measures, including non-availability of materials and equipment (Amoran & Onwube, 2013).In a study conducted at the Federal Medical Center (FMC), Gombe, in North Eastern Nigeria among nurses, it was found that some respondents were not aware that standard precautions is applied to all patients, and majority of the respondents have poor knowledge of the components of standard precautions (Saidu, Habu, Kever, Dathini, Inuwa, Maigari et al, 2015).
Standard precautions are infection control measures that are put forward by the United States Centre for Disease Prevention & Control (CDC), in 1996. By complying with standard precautions, a lot of infections can be avoided, such as occupational exposure to pathogens. While some health workers are familiar with the infection control measures, some are not. This may be due to lack of awareness or knowledge and moreover, the attitude that some who are familiar with the infection control measures, show towards practice is not encouraging. When one considers the importance of adequate knowledge and practice of infection control measures, by the healthcare workers, one cannot but think of what to do to improve on that knowledge and practice. Jain, Dogra, Mishra, Thakur and Loomba (2012), in their study among doctors and nurses in a tertiary care hospital, found that there is lack of knowledge and practice regarding basic infection control measures. This deficit in knowledge can be improved through educational intervention. Wasswa, Nalwadda, Buregyoya, Gitta, Anguzu and Nuwama (2015), in their study on implementation of infection control in health facilities in Uganda, found that with prior training on infection control, the respondents were more likely to wash their hands. Level of education and a prior nosocomial infection experience will have a role in the practice of infection control measures. In-service training on infection control measures will boost the practice of infection control measures.
Amoran and Onwube (2013) found that inadequate workers’ knowledge on infection control and environment related problems are crucial issues that need urgent attention. According to Gebresilassie, Kumei, and Yemane (2014) in their study, “there is suboptimal and inconsistent practice of standard precautions in the healthcare setting that put patients and healthcare workers at significant risk of acquiring infections”. They also emphasized the need for in-service training for the healthcare workers on infection control. Adly, Amin and Abd El-aziz, (2014) found that intervention influenced the compliance of nurses with infection control measures, because of the knowledge gained during the intervention or training programme. There is a standard of infection control measures that can guarantee infection safety among health workers and patients.
1.2 Statement of the Problem
Healthcare workers generally are at risk of infection. WHO (2006), reported that among the 35million health workers worldwide, about 3 million sustain percutaneous exposures to the blood borne pathogens each year, including 2 million to Hepatitis B virus (HBV), 0.9 million to Hepatitis C virus (HCV) and 170,000 to Human Immunodeficiency virus (HIV). These injuries may result in 70,000 HBV; 15,000 HCV and 5,000 HIV infections. Nurses are at higher risk of being infected with blood-borne pathogens from clinical blood exposure through injuries with sharp instruments and needle-stick injuries if infection control measures are not strictly followed. This is because they are usually the first contact with a patient on arrival in the hospital and provide 24 hour patient care. Studies have also shown evidence of clinical nurses becoming infected due to occupational exposure (Centers for Disease Control & Prevention, 2012). Abdulraheem, Amodu, Saka, Bolarinwa & Uthman (2012), in their study, among health workers in North Eastern Nigerian found that the level of knowledge and implementation of standard precautions is below standard to guarantee infection safety. They concluded that there is still much to learn and implement when it comes to infection control measures.
Furthermore, in some health institutions, the researcher observed that some nurses do not adhere to the components of standard precautions while providing nursing care. For example, few nurses were observed not to wash their hand after removing gloves and before commencing another procedure. In some of the wash hand basins in the outpatient department, liquid soap is not available for health workers and patients to wash their hands. When blood or body fluids are spilled on the floor, the house keepers do not decontaminate with hypochlorite solution before mopping with soap and water. The health institutions infection control units are not well equipped to function effectively to ensure compliance to standard precautions. It is in the light of the gaps that the researcher became interested in planning a training programme on knowledge, perception, attitude and practice of infection control for nurses at Babcock University Teaching Hospital (BUTH), Ilisan-Remo, Ogun state.
1.3 Objective of the Study
The main objective of this study is to determine the effects of a training programme on infection control among nurses. The specific objectives are to:
- assess the effectiveness of the training programme on knowledge of participants about
infection control;
- determine the effectiveness of the training programme on perceptions of participants
about infection control;
- document the effectiveness of the training programme on attitudes of participants
towards infection control;
- implement a training programme on infection control;
- determine the level of skills possessed and practice of participants on infection control;
- assess the effectiveness of a training programme on infection risk reduction and
- ascertain if there is any difference between the self-reported practices and the actual
observed practices of infection control in the experimental group.
1.4 Research Questions
This study attempted to answer the following research questions:
- What are the effects of training programme on attitudes of participants?
- What are the effects of training programme on the perceptions of participants?
- What are the effects of training programme on the knowledge of participants?
- What is the effect of the training programme on infection risk reduction?
1.5 Hypotheses
These three hypotheses were tested at 0.05 level of significance:
Ho 1. There is no significant difference in the mean knowledge score of infection control between the experimental group and the control group.
Ho 2. There is no significant difference in the mean practice score of infection control between the experimental group and the control group.
Ho 3. There is no significant difference between the self reported practice and observed practice of infection control in the experimental group.
1.6 Scope of the Study
This study focused on the knowledge, attitude, perception and practice of infection control among nurses. Specific areas are; hand hygiene, use of personal protective equipment (PPE), handling sharps/injection safety, cleaning and disinfection as well as waste management. The independent variable is the training package, and the dependent variables are the participants’ knowledge, attitude, perception and practice.
1.7 Significance of the Study
The importance of the training programme to nurses, patients, hospital and society cannot be over emphasized. The training programme may improve infection control practices among nurses. The practices include: hand washing, donning and removing PPE for example, gloves, gown, mask, eyewear, and injection safety. The study may also improve the knowledge of nurses on the components of standard precautions. Training and practicing standard precautions may lead to a situation where nurses actually feel more protected from the risk of exposures to HIV and Hepatitis, and are more likely to provide improved “physical care”. Nurses also experience less fear and are less judgmental towards patients, thus less likely to stigmatise or discriminate patients, leading to improved “psychosocial or emotional care” when rendering care to patients with highly infectious diseases.
In the practice of standard precautions, all patients are assumed to be possible sources of infection and must be handled professionally in that regard. The importance of this programme to the hospital is that the patients that receive care are not likely to have nosocomial infection. This may in turn allow the hospital to have recognition which may attract more patronage by Ogun state indigenes and beyond.
Adequate infection control measures may have economic as well as political effect on the society. However, the nurses will be conversant with what to do and how to do it, in terms of preventing infection. For instance, Hepatitis kills more quickly than HIV, if one is infected with either of the two, it will result in severe economic loss for the individual and the family, and when this is translated on to the national stage, it will be a great loss due to the multiplier effect.
1.8 Justification for the Study
Knowledge and practice of standard precautions has been shown to reduce the risk of exposure to blood and body fluids (Chan, Molassiootis, Chan, Chan, Ho, Lai, et al, 2002). Standard precautions are the basic level of infection control precautions which are to be used, as a minimum in the care of all patients. It is therefore necessary for nurses to have training and re-training programme on standard precautions to improve their compliance.
1.9 Operational Definition of Terms
Infection control: This refers to an aspect of healthcare delivery that deals with the curtailment of the spread of infection within the healthcare set-up, be it from patient-to-patient, patient-to-staff, staff-to-patients or staff to staff.
Nursing intervention: This refers to a training package that focuses on improving knowledge, attitude, perception and practices of infection control. The areas of focus include hand washing, PPE such as gowns, mask, goggles, and gloves. The training also includes injection safety/handling sharps, cleaning decontamination and sterilization, waste management as well as post exposure prophylaxis (PEP).
Knowledge: This means facts, information and skills acquired through experience or education on infection control.
Attitude: Internal mental disposition expressed towards infection control or feelings expressed towards infection control.
Perception: This means conscious understanding of what infection control is all about or meaning ascribed to infection control.
Practice: This refers to a regular repeated exercise in order to gain proficiency in skills on the components of infection control. This includes hand hygiene, use of personal protective equipment, injection safety/handling sharps, cleaning decontamination and sterilization, waste management as well as PEP.
Effectiveness: This refers to the positive impact of a training programme on infection control which may include increased level of participant’s knowledge and practice.
Nurses: These are registered nurses working at BUTH, Ilisan-Remo and Olabisi Onabanjo University Teaching Hospital (OOUTH), Ogun state.
Promotion of Infection Control: This means disseminating information about infection control.
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