KNOWLEDGE AND PRACTICE OF INFECTION CONTROL AMONG MIDWIVES

ABSTRACT
The aim of the study is to determine the knowledge, attitude and practices of nurses regarding
infection prevention and control within a tertiary hospital in Nigeria. A descriptive, research
design with a quantitative approach was applied to determine the level of knowledge,
attitudes and practices of nurses regarding infection prevention and control within a tertiary
hospital in Nigeria. The population for the study was nurses working in clinical environment
at a tertiary hospital in Nigeria. 312 nurses were the total population of nurses at this tertiary
hospital of which n= 140 (70%) were registered nurses, n= 80 (56%) enrolled nurses, n= 47
(33%) registered midwives, n= 23 (16%) enrolled midwives, n= 10 (7%) certified midwives
and n= 12 (8%) registered mental health nurses. According to table 3.1, n= 31 nurses
participated in the pilot study (10% of N= 312) while n= 196 nurses participated in the main
study (70% of N= 281). The sampling method that was utilized in this study was stratified
simple random sampling. This method of sampling enabled the study population to have an
equal and independent chance of appearing in the study sample. The current study revealed
that 76.4% (table 4.13) of nurses did not receive appropriate vaccination regarding infection
prevention and control. Furthermore, 61% (table 4.13) of the nurses indicated that personal
protective equipment is not always accessible. Therefore, both patients and nurses are
exposed to hospital acquired infections.
 TABLE OF CONTENTS

ABSTRACT

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

1.2 PROBLEM STATEMENT

1.3 STUDY OBJECTIVES

1.4 SIGNIFICANCE OF THE STUDY

1.5 STUDY QUESTIONS/HYPOTHESES

1.6 SCOPE AND LIMITATION OF THE STUDY

1.7 DEFINITION OF TERMS

CHAPTER TWO

REVIEW OF RELATED AND RELEVANT LITERATURE

2.1 INTRODUCTION

2.2 CONCEPTUAL CLARIFICATIONS

2.3 THEORETICAL STUDIES

2.4 EMPIRICAL STUDIES

2.5 RELATED LITERATURES

CHAPTER THREE

RESEARCH METHODLOGY

3.1 RESEARCH DESIGN

3.2 STUDY AREA

3.3 SOURCES OF DATA

3.4 POPULATION OF THE STUDY

3.5 SAMPLE SIZE DETERMINATION

3.6 INSTRUMENTATION

3.7 RELIABILITY AND VALIDITY OF INSTRUMENT

3.8 METHOD OF DATA ANALYSIS

CHAPTER FOUR

DATA PRESENATATION, ANALYSIS AND INTERPRETATION

4.1 DATA PRESENTATION

4.2 DATA ANALYSIS

4.3 DATA INTERPRETATION

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATION

5.1 SUMMARY

5.2 CONCLUSION

5.3 RECOMMENDATION

REFERENCES

APPENDIX
 CHAPTER TWO

INTRODUCTION

1.1 BACKGROUND
Infection-related diseases are still the main cause of death in Nigeria, according to the 2013
health profile acquired by the World Health Organisation (WHO, 2013) statistics. The burden
of disease in Nigeria includes HIV, TB, Malaria, other infectious diseases and respiratory
infections. Expansion of the infection prevention and control movements occur due to the
increase in infection occurrences in the country. This increase in infection-related disease’s
impact the increase health financing in Nigeria with a government contribution to health care
of 57.5% above the figures budgeted for (WHO, 2014).

Infectious patients are admitted into hospitals and therefore hospitals have become common
settings for transmission of diseases. In hospitals, infected patients are a source of infection
transmission to other patients, health care workers and visitors (Sydnor & Perl, 2011).
Nosocomial infection, also known as hospital-acquired infections is one of the leading causes
of death and has much economic cost due to increased hospitalization and prognosis (WHO,
2015). According to WHO (2010), Hospital acquired infection is defined as an infection
occurring in a patient during the process of care within a health care facility which was not
present or incubating at the time of admission. These infections are those occurring more than
48 to 72 hours after admission and within ten days after hospital discharge (Collins 2008:2).
Due to the admission of patients with different organisms, the hospital environment has
become saturated with highly virulent organisms, namely: Staphylococcus aureus,
Streptococcus pyogenic, Escherichia coli, Pseudomonas aureginosa and Hepatitis viruses that
survive in a hospital. These organisms cause diseases ranging from minor skin infections to
life-threatening conditions such as sepsis (Sydnor, & Perl, 2011).

The Nigeria Ministry of Health has indicated that Ebola virus disease epidemic is a public
health risk as neighbouring country are suffering from the diseases and therefore
preparedness in infection prevention and control measures should be strengthened. Efficient
knowledge, good attitude and best practices by nurses in
infection prevention and control may contribute to decreasing in infection rate in the hospital.

The Nigeria policy on health has stipulates that the health care institution should provide a
safe environment for the patients in their care. Hospital nurses form the backbone of infection
prevention and control, therefore possibly, will either contribute to infection transmission or
prevent and control infection. According to Damani (2012), the environment in which a
patient is nursed must be planned to reduce the risk of transmission of infection. Infection
prevention and control measures aim to protect the vulnerable people from acquiring an
infection while receiving health care (Damani, 2012). Lack of knowledge, bad attitudes and
poor practices amongst nurses in the prevention and control of infections can lead to hospital-
acquired infections.

In clinical practice, the researcher has observed cases where nurses handle contaminated linen
with bare hands, put needles in the patient’s mattress after giving injections, do not clean the
stethoscope between patients and do not wash hands regularly in the clinical environment.
Poor infection prevention and control practices among nurses increase the rates of hospital-
acquired infections.

Hand hygiene is the single most important intervention to prevent transmission of infection
and should be a quality standard in all health institutions. An attitude of not washing hands
among individuals involved in the provision of health care can increase the rate of hospital-
acquired infections. In a study that was conducted in India, where Nair, Hanumantappa,
Hinemath,Siraj and Raghunath (2013:3) assessed knowledge, attitude and practices of hand
hygiene among medical and nursing students at a tertiary health care centre, the majority of
students had poor knowledge with regard to hand hygiene.

Lack of knowledge among nurses can increase the rate of hospital-acquired infections. This is
supported by a study that was conducted in Zimbabwe by Tirivanhu, Ancia and Petronella
(2014:73) who determined the barriers of infection prevention and control practices among
nurses at the Bindura provincial hospital. The study revealed that the majority of nurses’ lack
knowledge on infection control principles as only n= 14 (28%) of n= 50 (100%) nurses had
excellent knowledge on
infection control principles, n= 21 (42%) of n= 50 nurses did not utilize the infection control
manuals. Infection control workshops were poorly organised as 68% of the nurses did not
attend any workshop on infection prevention and control practices (Tirivanhu et al., 2014).
Hayeh and Esena (2013:47) assessed the infection prevention and control (IPC) practices
among health workers at Ridge Regional Hospital in Accra (Ghana). The study showed that
knowledge in IPC practices among health care workers was moderate 51% (n= 204), as
availability and access to material for IPC practices at the facility was 58% (n= 118) and
overall compliance with IPC guidelines was 54% (n= 110).

The World Health Organisation (2016) has indicated that surgical site infections at this
particular tertiary hospital in Nigeria are a research priority as there was an increase in wound
infections of those people who had surgery at this hospital and this coincides with the
researcher’s experiences and proposal. Therefore, this study determined the knowledge,
attitude and practices of nurses in infection prevention and control within a tertiary hospital in
Nigeria.

1.2 PROBLEM STATEMENT

A research problem is an area of concern in which there is a gap in the knowledge base
needed for nursing practice (Burns & Grove 2011:146). The researcher has observed that
nurses do not apply infection prevention and control measures in the hospital setting which is
required to ensure patient safety. Lack of knowledge, attitude and practices in infection
prevention and control contribute to high rates of hospital-acquired infections (Jain, Dogra,
Mishra, Thaku and loomba, 2012 & Hayeh and Esena, 2013). Uncontrollable nosocomial
infection contributes to prolonged stay, morbidity and mortality which put stress on health
care economics of the country (Mishta, Banerjee & Gosain, 2014).

1.3 RESEARCH QUESTION

1.What is the level of knowledge, attitudes and practices of health care workers in infection
prevention and control in Maiduguri ?

1.4 RESEARCH AIM

In order to address the research question, the aim of the study is to determine the knowledge,
attitudes and practices of nurses regarding infection prevention and control in Maiduguri.

1.5 RESEARCH OBJECTIVES

Based on the aim, the following objectives have been set for the study to determine:

1.The knowledge of midwifes in infection prevention and control in Maiduguri.

2.The attitude of midwife in infection prevention and control in Maiduguri.

3.The practices of midwife in infection prevention and control in Maiduguri

4.To make recommendations to the risk programme and policies in Maiduguri
1.6 SIGNIFICANCE OF THE STUDY
This study on the knowledge and practice of infection control among midwives will be of
immense benefit to the general public on the concept of infection and will also help the
midwives to come to the understanding of the causes of infections during child birth and how
to prevent and control it. This study will also assist hospitals to put in place prevention
measures to curbing the rate of infection that occur during and after child birth. This study
will also add to existing literature in this study domain and will serve as a reference material
to scholars, researchers and students who may want to carry out further research on this topic
or related area in the future.
1.7 SCOPE OF THE STUDY
This study focuses on examining the knowledge of midwifes in infection prevention and
control in Maiduguri. This study will also examine the attitude of midwife in infection
prevention and control as well as the practices of midwife in infection prevention and control
in Maiduguri. This study will further make recommendations to the risk programme and
policies in Maiduguri. This study enroll nurses working at the federal government hospital,
Maiduguri as the participants for this study.
The major factors that posed a challenge to the researcher while carrying out this study were
inadequate literature on this study domain, insufficient time and finance.
1.8 DEFINITION OF TERMS
KNOWLEDGE: Knowledge is a familiarity, awareness, or understanding of someone or
something, such as facts, skills, or objects. By most accounts, knowledge can be acquired in
many different ways and from many sources, including but not limited to perception, reason,
memory, testimony, scientific inquiry, education, and practice.
PRACTICE: Practice is the act of rehearsing a behaviour over and over, or engaging in an
activity again and again, for the purpose of improving or mastering it, as in the phrase
'practice makes perfect'. It is important to note that practise is a verb and should not be
confused with the noun practice.
INFECTION: The invasion and multiplication of microorganisms such as bacteria, viruses,
and parasites that are not normally present within the body. An infection may cause no
symptoms and be subclinical, or it may cause symptoms and be clinically apparent.
CONTROL:Control is a function of management which helps to check errors in order to take
corrective actions, manage and prevent infection.
MIDWIVES: A midwife is a health professional who cares for mothers and newborns around
childbirth, a specialization known as midwifery.
 CHAPTER 2

LITERATURE REVIEW

2.1 INTRODUCTION
In this chapter, an overview of existing literature on the Hospital-acquired infection and
aspects related to knowledge, attitude and practices of midwifes in infection prevention and
control is presented. Due to limited studies conducted in Africa on this topic, the researcher
decided to broaden the literature review to other continents. Broadening the literature review
to other continents enabled the researcher to gather the latest and updated data on the topic.
Furthermore, the literature review showed that infection prevention and control and hospital-
acquired infections are not only a problem in Africa but also affect developed countries as
indicated in the review. The review includes relevant research findings on knowledge, attitude
and practice of nurses in infection prevention and control. The purpose of the literature review
was to understand what is currently known about knowledge, attitude and practices of nurses
in infection prevention and control. The role of nurses in infection prevention and control, as
well as the impact of inadequate knowledge in infection prevention, were included in the
literature review. Furthermore, the impact of negative and positive attitudes towards infection
prevention and control and nurses’ understanding of the code of conduct regarding infection
prevention and control was reviewed too.

2.2 LITERATURE REVIEW

The researcher identified key terms and variables in this case knowledge, attitude and
practices in infection prevention and control among nurses to perform a literature review.
Electronic databases such as PubMed was used to search for relevant articles and journals to
perform a literature review. Textbooks as well as online articles were used to perform a
literature review.

2.2.1 Hospital-acquired infection

Health-acquired conditions (HACs) are complications that originate from a stay in a clinical
or hospital facility (Lobdell, Stamou & Sanchez 2012:65). Hospital-acquired infections are
also known as nosocomial infections (Khan, Ahmad & Mehboo 2015:509-514). Hospital-
acquired infection is an infection contracted by the patient
while receiving care in a health facility but not seen at the time of admission (Nejad,
Allegranzia, Syed, Ellis & Pittet 2011:757-765). Hospital-acquired infections are the main
challenge for low and middle-income countries with inadequate health-care resources
(Shahida, Islam, Dey, Islam, Venkatesh & Goodman 2016:28-39). Health-care associated
infections (HAI) is a major worldwide safety concern for both patients and health-care
professionals (Nejad, Allegranzi, Syed, Ellis & Pittet, 2011:757-765). Risk factors include
lack of proper health care facilities such as isolation units, sinks, bed space; appropriate waste
management, decontamination of equipment and hand hygiene facilities (Shahida et al.,
2016:28-39).

According to McQuoid-Mason (2012:353-354), hospital acquired infections may develop

from surgical operations, urinary catheter, central lines and endotracheal tubes in intubated
patients. According to Khan et al. (2015:509-514), organisms that are frequently involved in
hospital-acquired infections include Streptococcus spp., Acinetobacter spp., enterococci,
Pseudomonas Aeruginosa, Coagulase-negative staphylococci, Staphylococcus aureus,
Bacillus cereus, Legionella and Enterobacteria family members. These micro-organisms can
be transferred from person to person, environment and contaminated water and food, infected
individuals, contaminated health care personnel’s skin or contact via shared items and
surfaces. According to NICE (2014:5), Health care associated infections can develop either as
a result of health care intervention (such as medical or surgical treatment) or from being in
contact with a health care setting. They can worsen current or primary conditions, increase the
length of hospital stay and increase mortality rates.

Unnecessary and improper use of broad-spectrum antibiotics, especially in health care

settings, is elevating nosocomial infection (Khan et al., 2015:509-514). Nosocomial infections
can be prevented by practicing hand hygiene, identifying patients at risk of nosocomial
infections and following standard precautions to decrease transmission (Mehta, Gupta, Todi,
Myatra, Samaddar, Patil, Bhattacharya
& Ramasubban 2014:149-163). Infection prevention in special subset patients – burns
patients, include identifying the source of the organism, identification of organisms, isolation
if required, early removal of necrotic tissue, prevention of tetanus, early nutrition and
surveillance (Mehta et al., 2014:149).

2.2.1.1 INFECTION-RELATED DISEASES

Mayo Clinic (2016:1) defines infectious disease as conditions caused by bacteria, viruses,
fungi or parasites. Some infectious diseases can be passed from one person to the other while
others are acquired by ingesting contaminated food. According to Mandal (2012:1),
Staphylococcus is one of the five most common causes of infection following injury or
surgery and it affects around 500,000 patients in American hospitals annually. The spread of
Staphylococcus aureus (S. Aureus) is through air droplets and through direct contact with
objects that are contaminated with the bacteria. Mandal (2012:1) states that S. Aureus can be
prevented by observing good hygiene and regular hand hygiene. Moreover, the fatal strain
Methicillin Resistance Staphylococcal Aureus may also be prevented from spreading by
adopting proper hand washing habits. Infection-related diseases have adverse clinical and
economic consequences. As indicated by Nathwani, Raman, Sulham, Gavaghan and Menon
(2014:32), patients who acquire Multidrug Resistance Pseudomonas aeruginosa seem to have
an increased death rate and length of hospital stay. The most common types of nosocomial
infections are surgical wound infections, respiratory infections, genital-urinary infections and
gastrointestinal infection (Shahida et al., 2016:33). According to Pasquale, Aliberti, Mantero,
Bianchini and Blasi (2016:1) hospital acquired pneumonia is a frequent cause of nosocomial
infection with mechanical ventilation demonstrating the main risk factor specifically
ventilator-associated pneumonia.

2.2.1.2 CENTRAL LINE-ASSOCIATED BLOOD STREAM INFECTIONS

Central venous catheters (CVCs) are accessed lines that are inserted into the central veins like
femoral, subclavian and internal jugular veins. CVCs can lead to life-threatening sepsis.
(Chopra, Krein, Olmsted, Safdar & Saint, 2013:211). O’Grady, Alexander, Burns, Dellinger,
Garland, Heard, Lipsett, Masur, Mermel, Pearson, Raad, Randolph, Rupp, Saint & the
Healthcare Infection Control Practices Advisory Committee (ICPAC;2011:8) provides
evidence-based recommendations for preventing central line associated infections.
Recommendations were made for catheter-associated infections by O’Grady et al.
(2011:8) who indicated that the major areas of emphasis include:

• Education and training health-care personnel caring for the central line.
• Using of aseptic techniques during insertion.
• Use central lines on selected patients.
• Not to keep the central lines longer than necessary.

2.2.1.3 CATHETER-ASSOCIATED URINARY TRACT INFECTIONS

Catheterization is an aseptic procedure and should only be undertaken by health-care workers
trained and competent in this procedure (Loveday, Wilson, Pratt, Golsorkhi, Tingle, Bak,
Browne, Prieto & Wilcox, 2014: 7). Catheter maintenance is vital in preventing catheter-
associated urinary tract infections. According to Loveday
et al. (2014:7), positioning the urine drainage bag below the level of the bladder on the stand
that prevents contact with the floor is recommended.

According to Nicolle (2014:1), urinary tract infection is one of the most common nosocomial
infections in patients with indwelling urinary catheters. 50% of catheterized patients lack
documentation on indications for insertion of urinary catheters (Welden, 2013:1). According
to Nicolle (2014:1), catheter-related- urinary tract infection are seen in 20% of patients with
bacteremia in acute care facilities, and over 50% in long-term care facilities. Prasanna and
Radhika (2015:182-186) assessed the knowledge regarding catheter care among staff nurses;
the study reviewed that only 46.7% had adequate knowledge. In this regard, Opina and
Oducado (2014:93) conducted a study to determine the relationship between the level of
knowledge and practices of nurses on infection control in the use of the urethral catheter. The
study revealed that nurses have a low level of knowledge and poor infection control practices
in the use of urethral catheters. The study further indicated that nurses’ level of knowledge
has a bearing on their practices on infection control in the use of urethral catheters (Opina and
Oducado, 2015:99). Labib and Spasojevic (2013:4) indicated that assessing the need for
catheterisation, selecting the appropriate type of catheter, aseptic technique during insertion
and catheter care can prevent CAUTIs. However, catheterization in the Sub-Saharan setting is
quite often performed using clean rather than aseptic technique which of course may lead to
CAUTI (Labib & Spasojevic, 2013:5). This is because not all of the necessary equipment for
catheterization is available all the time especially in remote areas (Labib & Spasojevic,
2013:5).

2.2.1.4 SURGICAL SITE INFECTIONS AFTER SURGERY

According to Salkind and Kavitha (2011:1), surgical site infection is defined as an infection
seen on the incision site within 30 days of surgery or within one year of implant insertion.
Andreson and Sexton (2016:135-153) indicated that surgical site infections account for 38
percent of nosocomial infections. Surgery that involves a cut (incision) in the skin can lead to
a wound infection after surgery. It is important to track patients after discharge for a period of
time to ensure that no infection has occurred (Magill, Edwards & Bamberg, 2014:1198-1208)
Surgical operations provide opportunities for transmission of infection between patients and
health-care workers and between patients (McGaw, Tennant, Harding, Cawich, Crandon &
Waiters 2012:1). According to McGaw et al. (2012:1), the risk of transmission of infection
may increase in under-developed and developing countries by low compliance with infection
control policies and precautions. For most patients undergoing clean-contaminated surgeries
(cardiothoracic, gastrointestinal, orthopaedic, vascular, gynecologic), a cephalosporin is the
recommended prophylactic antibiotic (Salkind & Kavitha, 2011:1). Mukosai, Bowa, Labib
and Spasojevic (2014:1-5) assessed the effectiveness of using preoperative bladder irrigation
with 1% povidone-iodine in reducing post transversical prostatectomy surgical site infections
(SSIs). The study reviewed that irrigating the bladder with 1% povidone-iodine resulted in
significant reduction in post-prostatectomy surgical site infection. It was evident that in the
control group 15 out of 65 patients developed SSI while in the study group, 6 out of 65
patients developed SSIs (Mukosai, Bowa, Labib & Spasojevic, 2014:1-5)

Teshager, Engeda and Worku (2015:1-6) indicated that over 50% of nurses who participated
in the survey lacked knowledge about surgical site infection prevention and practiced
inappropriately. According to Abbas and Pittet (2016: 319-322), SSI is a leading cause of
health-care associated infections that is why surveillance of SSI should be a priority for
infection control programmes even in resource-limited settings.

2.2.1.5 CLOSTRIDIUM DIFFICILE

Clostridium difficile infections (CDI) is the leading cause of hospital-associated
gastrointestinal disease leading to increased length of stay for patients and placing a
high burden on health care system. (Surawicz, Brandt, Binion, Ananthakrishnan, Curry,
Gilligan, McFaarland, Mellow & Zuckerbraun, 2013: 478-498).

Clostridium Difficile infection transmission and infection has proven to be difficult to prevent
(Carrico, 2013:8). According to Carrico (2013:8). Some of the patient care activities that
provide an opportunity for transmission of CDI include improper oral care procedure.
Procedures such as intubation, patient feeding and administration of drugs coupled with poor
hand hygiene and ineffective environmental cleaning provide an opportunity for transmission
of CDI (Carrico 2013:8). To prevent the spread of the disease early identification of patients
who are being investigated for, or diagnosed with CDI is the first step, followed by isolation,
use of personal protective equipment, encouraging hand hygiene, ensuring clean environment
and use of individual bedside commode for each patient with CDI which cannot be placed
into a private room (Carrico, 2013:8). Prevention of intestinal colonization of toxigenic
strains of CDI can be achieved through restoration of the intestinal microbiota with faecal
microbiota transplantation, as well as by colonising the gut with non-toxigenic CDI strains
(Kociolek & Gerding, 2016:150-160). Agency for Health-care Research and Quality, (2012:7)
indicated that Antimicrobial stewardship targeted to CDI reduction shows promise as a
complementary strategy for addressing the problem of CDI, because inappropriate antibiotic
use may contribute to increasing rates of CDI. Roth, Parker, Wale and Warrier (2014:122-
127), indicated poor knowledge of CDI among health professions, recommending a potential
for further education.

2.2.2 Infection prevention and control

According to Ojulong, Mitonga and Lipinge (2013:1071-1078), infection control practices are
aimed at reducing the incidence of nosocomial infections. Ojulong et al. (2013:1071-1078),
evaluated knowledge and attitudes of infection prevention and control among health science
students at the University of Namibia. The study revealed that knowledge about infection
prevention and control and awareness of its importance among health science students was
poor. It was therefore concluded that serious efforts are needed to improve or review
curriculum so that health science students’ knowledge on infection prevention and control is
imparted early, before they are introduced to the wards (Ojulong et al., 2013:1071-1078).

2.2.2.1 PRIMARY PREVENTION AND CONTROL

Primary prevention is a way of preventing disease as well as injury before it occurs.

Preventing (hazards leading to injury and disease are examples of primary prevention,
(Institute for Work and Health (IWH) 2015:1). According to IWH (2015:1), examples of
primary prevention include education about healthy and safe habits (hand hygiene) and
immunization against infectious diseases. In this regard, CDC (2016:144) indicates that
health-care personnel influenza vaccination is important to prevent getting and spreading the
infection. Influenza can easily spread from person to person, including from health-care
workers to patients. WHO (2010:41) considers universal immunisation to be the most
effective preventive measure against disease induced by infection with Hepatitis B.
Unsafe injection practices can result in transmission of a wide variety of pathogens, including
viruses, bacteria, fungi and parasites (WHO, 2010:13). Safe injection practice is a primary
intervention for prevention of transmission of infection. Therefore, according to the WHO
(2010:13), a safe injection does not harm both the recipient and the provider and does not
harm other people when disposed.

In order to make decisions about actions needed to control the risk and prevent the spread of
infection, risk assessment is performed (Advisory Committee on Dangerous Pathogens-
ACDP, 2015:9). This includes implementation of practical infection control measures,
information provision, training and health surveillance (ACDP, 2015:9). Hand Hygiene is
another measure that promotes primary infection prevention. CDC’s Clean Hands Count
campaign aims at improving adherence to hand hygiene recommendations among health
workers and empowers patients to play a role by reminding health workers to perform hand
hygiene (CDC, 2016:1).

Primary prevention may be accomplished by procedures intended to uphold general health

and welfare of people (Salama, 2015:13). Salama (2015:14) states that Protection against
occupational hazards are primary prevention, for example, safe handling of sharps by the use
of the sharps box. Encouraging patients and health-care workers to know their HIV status so
that they can reduce their exposure to TB infection (T.B 4, 2015:24) is another example of
primary infection prevention. Educating all staff on TB transmission and prevention is
primary infection prevention.

Service providers should ensure that they have antimicrobial stewardship initiatives in place,
including local antibiotic formularies for antibiotic prescribing, this is to try to reduce the
problem of antibiotic resistance (NICE, 2014:11).

2.2.2.2 SECONDARY PREVENTION AND CONTROL

Secondary prevention aims to lessen the bearing of illnesses or injury that has already
happened (Institute for Work and Health (IWH), 2015:1). By detecting and treating disease or
injury as soon as possible, as well as encouraging personal strategies to prevent re-injury the
impact of the disease is reduced (IWH, 2015:1). Use of personal protective equipment and
appropriate ventilation are good examples of secondary infection prevention as well as
Isolation of patients with TB, rapid diagnostic evaluation and rapid initiation of treatment
(T.B 4, 2015:7). Patients with TB are encouraged to stop smoking and minimize intake of
alcohol so as to reduce the impact of the disease (T.B 4, 2015:23). Paryford (2015:9)
indicated that patients should be instructed to follow the recommendations for respiratory
hygiene and cough etiquette by;
- Using a disposable, single use tissue to cover mouth and nose when coughing, sneezing,
wiping or blowing nose.
- Dispose of tissues promptly in a bin.
- Practice hand hygiene by washing hands with soap and water, and drying them
thoroughly after coughing, sneezing or using tissues.

Maintenance of an indwelling catheter is another example of secondary infection prevention.

NICE guidelines (2012:139) indicate that indwelling catheters should be connected to a sterile
closed urinary drainage system or catheter valve. The urine drainage bag should be below the
level of the bladder and should not be in contact with the floor. The urine bag should
frequently be emptied enough to maintain urine flow and prevent reflux. Urine samples must
be obtained from a sampling port using an aseptic technique and the meatus should be washed
daily with soap and water as part of routine daily personal hygiene (NICE guidelines
2012:139).

2.2.2.3 Tertiary prevention and control

Tertiary prevention aims to reduce the influence of an ongoing disease or injury that has
extensive effects. This is done by helping people cope with long-term, oftendifficult
conditions and injuries (e.g. chronic diseases, permanent impairments) in order to expand as
much possible their capability to function, the value of life and their life expectancy (HIV,
HAART) (IWH, 2015:1). T.B 4 (2015: Slide 4-3) states that BCG vaccination does not stop
infection with T.B but it does stop severe forms of childhood T.B and thus can be considered
tertiary prevention. All HIV- infected individuals are susceptible to a wide array of
opportunistic infections and are at higher risk to pathogenic organisms that plague the general
population (Haburchak, 2016:1). Prevention of opportunistic infections in patients with HIV
disease is important to optimize outcome (Haburchak, 2016:1). According to Haburchak
(2016:1), all HIV-related infections and malignancies escalate in frequency and morbidity as
the absolute CD4 T-lymphocyte count falls towards 200 cells/l1/4L and below. HIV patients
should be aware of their CD4 count and their risk of specific infections. An imperative
function of infection control and hospital epidemiology programs is the prevention of disease
transmission (Sydnor & Perl, 2011:141-73). Infection prevention is accomplished through
surveillance, outbreaks, education and training of health care providers and instituting
effective HAI prevention (Sydnor & Perl, 2011:141-73).

2.2.3 NURSES’ ROLE IN INFECTION PREVENTION AND CONTROL

Using their infection control training, nurses play a vital role in creating a culture of patient
safety (Stone, 2013:1). According to Stone (2013:1), nurses are on the front lines and can take
the lead to explain infection control procedures to the patients. According to NACNS
(2013:1), research and demonstration tasks have shown that the clinical nurse specialist’s
(CNS) role is distinctively suited to lead the execution of evidence-based quality development
actions that also lessen cost throughout the health care system. The CNS has an important part
to play in care organisation and transitions of care that result in reduced hospital length of
stay, fewer hospital readmissions and fewer nosocomial conditions (NACNS, 2013:1).

The role of the professional nurse in preventing hospital-acquired infections is significant

(Benson & Powers, 2011: 36-41). The nurse is a member of a health-care team who leads the
rest of the group in performing prevention approaches to keep the patient from infection
(Benson et al., 2011:36-41). However, Hakim, Mohsen and Bakr (2014:347) revealed that
housekeepers were significantly more knowledgeable
than physicians or nurses about hospital policies and systems for waste disposal, but less so
about specific details of disposal. Housekeepers also had the highest overall scores for
attitudes to waste disposal among nurses and physicians (Hakim et al., 2014:347).

Health care-associated infection is a prominent problem among patients in paediatric

intensive units as it could result in significant morbidity, prolonged hospitalization and an
increase in medical care costs (Yasmine, John & Walaa, 2014: 22). According to Yasmine et
al. (2014:22), who assessed the effect of health education program regarding infection control
measures on nurse’ knowledge and attitude in paediatric intensive care units stated that the
role of nurses is important in preventing hazards and sequels of health care-associated
infections. The study concluded that there is a scope for improvement in knowledge and
attitude after the educational program was offered to the nursing staff.

All nurses, in all roles and settings, can show leadership in infection prevention and control
by using their knowledge, expertise and immediately apply decisions to start appropriate
interventions. According to Yamin, Jain, Mandelia and Jayaram (2012:68), health-care
workers must know the various measures for their protection. They should improve the
organisation of work, implement standard precautions and dispose of biomedical waste
properly to prevent occupational exposure. Health-care workers should get themselves
immunised against Hepatitis B and report accidental exposure to infectious samples to the
infection control committee (Yamin et al., 2012:68-73). Nurses play a key role in infection
prevention, the health, and well-being of their patients and the financial health of their
employers (Olin, 2012:1).

2.2.4 Clinical environment and infection prevention and control

According to Garrett (2015:207) now more than ever, a clean and sanitary patient
environment is being measured as a component of infection prevention and control process.
In addition, outcome measures such as patient satisfaction and cleanliness of the environment
are common metrics in this era of continual health care reform (Garrett, 2015:207). Garrett
(2015:207) further indicates that patients, visitors and health care providers routinely
contaminate health care environments through daily activities. This can increase the risk of
infection transmission. According to Weber,
Anderson and Rutala (2013:338), the contaminated surface environment in hospitals plays
an important role in the transmission of pathogens like Methicillin-Resistance
Staphylococcus Aureus (MRSA) and Clostridium Difficile. Weber et al. (2013: 338), further
indicates that admission to a room previously occupied by a patient with MRSA and
C.difficile increases the risk for the subsequent patient admitted to the room to acquire the
pathogen. Therefore, improved surface cleaning and disinfection of room surfaces decreases
the risk of health-care associated infections (Weber al., 2013:338).

Hygiene and environmental cleaning are important in helping to control the spread of
infection (Parryford, 2015:5). According to Parryford (2015:5), experimental studies on the
survival of respiratory pathogens suggest that, depending on the organism, the type of
surface and the organic material load, they can survive for a limited time in the environment.

2.2.4.1 PATIENTS’ OUTCOME IN THE CLINICAL ENVIRONMENT.

Maintaining a clean and safe environment is an important component of infection prevention
and control (Vang, 2014:12). According to Parryford (2015:7), some people are at greater risk
of developing more severe disease and complications respiratory tract infection (typically
Pneumonia). Such people include patients with Diabetes Mellitus, immunosuppression,
pregnant mothers, chronic diseases (lung, heart, liver and kidney), and children under five
years old as well as people aged 65 years and older. Lemass, McDonnell, O’Connor and
Rochford (2013:4) indicates that patients are cared for in an environment that is safe and
clean, and where the risk of them acquiring an infection is kept as low as possible. A person-
centered approach is taken respecting the dignity, privacy and the needs of individual patients.
Every interaction in general practice should include a risk assessment of the potential for
infection transmission (Lemass, McDonnell, O’Connor & Rochford, 2013: 4). According to
NICE (2014:5), a number of factors can increase the risk of acquiring an infection, but high
standards of infection prevention and control including providing clean environments, can
minimise the risk.

2.2.5 KNOWLEDGE IN INFECTION PREVENTION AND CONTROL.

According to Olowookere, Abioye-Kuteyi, Adepoju, Esan, Adeolu, Adeoye, Adepoju and
Aderogba (2015:1), the study in which preparedness of health workers in the control and
management of Ebola Viral Disease (EVD) was assessed, the results showed knowledge gap
and poor infection control preparedness among respondents. Thus, knowledge and practices
of health workers towards EVD need improvement. The WHO Update (2014:1) states that the
occurrence of fatal infections such as severe acute respiratory syndrome (SARS) and viral
haemorrhagic fevers (e.g., Ebola Viral Disease) highlight the serious need for effective
infection control practices in health care. Failure to apply infection control measures leads to
transmission of infection, and health-care settings can act as amplifiers of disease in the
course of outbreaks, with a bearing on both hospital and public health (WHO Update,
2014:1).
2.2.5.1 ADEQUATE KNOWLEDGE IN INFECTION PREVENTION AND CONTROL
According to the Oxford dictionary (2010:827), knowledge is the information, understanding
and skills that are gained through education and experience in this case knowledge about
infection prevention and control. The surveillance of hospital-acquired infections are regarded
as an essential part of infection control and prevention. In this regard, Razine, Azzouzi,
Barkat, Khoudri, Hassouni, Chefchaouni and Abouqal (2012:26) determined the prevalence
of hospital-acquired infections (HAIs) in all institutions of Rabat University Medical Centre
in Morocco. The study showed that the prevalence of HAIs was high. Therefore,
recommendations for future control measures to focus on patients who stay longer in the
hospital, patients with invasive devices and irrational use of antibiotics were made. Sessa,
Giuseppe, Albano & Angelillo (2011:148) recommended education and training programmes
for nurses after their study found that although nurses level of knowledge was not
satisfactory. Lack of knowledge among nurses can increase the rate of the hospital-acquired
infections. Supported by a study that was conducted in Zimbabwe, Tirivanhu, Ancia and
Petronella (2014:73), determined the barriers of infection prevention and control practices
among nurses at the Bindura provincial hospital. The study revealed that the majority of
nurses’ lack knowledge of infection control principles as only 14 (28%) of 50 nurses had
excellent knowledge on infection control
principles, 21 (42%) of 50 nurses did not utilize the infection control manuals. Infection
control workshops were poorly organised as 68% of the nurses did not attend any workshop
on infection prevention and control practices. (Tirivanhu et al., 2014:69-73). Hayeh and
Esena (2013:47) assessed the infection prevention and control (IPC) practices among health
workers at Ridge Regional Hospital in Accra (Ghana). The study showed that knowledge in
IPC practices among health care workers was moderate 51% (n=204) as availability and
access to material for IPC practices at the facility was 58% and overall compliance with IPC
guidelines was 54%.
Assessing knowledge, attitudes and sources of information among Nursing Students towards
infection control and standard precautions, Ghalya and Ibrahim (2014:249-260), results
revealed that the overall knowledge scores for nursing students towards infection control and
standard precautions were acceptable, students achieved the highest score in hand hygiene
domain and lowest score in sharps disposal and sharps injuries. The main source of
information for students was the curriculum.

2.2.5.2 Inadequate knowledge of infection prevention and control

Failure to apply infection control procedures favours the transmission of pathogens, and
health-care settings can act as amplifiers of disease during epidemics, with a bearing on both
hospital and public health (WHO, 2016:1). According to WHO (2016:1), a huge gap exists
between the knowledge accumulated over the past decades and implementation of infection
control practices. This gap is even deeper in poor-resource settings with devastating
consequences. Breaches of infection control measures undermine every advance and
investment in health care (WHO, 2016:1). According to Eskanderl, Morsy and Elfeky
(2013:160), critical care nurses have an obligation to protect critically ill patients against
infection. The study to assess critical care nurse’ knowledge and evaluate their practice
regarding infection control standard precautions was performed. The study reviewed that two-
thirds (63.6%) of the studied sample had unsatisfactory Knowledge level. Hence
recommendations were made of updating knowledge and performance of critical care nurses
through continuing in-service educational programs (Eskanderl et al., 2013:160-174). El-
Enein, Younis, Mahdy and Hala (2011:3-10) determined the degree to which standard
precautions were applied by nurses in a dialysis unit interms of hand hygiene and use of
personal protective equipment. The study reviewed that less than half of the nurses (47.1%)
correctly knew that they had to wash their hands before and after caring for a patient.

According to Sessa et al. (2011:148), who assessed the level of knowledge, attitude and
practice regarding disinfection procedures among nurses in Italian hospitals. The study
indicated that the level of knowledge, particularly of the most common HAIs, was not
satisfactory and a small percentage of nurses reported that they appropriately perform the
disinfection in their working activity. Therefore, Sessa et al. (2011:148) recommended HAIs
control and training programmes to address shortfalls and to improve knowledge and
adherence to procedures and HAIs prophylaxis and management for patient safety and the
reduction of HAIs.

To assess the knowledge, attitude and practices of health-care personnel concerning the
transmission of pathogens via Fomites a study was conducted. The results showed a large gap
between the knowledge about fomites acting as vectors in the spread of pathogens and
practices are done to minimize this spread (Aftab, Zia, Zahid, Raheem & Beg, 2015: 208)

2.2.6 Attitude towards infection prevention and control

According to the Oxford dictionary (2010:80), attitude is the way you think, feel and behave
about something, in this case, attitude towards infection prevention and control. Despite the
knowledge that dirty hands play a significant role in the spread of health-care related
pathogens, and that hand hygiene (HH) decreases the spread of these organisms, health-care
worker’s adherence with HH is poor (Dixit, Hagtvedt, Reay, Ballermann & Forgie, 2012:1).
Dixit et al. (2012:1), who explored the attitude and beliefs about hand hygiene among
paediatric residents showed that paediatric residents’ compliance with HH was influenced by
role modeling, balancing hand hygiene with other competing factors and the drive for self-
protection and personal cues. According to Lemass et al. (2013:11), hands of practice staff are
the most important vehicles of cross-infection. Furthermore hands of patients can also carry
microbes to other body sites, equipment and staff. Hand hygiene is one of the most effective
means of preventing nosocomial infections (Lemass et al., 2013:18).
Table 2.1: The five moments of hand hygiene according to WHO

Source: WHO Guidelines on hand hygiene in health-care facilities (2009)

1 Before touching a patient Perform hand hygiene before touching a patient.

2 Before clean/ Aseptic procedure Perform hand hygiene before a clean/ sterile procedure.

Wash your hands with soap and water immediately

3 After body fluid exposure risk after
exposure risk to body fluids.

4 After touching a patient Perform hand hygiene after touching a patient.

After touching a patient Perform hand hygiene after touching any object or
5 surrounding furniture
in the patient’s immediate surroundings.

There is now absolute indication that strict adherence to hand hygiene decreases the risk of
cross-transmission of infection (Mathur, 2011:611-620). In settings with insufficient
financial and human resources, lack of time is an important observed and self-reported
barrier to hand hygiene (WaterAid, 2016:3).
 Standard Precautions are a set of practices that should be used in the care and treatment of
all patients, regardless of whether they are known or suspected to be infected with a
transmissible organism (Lemass et al., 2013:11). According to Lemass et al. (2013:11), the
purpose of Standard Precautions is to break the chainof infection. Sarani, Balouchi,
Masinaeinezhad and Ebrahimitabs (2015:193-198)

assessed the knowledge, attitude and practices of nurses about Standard Precautions for
Hospital-Acquired Infections in Teaching Hospitals. The results showed that 43% of nurses
had a poor attitude, 37% had an average attitude and 33% had a good attitude towards
standard precautions. Implementation of Standard precautions is vital in the prevention of
transmission of infection to patients and staff (Lemass et al., 2013:11).

Previous studies had shown that it is possible to determine nurses’ attitude. Hu, Zhang, Li,
Liu, He, Zhu, Wang, Cao and Zhao (2012:1), examined the knowledge, attitudes and self-
reported behaviour and barriers to compliance with the use of personal protective equipment
(PPE). The study involved ICU health care workers (HCWs) during pandemic influenza. The
study showed that only 55% of Chinese critical care clinicians reported compliance with PPE
use during pandemic influenza, putting HCWs and their patients at risk. Both attitudes
towards PPE use and perceived organisational norms have been recognised as predictors of
compliance. Hand hygiene is the single most important intervention to prevent transmission
of infection and should be a quality standard in all health institutions.

An attitude of not washing hands among individuals involved in the provision of health care
can increase the rate of hospital-acquired infections. In a study that was conducted in India,
where Nair, Hanumantappa, Hinemath, Siraj and Raghunath (2013:3) assessed knowledge,
attitude and practices of hand hygiene among medical and nursing students at a tertiary health
care centre, the majority of students had poor knowledge with regard to hand hygiene.

Transmission of blood-borne viruses and other microbial pathogens to patients during routine
health care procedures continues to occur due to unsafe and incorrect injection practice,
Infusion and medication vial practices being used by health care professionals (PIDAC,
2015:35). Despite advances in health care system, nosocomial infections remain a preventable
disease threatening public health (Olalekan, Olusegun, Olufunimalayo and Lanre, 2012:285-
289). The study assessed awareness and attitude of health care workers in LAUTECH
Teaching Hospital Osogbo towards nosocomial infections. The study showed that there was a
need to raise awareness of nosocomial infections among health care workers as well
aspreventive measures against these infections as preventive practices towards nosocomial
infections were favourable for hand washing, and unfavourable for self-reporting to the staff
clinic when sick. There was no significant (p>0.05) association between ever reported or
willingness to report nosocomial infections and awareness of hospital policy or the presence
of infection control committee in the hospital (Olalekan, Olusegun, Olufunimalayo and Lanre,
2012:285-289.

2.2.6.1 Negative attitude towards infection prevention and control

The negative attitude towards infection prevention and control can promote transmission of
infection from one point to another. According to Ward (2012:301-306), nursing students
generally observed a bad approach towards infection prevention and control from qualified
staff, besides IPC was considered to be an added job load as different to a central feature of
patient safety and excellent care. Surgical operations provide opportunities for the
transmission of infection between patients and health-care workers (HCWs) and between
patients. This risk may increase in underdeveloped and developing countries by low
compliance with infection control policies and precautions (McGaw, Tennant, Harding,
Cawich, and Crandon & Waters, 2012:1-9). MacGaw et al. (2012:1-9) investigated HCWs
attitudes and compliance with infection control practices in the operating department of a
Jamaican teaching hospital, with the objective of obtaining data to design evidence-based
interventions. The study concluded that HCWs had sub-optimal levels of compliance with
standard infection control guidelines as only 17% of all participants were compliant with all
seven infection control policies.

2.2.6.2 Positive attitude towards infection prevention and control

Positive attitude towards infection prevention and control can reduce the rate of Hospital
acquired infections. Conducting a study to assess knowledge and attitude of health-care
workers (HCWs) and patients on health care associated infections (HAIs) in the central
regional hospital in Ghana, Ocran and Tagoe (2014:135-139) indicated that attitudinal change
is the best means of prevention. The study showed an increase in the number of subjects in
each category scoring good and excellent in the post-education questionnaire. Sessa,
Giuseppe, Albano and Angelillo (2011:
148) assessed the level of knowledge, attitudes and practices regarding disinfection
procedures among nurses in Italian hospitals. The study revealed an extremely

positive attitude towards the utility of guidelines and protocols for disinfection procedures.
2.2.7 Practices of midwife in infection prevention and control
According to the Oxford dictionary (2010:1148), to practice is to do something regularly as
part of your normal behaviour which in this case is infection prevention and control practices.
It is, therefore, important that all health workers strictly adhere to infection control guidelines,
especially nurses because they spend more time with the patients.

In dwelling urinary catheters (IUCs) are frequently used in hospitalised elderly patients.
Catheter-associated urinary tract infections (CAUTIs) account for 34% of all hospital-
acquired infections in the United States associated with additional ill health and leading to
health care costs. Devotion to CAUTI prevention practices has not been well defined (Fink,
Gilmartin, Richards, Capezuti, Boltz & Wald, 2012: 1). Fink et al. (2012:1), examined IUC
care practices for CAUTI prevention and concluded that even though CAUTI prevention
practices at Nurses Improving Care for Health system Elders hospitals are in alignment with
evidence-based guidelines, there is a possibility for improvement.

A safe injection is one that does not hurt the recipient, does not render the provider to any
preventable risks and does not cause harm to the community when disposed of. Unsafe
injection practices can lead to the transmission of bloodborne pathogens, with their associated
burden of disease (WHO, 2010:13). Safe injection practices are standard precautions aimed at
maintaining basic levels of patient safety and provider protections. In this regard, Ambulatory
Surgical Center (ASC) quality collaboration (2016:1) states that when safe injection practices
are not used, diseases like HIV, hepatitis C virus and hepatitis B virus can be spread from
patient to patient when safe injection practices are not used.

2.2.7.1 Good practices in infection prevention and control

According to NHS Professionals (2013:3), good hand hygiene is the most important practice
in reducing transmission of infectious agents as well as health-care associated infections.
Respiratory hygiene or cough etiquette has been added to standard infection control
precautions due to a recent global influenza pandemic

(NHS professionals, 2013:4). Furthermore general good practices include ensuring that
occupational immunisation and clearance are up to date for all staff. All staff must dispose of
clinical waste according to local policy with sharps in assembled sharp container.
Personal protective equipment (PPE) refers to a range of barriers and respirators used alone or
in combination to protect mucous membranes, airways, skin, and clothing from contact with
infectious agents (Lemass et al., 2013:26). According to Lemass et al. (2013:26), practice
staff should make a risk assessment of planned procedure/action and select PPE depending on
the nature of the procedure, the risk of exposure to blood, body fluids, mucous membranes
and non-intact skin as well as the risk of contamination. Furthermore, glove use does not
remove the need to comply with hand hygiene. Hands should be washed prior to putting on
gloves and hand hygiene should be performed immediately after glove removal.

The Tuberculosis (TB) epidemic in South Africa is characterised by one of the highest levels
of TB/HIV co-infection and growing multidrug-resistant TB worldwide (Sissolak, Marais &
Mehtar, 2011:1). Sissolak et al. (2011:1), investigated nurse’ experiences of factors
influencing TB infection prevention and control (IPC) practices to identify risks associated
with potential nosocomial transmission. The study recommended the need for the
implementation and evaluation of comprehensive contextually appropriate TB-IPC policy
with the setting and auditing of standards for IPC provision and practice, adequate TB
training for both staff and patients, and the establishment of a cross-cultural communication
strategy, including rapid access to interpreters ( Sissolak et al., 2011:9).

Assessing knowledge, attitudes and sources of information among Nursing Students towards
infection control and standard precautions, Ghalya and Ibrahim (2014:249-260), results
revealed that the overall knowledge scores for nursing students towards infection control and
standard precautions were acceptable. Students achieved the highest score in hand hygiene
domain and lowest score in sharps disposal and sharps injuries.

Good practices of nurses in infection prevention and control reduces the potential for
nosocomial infection thereby promoting patient safety. However, patient safety canbe
jeopardised if nurses intentionally fail to comply with implemented infection control
measures leading to negligence/malpractice.

Lemass et al. (2013:15) indicates that immunisation must be seen as one part of a wider
policy to prevent transmission of infection to health workers and their patients. Therefore
vaccination should ideally take place before employment, routine review of general
immunisation status may also be appropriate.

2.2.7.2 Patient safety in infection prevention and control

Patient safety has become a cornerstone of care, and preventing health-care associated
infections remains a priority (NICE, 2012:139). According to CDC (2016:3), health-care
associated infections are a major yet preventable threat to patient safety. Health-care
associated infections can occur in otherwise healthy individuals, especially if invasive
procedures or devices are used. For example, indwelling urinary catheters are the most
common cause of urinary tract infections, and bloodstream infection is associated with
vascular access (NICE, 2012:139). Preventing transmission of microorganisms to other
patients is a patient safety issue and preventing transmission to staff is an occupational health
and safety issue (PIDAC, 2015:7).

According to Benson and Powers (2011:36-41), a nurse is an essential member of the health
care team who can transform patients negative experience to a positive health-care
experience. A nurse can also make a major influence in reducing the patient likeliness for
contracting nosocomial infections. Infectious diseases can be transmitted to patients who are
taken care of by ill health workers. Health-care workers have the responsibility to look after
their own health to avoid compromising patient safety (Benson & Powers, 2011:36-41).

2.2.7.3 Negligence
Negligence is defined as failure to practice that amount of care that any sensible and cautious
person would practice under similar situations. If a professional such as a physician or nurse,
is negligent while acting in his/her professional capacity, the term is coined medical
negligence or malpractice (Dearmon, 2014:470-493). According to McQuiod-Mason
(2012:353-354), liability for hospital-acquired infections (HAIs) depends on whether the
hospital has introduced best practice infection controlmeasures and has implemented them.
Alternatively, will be vicariously liable for negligent or intentional failures by staff to comply
with infection control measures implemented (McQuiod-Mason, 2012:353-354). According
to McQuiod-Mason (2012:353-354) a hospital and hospital administrators may be held
directly liable for not introducing or implementing best practice infection control measures,
resulting in harm to patients. The hospital may also be held vicariously liable where patients
have been harmed because hospital staff negligently or intentionally failed to comply with the
infection control measures that have been implemented by the hospital, during the course and
scope of their employment (McQuiod-Mason, 2012:353-354). According to PIDAC
(2015:16), Personal hand hygiene for patients is also important and is often overlooked.
Alcohol-based hand rub should be provided for patients and visitors in the area to reduce the
risk of environmental contamination.
The risk of cross infection is reduced by appropriate use of and adhering to the WHO 5
moments of hand hygiene. Handling contaminated linen with bare hands pose a risk for
nosocomial infection. Contaminated linen is described as infected and should be handled with
personal protective equipment. The nurse is negligent if the risk of disease transmission
occurs while not wearing protective equipment (Damani, 2012:338). To stick a needle in the
mattress is not an injection safety practice. Onyemoho, Anekoson and Pius (2013:171)
assessed the level of knowledge and practice of injection safety among health-care workers of
a Nigerian prison service health facility in Kaduma State Command. The findings of this
study showed that n= 74 (54%) of health workers had good knowledge scores of key injection
safety practice, n= 20 (17%) had fair knowledge while n= 40 (29%) had poor general
knowledge scores. Furthermore, n= 70 (50%) of n= 138 prison health workers had fair
practices of injection safety. Lemass et al. (2013:31) recommends that providers should use
one sterile needle and one syringe only a single time. Each practice should have a policy in
place that outlines the risk assessment, management and advice to staff following needle stick
injury and blood and body fluid exposure. Education of all practice staff on sharps injuries,
their significance, prevention and management are essential (Lemass et al., 2013:33).

Stethoscopes utilised in clinical practice should be cleaned on a continuous basis as it is a

source for micro-organisms to be transmitted from patient to patient. A studydone by Jain,
Shah, and Sharman (2013:236) confirmed that the majority of the stethoscopes are
contaminated with micro-organisms and recommended regular reminders such as posters or
circulars. Jain et al. (2013:236) further recommended motivating posters for health care
workers to clean the diaphragm of the stethoscope. Indwelling urinary catheters (IUCs) are
usually used in certain hospitalised patients. Catheter-associated urinary tract infection
(CAUTIs) account for 34% of all nosocomial infections in the United States, related to
additional ill health and health-care expenses (Fink, Gilmartin, Richards, Capezuti, Bolt &
Wald, 2012:1-6). Fink et al. (2012:1-6) suggested further research to find the effect of
improved compliance related to prevention practices on the prevalence of CAUTI.

2.2.8 Nurses/Midwifes’ code of conduct regarding infection prevention and control

Nurses and midwifes are required to uphold their Code of conduct of the profession which
includes Infection prevention and control. According to Nurses and Midwives Act No. 55 of
1990 in Nigeria which was reviewed in the late 1999’s, the nursing profession would be
allowed to improve the quality of nursing and midwifery services delivery through expanded
scope of education and practice to meet the challenging care trends and needs in Nigeria.
According to Sharp, Palmore and Grady (2014:307-309), information about hospital-acquired
infection (HAI) could empower patients to make day-to-day decisions. Such decisions
include; personal hygiene, specific procedures and intervention, interaction with care
providers, and adherence to recommendations. However, some may argue that HAI
information might produce undue stress without expanding patient’ rational options in any
meaningful way. Nevertheless, in extreme cases, such concerns are insufficient to override an
obligation to disclose risks (Sharp et al., 2016:307-309). Sharp et al. (2014:307-309) indicated
that health-care facilities should inform patients about HAI risk, prevention, and hospital
policies. This will empower them to act as partners in creating a safer health-care
environment, motivated by respect for patient autonomy and promotion of patient autonomy.

2.2.8.1 NURSING/MIDWIFERY ACT

Under the Health and Social Care Act 2008 of The United Kingdoms (UK), the Code of
Practice health and adult social care on the prevention and control of infections and related
guidance requires all trusts to have perfect measures for the effective
prevention, detection and control of hospital acquired infections (Royal Cornwall Hospitals,
2015:1-15). According to the Missouri nursing practice act, the aim of the nursing practice act
is to protect the public from unsafe and unlicensed practice by regulating nursing practice and
nursing education. The nursing practice act defines nursing, set standards for the nursing
profession and gives guidance regarding the scope of practice issues. Nursing practice
requires specialized knowledge, skill as well as independent decision making (Russell,
2012:36). Russell (2012:36) furthermore states that nursing practice involves behaviour,
attitude and judgement, as well as bodily and sensual abilities in the use of information,
services and capabilities for the advantage of the client. Additionally, Russell (2012:36)
indicated that health services expose the public to the risk of harm if practiced by
professionals who are unskilled. In this regard, professionals are ruled by laws and guidelines
intended to reduce the risk of harm.

2.2.8.2 NURSING STANDARDS

According to Russell (2012: 36) education and standards provided by laws designed to protect
the public provide guidance in nursing practice. Nursing profession takes widely different
paths- practice emphasis differs by setting, by nature of clients, by different illnesses and by
therapeutic method or level of rehabilitation (Russell, 2012:36).
Nurses have the distinctive opening to lessen the potential for nosocomial infections. Utilizing
the skills and knowledge of nursing practice can facilitate patient recovery while minimizing
complications related to infections (Benson & Powers, 2011:36-41). According to Benson and
Powers (2011:36-41) some of the most basic strategies resulting in positive patient outcomes
include:
o Exercising hand hygiene
o Routine use of sterile technique o
Clean and safe environment
o Use of universal precautions o
Patient education
o Patient nursing diagnosis and extra safety measures. o
Practice of safe strategies
o Avoiding use of unnecessary invasive devices
o Use of bundle strategies o
Fit for duty.
Hand hygiene is one of the most important procedures for preventing the transmission of
hospital acquired infection (HAI).

2.2.8.3 ETHICS IN NURSING

The code of ethics for registered nurses serves as a foundation for nurses’ ethical practice
(Canadian Nurses association 2008:1-64). According to Canadian Nurses association (CNA)
2008:1-64, the code provides guides for ethical relationships, responsibilities, behaviours and
decision-making, and it is to be used in conjunction with the professional standards, laws and
regulation that guide practice. The code helps as an ethical foundation from which nurses can
promote for clean and safe work environments that support the delivery of quality,
empathetic, skilled and just care. Nurses encounter personal risk when providing for those
with known or unknown communicable or infectious disease. During the natural or human-
made disaster, including a communicable disease outbreak, nurses have a duty to provide care
using appropriate safety precautions (CNA, 2008:1-64).

Two deeply intertwined ethical considerations – patient autonomy and patient welfare
– Motivate empowering patients for Hospital Acquired Infection Prevention (Sharp, Palmore
& Grandy, 2014:307-309). According to Sharp et al. (2014:307-309), hospitalised patients are
often vulnerable, and vast asymmetries in medical knowledge exist between providers and
patients. These conditions can jeopardize adequate consideration of patients’ values and
interests. Giving patients an opportunity to act in light of their beliefs and welfare as well as
to promote patient autonomy. Providing patients with the right to information relevant to the
medical decision is important to this practice (Sharp et al., 2014:307-309). Empowering
patients could also possibly improve patient safety and well-being by prompting behaviours
that could prevent nosocomial infections. Improving hand hygiene among health workers is a
major focus of HAI prevention efforts (Sharp et al., 2014:307-309).

2.2.8.4 SOCIAL RESPONSIBILITY OF THE NURSING/MiDWIFERY PROFESSION

According to Royal Cornwall Hospital Infection Prevention and Control Policy (2015:1-15);
Under the Health and Social Care Act 2008 of The United Kingdoms, the Code of Practice
health and adult social care on the prevention and control of infections and related guidelines
requires all hospitals to have clear schedules for the effective prevention, detection and
control of hospital acquired infections infections. The policy further states that the Chief
Executive Officer (CEO) is eventually accountable for ensuring that there are effective
measures in place for infection prevention and control and that appropriate funds are
accessible to manage the risk of infection. The CEO will designate the prevention and control
of health-care associated infection as a core part of the organisations clinical governance. The
infection prevention and control team is multi-disciplinary. The infection control nurse is
specialised in identifying, controlling, and preventing outbreaks of infection in health-care
settings and the community. Activities include the collection and analysis of infection-control
data as well as planning, implementation, and evaluation of infection prevention and control
measures. Other activities include education of individuals about infection risk, prevention,
and control as well as development and revision of infection control policies and procedures.
Investigation of suspected outbreaks of infection, provision of the consultation on infection
risk assessment, prevention and control strategy too (Royal Cornwall Hospital Infection
Prevention and Control Policy, 2015:1-15).

2.3 THE ROLE OF THE CONCEPTUAL FRAMEWORK (FLORENCE

NIGHTINGALE’S ENVIRONMENTAL THEORY) IN INFECTION PREVENTION
AND CONTROL
Florence Nightingale’s theory on infection control was adopted for this study. The theory
states that nurses have to provide a clean environment for the patient by promoting infection
prevention and control in this case. The nurse plays an important role in the translation of
knowledge to attitude and practice in infection prevention and control. Nightingale acted out
prevention and control practices through her knowledge, attitude regarding infection
prevention and control which placed the patient in the best possible position for healing
(Hegge, 2013 and Gurler, 2014). Nightingale stressed that cleanliness (sanitation, hygiene)
and infection prevention and control measures in the clinical environment contribute to
improving health care

(Hegge, 2013 Gurler, 2014). The clinical environment impacts the patients’ exposure to
infection-related diseases. Nightingale focused on caring for the sick and placed emphasis on
the importance of hygiene and patient care in infection prevention and control (Hegge, 2013
and Gurler, 2014).

• Nurse: the knowledge and skills that the nurses acquires enable them totranslate it
into a positive attitude and good practice in preventing and controlling infection.
Nurses and midwifes have the responsibility to prevent the spread of infection in a
clinical setup (Hegge, 2013 and Gurler, 2014).
• Environment: the nurse’s/midwifery knowledge, attitude and practices in
infectionprevention and control affect the clinical environment. A poor evidenced-
based practice environment exposes the patient to infection. Isolation procedures
should be well known by nurses and midwife to prevent the spread of infectious
conditions (Hegge, 2013 and Gurler, 2014).
• Patient : the clinical environment exposes the patient to hospital acquiredinfections.
These infections have an impact on patient outcome such as delayed hospitalization
(Hegge, 2013 and Gurler, 2014).

CHAPTER 3
RESEARCH METHODOLOGY

3.1 INTRODUCTION
This chapter includes the research methodology that was applied to determine the knowledge,
attitudes and practices of nurses/Midwife regarding infection prevention and control in
Maiduguri,Borno state, Nigeria. The research design, population and sampling procedures,
data collection and data analysis methods are also discussed.

3.2 AIM OF THE STUDY

The aim of this study is to determine the knowledge, attitudes and practices of nurses
regarding infection prevention and control within a tertiary hospital.

3.3 THE OBJECTIVES OF THE STUDY

The objectives of this study were to determine:
• the knowledge of nurses in infection prevention and control in Maiduguri
• the attitude of nurses in infection prevention and control in Maiduguri
• the practices of nurses in infection prevention and control in Maiduguri
• To make recommendations to the risk programme and policies of the tertiary hospital.

3.4 STUDY SETTING

The study setting was federal government hospital, Maiduguri in Borno state, Nigeria which
consist of general wards, high- risk multidrug resistance, surgical ward, gynaecology, post-
natal, maternity, special baby care unit, intensive care unit, casualty, outpatient, theatre,
orthopaedic and the psychiatry unit. The study was conducted at federal government
hospital,Maiduguri,Borno state, Nigeria.

3.5.1 Research design

The research design is defined as a plan or blue print of how you intend conducting the
research (Mouton 2011:55). A quantitative, descriptive study was conducted to determine the
level of knowledge, attitudes and practices of Midwife regarding infection prevention and
control within a tertiary hospital in Maiduguri. Quantitative research is defined as an official,
objective, organized procedure used to describe variables, test relationship between them, and
examines cause and effect relations among variables (Burns & Grove 2011). The descriptive
study can provide information about the naturally according to status, behaviour attitude and
relationships (Brink, Van der Walt & Van Rensburg, 2012).

The research design enabled the researcher to describe the data gathered. The researcher
applied the research design by aiming at gathering information about knowledge, attitudes
and practices of midwifes in infection prevention and control, describing it, as well as
identifying problems that lead to poor practices among nurses’ in infection prevention and
control. Hence the recommendations for future practice.
3.5.2 Research question
The research question guiding the study is: What is the knowledge, attitudes and practices of
nurses in infection prevention and control in Maiduguri?

3.5.3 Population and sampling

The population is all elements (individuals, objects, or substances) that meet certain criteria
for inclusion in a study (Burns & Grove 2011:544). The population for the study was
midwifes working in federal government hospital, Maiduguri, Borno state, Nigeria. 312
nurses were the total population of midwifes at this government hospital of which n= 140
(98%) were registered nurses, n= 80 (56%) enrolled nurses, n= 47 (33%) registered midwives,
n= 23 (16%) enrolled midwives, n= 10 (7%) certified midwives and n= 12 (8%) registered
mental health nurses. The above information was obtained from Human Resource department
who got the information from the register. The letter was written by the researcher (addendum
G) to theSenior Medical Superintendent explaining why the information was needed before
the above information could be released. The sample is a subgroup of the population that is
designed for a study (Burns & Grove 2011).
The sample set for this study was n=196 participants (Table 1.1). The sampling method that
was utilized in this study was stratified simple random sampling. This method of sampling
enabled the study population to have an equal and independent chance of appearing in the
study sample. In each category of nurses were allocated numbers using an Excel spreadsheet
developed by the statistician? The researcher utilised stratified simple random sampling to
select 70% (n= 196) of nurses from each category as a sample for the study as indicated in
Table 1. The sample size 70% for this study was selected in consultation with a statistician,
supervisor and co-supervisor. A large sample size was more representative of the population
and broadened the gathered data for analysis (Burns & Grove 2011).

Table 3.1: Sample framework of nurses who participated in the study

No. Category Total per Sample (70% per
categor category
y )

1 Registered Nurses 126 88

2 Enrolled Nurses 72 50

3 Registered Midwives 42 29

4 Enrolled Midwives 21 15
 5 Certified Midwives 9 6

6 Registered Mental Health Nurse 11 8

Total N=281 n=196

3.5.4 Inclusion criteria

The inclusion criteria was nurses working at the federal government hospital, Maiduguri. All
nurses working in a clinical environment were included in the study because it is in the
clinical environment where transmission of infection occurs.

3.5.5 Exclusion criteria

Participants utilised for the pilot study were excluded from the main study. That was 10%
(N= 31) of the total population of each category of nurses at the government tertiary hospital
where the study was conducted. To conduct the pilot study 10% of
312 nurses (n= 31) at the same government tertiary hospital from each category was selected
using stratified random sampling method as indicated in table 3.2 (n= 31). The pilot study
consisted of 10% from N= 312 nurses which is n= 31 nurses of which N= 281 nurses from
which 70% (n= 196) was enrolled in the main study. Nursing managers were also excluded
because they do not practice in a clinical environment as they spend most of their time in
offices performing administrative work.

3.5.6 Instrumentation
A questionnaire is a document containing questions and other types of items designed to
solicit information appropriate for analysis (Babbie & Mouton 2007; 646). The researcher
utilized a self-developed structured questionnaire with closed-ended questions to collect data
for the study. The compilation of the questionnaire was done through literature review,
consultation with experts in the field of infection control, the supervisor and co-supervisor as
well as the statistician who supervised the application of statistics. The content of the
questions included best practices from Nigerian infection control guidelines (2003), Centre
for Disease Control guidelines(2009 & 2011) as well as WHO’s guidelines on prevention of
hospital-acquired infections (2002 & 2013). The questionnaire was validated because the
same questionnaire was used during the pilot study and it measured what it was expected to
measure in a specific population (nurses).
The questionnaire consisted of 44 closed ended questions. There are no open-ended questions.
It consisted of a Likert scale of agree (1), disagree (2) and not applicable (3) to choose from,
which provided greater uniformity of responses as such data was easily processed. A Likert
scale is psychometric response scale used in questionnaires to obtain participants’ degree of
agreement with set statements (Brink, Van der Walt & Van Rensburg, 2012). The time frame
to complete the questionnaire was 40 minutes as observed during the pilot study.

The questionnaire consisted of 2 sections (Appendix A):

Section 1: Demo-graphical information which included:
• Gender
• Age
• Marital status
• Nursing category
• Years practiced as a nurse
• Employment status
• Number of years in current nursing department

Section 2 consisted of questions on Knowledge, Attitudes and Practices related toinfection

prevention and control. The questionnaire consisted of closed-ended questions with a Likert
scale of agree (1), disagree (2) and not applicable (3) to choose from. A Likert scale is
psychometric response scale used in questionnaires to obtain participants’ degree of
agreement with set statements (Brink, Van der Walt & Van Rensburg, 2012).

The questions included;

• The Variable knowledge had questions from 2.1.1 to 2.1.12.
• The Variable attitude had questions from 2.2.1 to 2.2.12.
• The Variable Practices had questions from 2.3.1 to 2.3.13.

3.5.7 Pilot study

A pilot study is a smaller version of a proposed study conducted to develop and refine the
methodology such as the treatment, instruments or data collection process to be used in the
larger study (Burns & Grove 2011:544). To conduct the pilot study 10% of 312 nurses (n=
31) at the same hospital from each category was selected using stratified random sampling
method as indicated in table 3.2 (n= 31). The pilot study consisted of 10% from N= 312
nurses which is n= 31 nurses of which N= 281 nurses from which 70% (n= 196) was enrolled
in the main study.
Table 3.2 shows the framework of 31 nurses who participated in the pilot study. Before the
pilot study, the field worker was trained on how to collect data. The time required to complete
the questionnaire was confirmed as proposed in the research protocol. The pilot data and
participants were excluded from the main study but reported on within chapter 3. All 31
nurses completed the questionnaire. Performing a pilot study ensured content and face
validity of the instrument.

Table 3.2: Pilot study framework

Category Total per category 10% no of total category

Registered Nurses 140 14

Enrolled Nurses 80 8

Registered Midwives 47 5

Enrolled Midwives 23 2

Certified Midwives 10 1

Registered Mental Health Nurses 12 1

Total N= 312 n=31

The following findings of the pilot study were recorded:

Of the 31 questionnaires distributed, 31 participants completed the questionnaires, response
rate of 100%. The majority of the participants were female; 87.1% (n= 27) while 12.9% (n=
4) were male. The majority of participants had good knowledge in infection prevention and
control with the mean score of 83.21%. The attitude towards infection prevention and
control was good with the mean score of 81.37%.The practice in infection prevention and
control was poor with the mean score of 48.88%.

3.5.7.1 SHORTCOMINGS IDENTIFIED DURING THE PILOT STUDY

Questionnaire: During the pilot study, shortcomings were identified within the questionnaire
(addendum A) which relates to the numbering of variable 2.3 relating to practice. The
number 2.3.7 till 2.3.13 had missing numbers in between as well as duplications of numbers.
This affected the data analysed during the pilot study as data pertaining to the questions
 appeared twice. This has been corrected on the questionnaire for data collection of the main
study.

The correct numbering due to technical fault was as follows:

• 2.3.7 – 2.3.8 was missing and was corrected.
• 2.3.9. Was duplicated and was corrected
• 2.3.8. Was incorrectly listed and was then corrected for the main study.
• The second 2.3.9 was replaced with 2.3.10
• 2.3.10 was replaced with 2.3.11
• 2.3.11 was replaced with 2.3.12
• 2.1.12 was replaced with 2.1.13

The following approach was applied:

• The numbering of variable 2.3 on the questionnaire was corrected before distribution
of the questionnaire to collection data for the main study.
• The questionnaire was again checked by supervisor and co-supervisor before
distribution

3.5.8 Reliability
Reliability is defined as the extent to which an instrument consistently measures a concept
(Burns & Grove 2011:546). The instrument was designed by the researcher in conjunction
with the supervisor.

3.5.9 Validity
Validity is the extent to which an instrument accurately reflects the abstract construct (or
concept) being examined (Burns and Grove 2011:552). To maximize validity, representative
questions for each category (KAP) were designed and evaluated against the desired outcome.
To establish the validity of the instrument, a pilot study was conducted on 31 nurses, that is,
10% of each category of nurses at the same government tertiary hospital where the main study
was conducted. The nurses that participated in the pilot study did not participate in the main
study. To conduct the pilot study 10% of 312 nurses (n= 31) at the same government tertiary
hospital from each category was selected using stratified random sampling method as
indicated in table 3.2 (n= 31). The pilot study consisted of 10% from N= 312 nurses which is
n= 31 nurses of which N= 281 nurses from which 70% (n= 196) was enrolled in the main
study. Therefore, the piloted sample was protected from participating in the main study.
A specialist in nursing practice, infection prevention and control professional nurse and
nursing academic agreed on the face and content validity of the questionnaire. The
questionnaire consisted of questions on knowledge, attitude and practices (KAP) of nurses in
infection prevention and control. The pilot data was excluded from the main findings. Data
from the pilot study revealed that participants were able to complete the questionnaire within
40 minutes as anticipated in the proposal.

• Content validity: is the extent to which the method of measurement includesall the
major elements relevant to the construct being measured (Burns & Grove 2011:535).
In this cases Knowledge, attitudes and practices among nurses were measured in
relation to infection prevention and control. The contents of the instrument included
best practices from the Nigerian (2003) Infection Control Guidelines, CDC guidelines
(2009 & 2011) as well as WHO’s guidelines in the prevention of HAIs (2001 &
2013).

• Face validity: A specialist in nursing practice, infection prevention and

controlprofessional nurse and nursing academic agreed on the face and content
validity of the questionnaire. The questionnaire was validated because the same
questionnaire was used to during the pilot study and it measured what it was supposed
to measure.

• Construct validity: To maximize validity, representative questions for eachcategory

knowledge, attitudes and practices (KAP) were designed and evaluated against the
desired outcome of infection prevention and control.

3.5.10 Data collection

• Burns and Grove (2011:535) define data collection as the identification of subject and
the precise, systemic gathering of information (data) related to the research purpose or
the specific objectives, or hypothesis of the study. The researcher utilized a self-
developed validated close-ended questionnaire
(Addendum B) to collect data. The timeline for collecting data was from 1 st August to
31st August 2015 as indicated in the study time frame. Theresearcher collected the data
with the help of a qualified health care provider as a field worker. About 10 (ten)
questionnaires were completed every day excluding weekends. Distribution of
questionnaires to identified participants for the main study was by hand. The
researcher and fieldworker waited for the participants to complete the questionnaire,
 which improved the response rate. 196 questionnaires that were distributed and 196
were returned. Therefore the response rate was 100%.

Table 3.3: Summary of the number of questionnaires distributed and returned

Category Questionnaires Questionnaires Questionnaires
distributed returned Discarded

Registered Nurses 88 88 0

Enrolled Nurses 50 50 0

Registered Midwives 29 29 0

Enrolled Midwives 15 15 0

Certified Midwives 6 6 0

Registered Mental
health 8 8 0
Nurses

Total 196 196 0

3.5.11 Data analysis and interpretation

According to Burns and Grove (2011:535), data analysis is the technique used to reduce,
organise and give meaning to data. Upon completion of data collection, data was coded and
captured on to excel spreadsheet as advised by a qualified statistician. The statistician was
further consulted for data analysis. A statistical package (IBM SPSS version 22) was used to
statistically analyse the data which was analysed and reported on by using descriptive and
inferential statistics, such as frequency tables and relative frequencies, and graphically
illustrated by using bar charts. Continuous variables were summarised, using means and
standard deviations. Knowledge was scored by summing up correct responses to knowledge
items and expressing as a percentage of the total items. Attitudes and practices were scored
in the same way, using the more favourable response as correct. Scores were checked for
normality using histograms and the Kolmogorov-Smirnov test. Kolmogorov-Smirnov test is
used to test for ‘goodness of fit’ between a sample distribution and anotherdistribution,
which often is the normal (bell-shaped) distribution. The test compares the set of scores in
the sample to a normally distribute set of scores with the same mean and standard deviation
(Changing minds, 2016). Standard deviation is the square root of the variance (spread or
 dispersion of scores), it provides a measure of the average deviation of a value from the
mean in a particular sample (Burns & Grove 2011:388).

All scores were found to be plausibly normally distributed, and parametric correlation
coefficients (Pearson’s correlation) were calculated to assess the correlation between the three
scores of knowledge, attitudes and practices of infection prevention and control. Pearson’s
correlations is the parametric test used to determine relationships among variables (Burns &
Grove 2011:394).The level of statistical significance (P-value) is the probability level at
which the results of statistical analysis, are judged to indicate a statistically significant
difference among groups (Burns & Grove, 2011:377).

Standard deviation is the square root of the variance (spread or dispersion of scores), it
provides a measure of the average deviation of a value from the mean in a particular sample
(Burns & Grove 2011:388). The mean is the sum of the scores divided by number of scores
being summed (Burns & Grove 2011:387). It indicates therefore the average score as referred
to above in text. The median is the midpoint or the score at the exact center of the ungrouped
frequency distribution. The median is obtained by rank ordering the scores, if the number of
scores is even then the median is the average of the two median scores (Burns & Grove
2011:385)

3.5.12 ETHICAL CONSIDERATIONS

Where research involves the acquisition of material and information provided on the basis of
mutual trust, it is essential that rights, interests and sensitivities of those studied be protected
(Mouton 2011:243). Ethical reviewing and approval for this study will be done by the Health
Research Ethics Committee of the University. Preliminary permission letter (Addendum D) to
conduct the study has been obtained from the Ethics Committee while Permission to conduct
the study was obtained from theSenior Medical Superintendent (addendum G) and the head
of nursing of the tertiary hospital where the study will be conducted.

3.5.12.1 RIGHT TO CONFIDENTIALITY AND ANONYMITY

Confidential information provided by research participants must be treated as confidential,
even when this information enjoys no legal protection or privilege, and no legal force is
applied (Mouton, 2011:244). Informants/ Participants have the right to remain anonymous
(Mouton, 2011:243). Principles of confidentiality and anonymity were maintained throughout
the study. No personal details appeared on the questionnaire. Only the researcher, supervisor,
co-supervisor and statistician had access to any information and data obtained for the purpose
of this study. Data will be kept in a locked cupboard in the researcher’s house for a period of
5 years allowing access to only the researcher.
3.5.12.2 RIGHT TO SELF-DETERMINATION
This principle states that participants have the right to refuse to participate in the study as well
as to decline at any stage during the research process. The principle of respect for participants
indicates that people should be treated as autonomous agents with the right to self-
determination (Burn & Grove, 2011:107). Participation was entirely voluntary and
participants were informed that they are free to decline to participate any time without
suffering any negative consequences. Participants were given adequate information about the
study. A written informed consent (addendum E) was obtained from participants before
answering the questionnaire.
3.5.12.3 RIGHT TO PROTECTION FROM HARM AND DISCOMFORT
The researcher has the primary responsibility to protect participants from physical and mental
harm. The process of conducting research must not expose the participants to the substantial
risk of personal harm (Mouton 2011:245). In order to minimise harm the researcher should
ensure that confidentiality and anonymity of participants are protected. By allowing
participants to withdraw from the study at any time, participants are protected from harm and
discomfort. Researchers have to be extremely watchful in respecting participants’ right to
privacy (Mouton, 2011:243). The right to privacy was maintained throughout the study.
Participants were informed
that they had the right to refuse to answer the questionnaire. The principle of beneficence was
ensured throughout the study by maximising possible benefits, minimising possible harms
and by ensuring that participants are not harmed.

3.6 SUMMARY
This chapter included the research methodology that was applied to determine the knowledge,
attitudes and practices of nurses regarding infection prevention and control in federal
government hospital, Maiduguri. The research design, population and sampling procedures,
data collection and data analysis methods were discussed too. In the next chapter, the results
and interpretation of the collected and analysed data are presented and discussed.
 CHAPTER 4
RESEARCH FINDINGS

4.1. INTRODUCTION
In this chapter, the findings on the data collected and analysed are presented. The study
results are described, discussed and analysed data is presented in tables, histograms and
graphs. Data was analysed to determine nurses’ knowledge, attitude and practices in infection
prevention and control at federal government Hospital in Maiduguri. The Statistical package
(IBM SPSS version 22) was used to analyse data with the support of an experienced
statistician from Stellenbosch University. The collected data was captured on to excel
spreadsheet that was prepared by the statistician for the purpose of the study.

4.2. SECTION 1: BIOGRAPHICAL DATA.

This section aims at collecting participants information which consists of seven questions
regarding gender, age, marital status, nursing category, years practiced as a nurse
employment status and the number of years in the current department.

4.2.1. Variable 1: Gender

The majority of the participants who completed the questionnaire were female n= 166
(84.7%), compared to male participants n= 30 (15.3%).

Table 4.1: Gender distribution of participants (n=196)

Gender n %

Male 30 15.3
Female 166 84.7

Total (N) 196 100.0

It is evident that nursing profession is populated by females. Of the total 196 participants 166
were female nurses while n=30 were male nurses. According to Zamanzadeh, Valizadeh,
Negarandeh, Monadi and Azadi (2013:49-56) male nurses confront challenging traditional
gender-defined roles and stereotypes from the society when choosing to enter a female-
dominated profession (nursing). That is why the nursing profession is female-dominated.
4.2.2. Variable 2: Age
The largest age group that completed the questionnaire were 30 – 39 years n= 80 (40.8%),
followed by age group 20 – 29 years old n= 72 (36.7%) and age group 40 – 49 years n= 32
(16.3%), lastly >50 years of age were n= 12 (6.1%).
Table 4.2: Age distribution of participants who participated in the study
Age n %

20-29 72 36.7
30-39 80 40.8
40-49 32 16.3
>50 12 6.1

Total (N) 196 100.0

According to Table 4.2 the majority of nurses where between 30 to 39 age group n= 80
(40.8%), followed by 20 to 29 age group n= 72 (36.7%) then 40 to 49 age group n= 32
(16.3%) and lastly above 50 years old n= 12 (6.1%)

4.2.3. Variable 3: Marital status

The majority of participants were married participants n= 97(49.5%) followed by single
participants n= 86 (43.9%) while other was n= 13 (6.6%)

Table 4.3: Marital distribution of participants who participated in the study

Marital Status n %

Single 86 43.9

Married 97 49.5

Other 13 6.6

According to Table 4.3, it is evident that most of the nurses are married while a good
number was single. Least number of nurses were neither married nor single.

4.2.4. Variable 4: Nursing category

The majority of participants were registered nurses n= 89 (45.4%), followed by enrolled
nurses n= 52 (26.5%), then registered midwives n= 25 (12.8%), then enrolled midwives n=
16 (8.2%), then certified midwives n= 6 (3.1%) and lastly registered mental health nurses
n= 8 (4.1%).

Table 4.4: Distribution of nursing categories who participated in the study

type n %

RN 88 45.4
EN 50 26.5
RM 29 12.8
EM 15 8.2
CM 6 3.1
RMHN 8 4.1

Total 196 100.0

To conduct the pilot study 10% of 312 nurses (n= 31) at the same hospital from each
category was selected using stratified random sampling method as indicated in table 3.2 (n=
31). The pilot study consisted of 10% from N= 312 nurses which is n= 31 nurses of which
N= 281 nurses from which 70% (n= 196) was enrolled in the main study. Therefore, the
piloted sample was protected from participating in the main study.

4.2.5. Variable 5: year practiced as a nurse

The number of nurses who had practiced as a nurse for 0-1 were n= 23 (11.7%), 1-3 years
were n= 63 (32.1%), 4 to10 years were n= 63 (32.1%), 10 years and above n= 47 (24%).

Table 4.5: Distribution of years practiced for nurses who participated in the study
Years practiced n %

0-1 23 11

1-3 63 32.1

4 -10 63 32.1

10 and above years. 47 24

Table 4.5 indicates that the number of nurses that practiced from 1 to 3 years and 4 to 10
year was the same. The number of nurses that practiced for 10 years and above were more
than those who practiced for 0 to 1 years.

4.2.6. Variable 6: Employment status

The majority of participants were full-time employees n= 173 (88.3%), n= 16 (8.2%)
were employed on a contract, while other had n= 3 (3.6%).

Table 4.6: Distribution of employment status for nurses

Employment status n %

Full-time 173 88.3

Contract 16 8.2

Agency

Other 3 3.6

Total (N) 196 100

According to table the majority n= 173 (88%) of nurses who participated in the study were
full-time followed by a few on a contract while the least were in the other category.

4.2.7. Variable 7: number of years worked in current department

The majority of nurses n= 106 (54.1%) worked for two years in the same department before
they were placed to another department. While n= 61 (31.1%) had worked for 2-4 years in
the same department. Nurses who worked for 5-10 years in the same department were n=
21(10.7%) while n= 8 (4.1%) worked for 10 years and above in the same department.

Table: 4.7. The Distribution of number of years worked in current departments for
nurses who participated in the study.

Years worked in current n %

department

0-2 106 54.1

2-4 61 31
 5-10 21 10

>10 8 4.1

Table 4.7 shows that the majority of nurses had worked in the same department for 0-2,
while some nurses worked in the same department for 2-4 years. Very few n= 8 (4.1%)
nurses have worked in the same department for more than 10 years.

4.3. SECTION 2: QUESTIONS ON KNOWLEDGE, ATTITUDE AND PRACTICES

ON INFECTION PREVENTION AND CONTROL AMONG NURSES

Refer to questionnaire:

Table 4.8: 2.1. Knowledge consists of questions 2.1.1 to 2.1.12.

Question
2.1.
referring
to
Variable
Knowledge
component
Hospital acquired infection can be transmitted by medical equipment such
2.1.1 as
syringes, needles, catheters, stethoscopes, thermometers etc.

2.1.2 Nosocomial infection is an infection that the patient comes with from home.

2.1.3 I know the worlds health organisation’s ‘5 moments of hand hygiene.

2.1.4 Some instrument can be stored in an antiseptic solution for up to36 hours.

2.1.5 If there is limited beds available, patients with communicable diseases may be
admitted in the same ward with other patients.

2.1.6 Micro-organisms are destroyed by using clean water

2.1.7 Bathing every day is a universal precaution

2.1.8 Standard precautions apply to all patients regardless of their diagnosis.

2.1.9 I am familiar with hospital-acquired infection guidelines

2.1.10 All staff and patients should be considered potentially infectious.

2.1.11 You can handle body fluids with bare hands if gloves are not available

2.1.12 I know how to prevent and control hospital-acquired infections

Table 4.9: 2.2. Attitudes consist of questions 2.2.1 to 2.2.12.

Question
2.2.
Variable
referring
to attitude
component

2.2.1 I do not have to wash hands if I used gloves.

2.2.2 Policies and procedures on infection control should be adhered to at all times

I should attend in-service training/workshop related to infection prevention

2.2.3 and control
regularly.

2.2.4 The workload affects my ability to apply infection prevention guidelines

I am aware that patients expect me to wash hands before touching them and
2.2.5 after
touching them.

2.2.6 I feel that infection control policies and guidelines are enough in the hospital

It is not my responsibility to comply with hospital-acquired infection

2.2.7 guidelines.

2.2.8 Infection prevention guidelines are important to this hospital.

2.2.9 I have enough time to comply with infection prevention guidelines

I believe that following the prevention guidelines will reduce rates of

2.2.10 hospital-acquired
infection.
2.2.11 I should follow the procedure guidelines of the unit.

2.2.12 I feel that needles should be recapped after use and before disposal

Table 4.10: 2.3. Practices consist of question 2.3.1 to 2.3.13

Question
2.3.
referring Variable
to Practice
component

2.3.1 I always wash hands before and after direct contact with the patients

2.3.2 I always put on a mask and glasses when performing invasive and body fluid
procedures.

Knowledge of infection prevention and control are being monitored in the

2.3.3 hospital

I attend in-service training/workshop related to infection prevention and control

2.3.4 yearly.

2.3.5 Surgical operation sites are shaved with razors.

2.3.6 The latest infection and prevention guidelines date is between 2015 and 2013.

Screening of patients is being done to detect colonisation even if no evidence

2.3.7 of
infection.

2.3.8 Vaccination is provided to staff.

2.3.9 Personal protective equipment are always accessible

Our hospital monitors patients with urinary catheters for urinary tract infection
2.3.10 and
gives feedback on urinary tract infection rates.

2.3.11 Infection prevention does not improve patient outcome

2.3.12 We wear personal protective equipment when handling linen.

2.3.13 We shake linen out to release dust from the linen.

4.3.1. Knowledge questions from 2.1.1 to 2.1.12.

Table 4.11. Questions on nurse’s knowledge in infection prevention and

control(Variables 2.1.1 - 2.1.12).

DISAGRE NOT TOTAL

VARIABLE AGREE E APPLICABLE (N)
Hospital acquired
2.1.1 infection n=189 n=6 n=1 N=196
can be transmitted by
medical equipment
such as (96.4%) (3.1%) (0.5%) (100%)
syringes, needles,
catheters,
stethoscopes,
thermometers
etc.
Nosocomial infection
2.1.2 is an n=36 n=158 n=2 N=196
infection that the
patient
comes with from
home. (18.4%) (80.6%) (1%) (100%)
I know the worlds
2.1.3 health n=167 n=29 n=0 N=196
organisation’s ‘5
moments of
hand hygiene. (85.2%) (14.8%) (0%) (100%)
Some instrument can
2.1.4 be n=66 n=123 n=7 N=196
stored in an antiseptic
solution for up to 36
hours. (33.7%) (62.8%) (3.6%) (100%)

2.1.5 If there is limited beds n=25 n=169 n=2 N=196

available, patients
with
communicable
diseases may (12.8%) (86.2%) (1%) (100%)
be admitted in the
same
ward with other
patients.

2.1.6 Micro-organisms are n=9 n=183 n=4 N=196

 destroyed by using
clean
water (4.6%) (93.4%) (2%) (100%)

2.1.7 Bating every day is a n=123 n=61 n=12 N=196

universal precaution
(62.8%) (31.1%) (6.1%) (100%)

Standard precautions
2.1.8 apply n=182 n=14 n=0 N=196
to all patients
regardless of
their diagnosis. (92.9%) (7.1%) (0%) (100%)

2.1.9 Ihospital
am familiar with n=165 n=31 n=0 N=196
acquired infection
guidelines.
(84.2%) (15.8%) (0%) (100%)

All staff and patients

2.1.10 should n=187 n=9 n=0 N=196
be considered
potentially
infectious. (95.4%) (4.6%) (0%) (100%)
You can handle body
2.1.11 fluids n=4 n=192 n=0 N=196
with bare hands if
gloves are
not available (2%) (98%) (0%) (100%)
I know how to prevent
2.1.12 and n=181 n=15 n=0 N=196
control hospital
acquired
infections (92.3%) (7.7%) (0%) (100%)

4.3.1.1. Variable 2.1.1. Hospital acquired infection can be transmitted by medical

equipment such as syringes, needles, catheters, stethoscopes, thermometers, etc (N=196):
According to Table 4.11, the majority of nurses n= 189(96.4%) agreed that hospital-acquired
infections can be transmitted by medical equipment such as syringes, needles, catheters,
stethoscopes, thermometers etc. While a few participants n=6 (3.1%) disagreed and only one
participant n=1 (0.5%) thought it was not applicable.

If nurses are knowledgeable in infection prevention and control, the rate of hospital acquired
infection can be reduced.
Literature has shown that hospital acquired infection can be transmitted through contaminated
equipment. In agreement, (CDC) Centres for Disease Control and Prevention (2014:24)
indicated that Pseudomonas Aeruginosa could spread by equipment that gets contaminated
and not properly cleaned. In this regard, the study has shown that n= 7 (3.6%) of the nurses
who participated in the study lacked knowledge in infection prevention and control posing a
risk in transmitting HAIs.

4.3.1.2. Variable 2.1.2 Nosocomial infection is an infection that the patient comes with
from home. (N= 196): Table 4.11 indicates that the majority of nursesn=158 (80.6%)
disagreed with the statement that nosocomial infection is an infection that the patient comes
with from home. A number of nurses n= 36 (18.4%) agreed while only two participants n= 2
(1%) thought that it was not applicable.

However, the study has shown that n= 38 (19, 4%) of the nurses who participated in the study
have the knowledge that nosocomial infection is acquired at home. This indicates that these
nurses did not know how hospital-acquired infections were acquired hence posing a risk of
transmitting nosocomial infection.

4.3.1.3. Variable 2.1.3 I know the worlds health organisation’s ‘5 moments of hand
hygiene. (N= 196): According to Table 4.11 the large majority of nurses n=167 (85.2%)
agreed that they were aware of the world health Organisation’s “5 moments of hand hygiene”
the remaining portion of nurses n= 29 (14.8%) disagreed. However, n= 29 (14.8%) of nurses
who participated in the study did not have
knowledge about WHO (2009) 5 moments of hand hygiene hence posing a risk of
transmitting infection.

4.3.1.4. Variable 2.1.4 Some instruments can be stored in an antiseptic

solution for up to 36 hours (N= 196): Table 4.11 shows that the majority of nursesn= 123
(62.8%) disagreed that instruments can be stored in an antiseptic solution for up to 36 hours.
A third n= 66 (33.7%) of the participants agreed that instruments could be stored in an
antiseptic solution for up to 36hrs while a few nurses n= 7 (3.5%) thought it was not
applicable.

According to the current study n= 189 (97.5%) lack knowledge on instrument

decontamination and therefore pose a risk of hospital acquired infection.
4.3.1.5. Variable 2.1.5 If there is limited beds available, patients with communicable
diseases may be admitted in the same ward with other patients (N= 196): As per table
4.11 the large majority of nurses n= 169 (86.2%) disagreedwith the statement that if there are
limited beds available, patients with communicable diseases may be admitted in the same
ward with other patients. A quarter of the participants n= 25 (12.8%) agreed while n= 2 (1%)
thought it was not applicable.

Isolation is necessary to either prevent transmission of infection from an infected patient to

others or to protect a patient who is susceptible to infection (West Hertfordshire Hospital
Policy, 2013:3). However, the current study shows that n= 27 (13.8%) had no knowledge
about the importance of isolating patients with communicable diseases hence posing a risk for
hospital-acquired infections.

4.3.1.6. Variable 2.1.6 Micro-organisms are destroyed by using clean water

(N= 196): according to the table 4.11 the majority n= 183 (93.4%) of participantsdisagreed
with the statement that micro-organisms are destroyed by clean water. A few nurses n= 9
(4.6%) agreed that micro-organism can be destroyed by clean water, while four n= 4 (2%)
thought it was not applicable.

Micro-organisms can not be destroyed by clean water. Micro-organisms are killed by

disinfectants which are antimicrobial agents that are applied to non-living objects to destroy
micro-organisms. However, n= 13 (6.6%) believe that clean water can
destroy micro-organisms indicating that they lack knowledge in infection prevention and
control.

4.3.1.7. Variable 2.1.7 Bathing every day is a universal precaution (N= 196):
according to Table 4.11 most of the participants n= 123 (62.8%) agreed that bathing every
day is a universal precaution. A third of the nurses n= 61 (31.1%) disagreed with the
statement that bathing every day is a universal precaution while n= 12 (6.1%) indicated that it
is not applicable.

The current study n= 123 (62.8%) agreed with the statement that bathing every day is a
universal precautions indicating that the majority of nurses did not understand the meaning of
the term universal precautions. This is an indication of a gap in knowledge.

4.3.1.8. Variable 2.1.8 Standard precautions apply to all patients regardless of their
diagnosis (N= 196): Accordind to table 4.11 a large majority of nursesn=182 (92.9%) agreed
that standard precautions apply to all patients regardless of their diagnosis. A relatively small
number of nurses n= 14 (7.1%) disagreed with the statement that standard precaution apply to
all patients regardless of their diagnosis as per Table 4.11.

The current study shows that n= 14(7.1%) indicated that standard precautions do not apply to
all patients regardless of their diagnosis. These nurses pose a risk to transmission of infection.
Srejic (2015:1) indicated that standard precautions are basic effective practices designed to
protect health-care workers (HCWs) and prevent HCWs from spreading infections among
patients. These safety measures apply to all hospitalised patients, regardless of the disease the
patient is suffering from. (Srejic 2015:1).

4.3.1.9. Variable 2.1.9 I am familiar with hospital-acquired infection

guidelines (N= 196): According to Table 4.11 the majority of participants n= 165(84.2%)
agreed that they were familiar with hospital-acquired infection guidelines, whereas some
participants n= 31 (15.8%) disagreed that they were unfamiliar with hospital-acquired
infection guidelines.

Infection control guidelines are important because they guide health-care workers in
prevention of hospital acquired the infection. Brisibe, Ordinioha and Gbeneolol (2014:691-
695) indicated that implementation of infection control policy result in some improvements in
certain infection control practices. However, the present study indicated that n= 31 (15.8%)
were not familiar with hospital-acquired infection guidelines.

4.3.1.10. Variable 2.1.10. All staff and patients should be considered

potentially infectious (N= 196): As indicated in Table 4.11, a large number ofparticipants n=
187 (95.4%) considered all staff and patients as potentially infectious whereas a relatively
small group of participants n= 6 (4.6%) did not consider all staff and patients as potentially
infectious.

Standard precautions apply to the care and treatment of all patients in the clinic environment,
regardless of their infectious status as well as in handling all bodily fluids, non-intact skin and
mucous membranes (The University of Sydney, 2015:2)

4.3.1.11. Variable 2.1.11. You can handle body fluids with bare hands if
gloves are not available (N= 196): The results in Table 4.11 showed that almost
allparticipants n= 192 (98%) disagreed with the statement that they can handle body fluids
with bare hands if gloves are not available. Unfortunately, four participants n= 4 (2%) agreed
that they could handle body fluids with bare hands if gloves are not available.

Use of personal protective equipment (gloves) is one of the practices required to achieve a
basic level of infection control (The University of Sydney 2015:1).

4.3.1.12. Variable 2.1.12: I know how to prevent and control hospital-acquired infections
(N= 196): Table 4.11 showed that a large number ofparticipants n= 181 (92.3%) agreed that
they know how to prevent and control hospital acquired infections whereas only a minority
n= 15 (7.7%) disagreed to know how to prevent and control hospital acquired infections.

Even though the majority n= 181 (92%) of nurses indicated that they have knowledge on how
to prevent hospital acquired infection, the current study reviewed that the majority n= 123
(62.8%) of nurses did not understand the meaning of universal
precautions. Furthermore, n= 15 (7.7%) did not know how to prevent and control hospital
acquired infections. This indicates that there is still a gap in the level of knowledge on how to
prevent hospital acquired infections.

4.3.1.13. Summary of the extent agreement on knowledge towards infection

prevention and control among nurses..
Results are reflected within the graph below Figure 4.1 shows the extent of agreement on
knowledge among nurses in infection prevention and control. The high or low level of
agreement does not indicate a favourable answer. Each variable is explained in section 4.3.1
above.

Figure 4.1. Results reflected within the graph below shows the extent of agreement

on knowledge among nurses in infection prevention and control

 (y= Questions on knowledge 2.1.1-2.1.12)

4.3.1.14. Questions on knowledge

Feedback of responses on the y-axis of fig 4.1 referring to knowledge

2.1.1. 96.4% of the nurses agreed that hospital acquired infection can betransmitted by
medical equipment such as syringes, needles, catheters, stethoscope, thermometers etc.

2.1.2. 18.4% of the nurses agreed that nosocomial infection is an infection that apatient comes
with from home.

2.1.3. 85.2% of the nurses agreed that they know the world health organisation’s 5moments of
hand hygiene.

2.1.4. 33.7% of the agreed that some instrument could be stored in an antisepticsolution for up
to 36 hours.

2.1.5. 12.8% of the nurses agreed that if there is limited beds available, patientswith
communicable diseases may be admitted in the same ward with other patients.

2.1.6. 4.6% of the nurses agreed that micro-organisms are destroyed by usingclean water.

2.1.7. 62.8% of the nurse agreed that bathing every day is a universal precaution.

2.1.8. 92.9% of the nurses agreed that standard precautions apply to all patientsregardless of
their diagnosis.
2.1.9. 84.2% of the nurses agreed that they were familiar with hospital-acquiredinfections
(HAIs) guidelines.

2.1.10. 95.4% of the nurses agreed that all staff and patients should be consideredpotentially
infectious.

2.1.11. 2% of the nurses agreed that they could handle body fluids with bare handsif gloves
were not available.

2.1.12. 92.3% of the nurses agreed that they knew how to prevent and control HAIs.

4.3.2. Attitudes questions from 2.2.1 to 2.2.12

One participant did not complete the section on Attitudes questions from 2.2.1 to
2.2.12.Therefore this section was completed by N=195.

Table 4.12: Questions on attitudes towards infection prevention and control among
nurses.
NOT
AGRE DISAGR APPLICABL TOTA
VARIABLE E EE E L
(N)
I do not have to wash
2.2.1 hands if I used n=6 n=189 n=0 N=195
gloves.
(3.1%) (96.9%) (0%) (100%)
Policies and procedures on
2.2.2 infection n=188 n=7 n=0 N=195
control should be adhered
to at all
times (96.4%) (3.6%) (0%) (100%)

2.2.3 I should attend in-service n=188 n=7 n=0 N=195

training/workshop related
to infection
prevention and control
regularly. (96.4%) (3.6%) (0%) (100%)
The workload affects my
2.2.4 ability to n=129 n=66 n= (0%) N=195
 apply infection prevention
guidelines.
(66.2%) (33.8%) (100%)

I am aware that patients

2.2.5 expect me n=151 n=42 n=2 N=195
to wash hands before
touching them
and after touching them. (77.4%) (21.5%) (1%) (100%)

I feel that infection control

2.2.6 policies n=92 n=103 n=0 N=195
and guidelines are enough
in the
hospital (47.2%) (52.8%) (0%) (100%)

It is not my responsibility
2.2.7 to comply n=13 n=181 n=1 N=195
with hospital acquired
infection
guidelines. (6.7%) (92.8%) (0.5%) (100%)

Infection prevention
2.2.8 guidelines are n=192 n=2 n=1 N=195
important to this hospital.
(98.5%) (1%) (0.5%) (100%)
I have enough time to
2.2.9 comply with n=85 n=109 n=1 N=195
infection prevention
guidelines
(43.6%) (55.9%) (0.5%) (100%)

I believe that following the

2.2.10 prevention n=190 n=5 n=0 N=195
guidelines will reduce
rates of
hospital acquired infection. (97.4%) (2.6%) (0%) (100%)
I should follow the
2.2.11 procedure n=190 n=4 n=1 N=195
guidelines of the unit.
(97.4%) (2%) (0.5%) (100%)

I feel that needles should

2.2.12 be n=13 n=181 n=1 N=195
recapped after use and
before
disposal (6.7%) (92.8%) (0.5%) (100%)

4.3.2.1. Variable 2.2.1: I do not have to wash hands if I used gloves (N=
195): According to Table 4.12 the majority of nurses n= 189 (96.4%) disagreed withthe
statement that they do not have to wash hands after using gloves. While a relatively small
group of nurses n= 6 (3.1%) agreed with the statement that they do not have to wash hands
after using gloves.

It is important to wash hands with soap and water after removing gloves because there is a
risk of hand contamination during removal of gloves. In agreement Pang, Carter, Scott,
Salazar and Johnson (2014:14-16) indicated that gloves should be removed as soon as the
episode of care is completed followed by decontamination of hands. Moreover, gloves
provide an ideal, warm, moist environment where bacteria thrive, therefore, hand
decontamination will remove any transient bacteria from a previous patient environment
(Pang et al., 2014:14-16). Pang et al., (2014:14-16) indicated that hand hygiene remains the
cornerstone of infection prevention and all health workers must be aware that wearing PPE
does not replace the need to carry out safe hand-hygiene practices and hand decontamination.
However, the present study shows that n= 6 (3.1%) of nurses still feel that they do not need to
wash hands after removing gloves posing a risk to transmission of infection.

4.3.2.2. Variable 2.2.2: Policies and procedures on infection control should be adhered to
at all times (N= 195): as per Table 4.12 the majority of nurses n=188 (96.4%) agreed that
they should adhere to policies and procedures on infection control at all times. A few nurses
n= 7 (3.6%) disagreed with the fact that they should adhere to policies and procedures on
infection control at all times.

Even though n= 188 (96.4%) agreed that they should adhere to policies and procedures on
infection control all the time, the current study shows that n= 103 (53%) as shown in (Table
4.12) indicated that policies and guidelines on infection control are not enough at their
hospital. Furthermore n= 7 (3.6%) indicated that they should not adhere to policies and
procedures on infection control at all times posing a risk of infection transmission.

4.3.2.3. Variable 2.2.3: I should attend in-service training/workshop related

to infection prevention and control regularly. (N= 195): Table 4.12 indicates that
a good number of nurses n=188 (96.4%) agreed that they should attend in-service
training /workshop related to infection prevention and control regularly. A few participants
n=7 (3.6%) disagreed with the statement that they should attend in-service training/workshop
related to infection prevention and control regularly.
Even though n= 188 (96.4%) agreed that they should attend in-service training/workshop
related to infection prevention and control regularly, the current study in table 4.13 indicated
n= 178 (91.3%) do not attend in-service training/workshop related to infection control
regularly. Furthermore, n= 7 (3.6%) indicated that it is not important to attend in-service
training/workshop related to infection control.

4.3.2.4. Variable 2.2.4: The workload affects my ability to apply infection

prevention guidelines. (N= 195): Table 4.12 indicates that most of the participantsn= 129
(66.2%) agreed that the workload affects their ability to apply infection prevention guidelines,
while some participants n= 66 (33.8%) disagreed that the workload affects their ability to
apply infection prevention and control. The current study shows that n= 129 (66.2%) nurses
agreed that the workload affects their ability to comply with infection prevention guidelines.
In agreement, Cimiotti, Aiken, Sloane
& Wu (2012:486-490) indicated that there is a relationship between nurse staffing and
hospital acquired infections. Therefore, decreasing exhaustion in nurses is a favourable
approach to help control transmission of infections in hospitals. Therefore recommendations
were made to improve nurse staffing and alleviate job-related burnout in nurses hence
improving the quality of patient care.

4.3.2.5. Variable 2.2.5: I am aware that patients expect me to wash hands before
touching them and after touching them. (N= 195): As shown in Table 4.12most of the
participants n= 151 (77.4%) agreed that they are aware that patients expect them to wash their
hands before and after touching them while some nurses n= 42 (21.5%), disagreed that they
are aware that patients expect them to wash their hands before and after touching them. Very
few nurses n= 2 (1%) thought it was not applicable.

The current study shows that n= 44 (22.5%) of nurses are not aware that patients expect them
to wash their hands before and after touching them. In this regard, according to Safe Care
Campaign (2007 to 2016:1), the literature shows that patients
can have a role in promoting hand hygiene among doctors and nurses. Hand hygiene video
empowers patients to remind hospital caregivers to clean their hands, a strategy that is critical
in the fight to prevent infections (Safe Care Campaign 2007 to 2016:1).

4.3.2.6. Variable 2.2.6: I feel that infection control policies and guidelines
are enough in the hospital (N= 195): Table 4.12 indicates that a large group ofnurses n= 103
(52.8%) feels that infection control policies and guidelines are not enough in the hospital
while close to half of the participants n= 92 (47.2%) reported that infection control policies
and guidelines are enough in the hospital.

Infection control policies and guidelines are documents that contain information used to
minimise the risk of spreading infection. Therefore these documents are important because
they help reduce the rate of nosocomial infection if the nurses comply to them. However the
current study reviews that n= 103 (52%) indicated that infection control policies and
guidelines are not enough in the hospital.

4.3.2.7. Variable 2.2.7: It is not my responsibility to comply with hospital-acquired

infection guidelines. (N= 195): As per table 4.12 the large majority ofnurses n= 181 (92.8%)
disagreed with the statement that it is not their responsibility to comply with the hospital
acquired infection guidelines. Whiles some participants n= 13 (6.7%) agreed that it is not
their responsibility to comply with the hospital acquired infection guidelines and one n=
1(0.5%) thought it was not applicable. The current study shows that n= 14 (7.2%) nurses
indicated that it was not their responsibility to comply with HAIs guidelines hence posing a
risk with HAIs. Transmission of HAIs through health-care workers can be avoided. Therefore
it is their responsibility to comply with HAIs guidelines in order to reduce the rate of HAIs.

4.3.2.8. Variable 2.2.8: Infection prevention guidelines are important to this hospital (N=
195): Table 4.12 shows that the large majority of participants n= 192(98.5%) agreed that
infection prevention guidelines are important to their hospital. While very few participants n=
2 (1%) disagreed that infection prevention guidelines are important to their hospital and one
participant n= 1 (0.5%) thought it was not applicable.

Infection prevention guidelines are important to all health-care settings because they guide
health-care workers on how to control and prevent hospital acquired infection. In the current
study n= 192 (98.5%) indicated that infection prevention guidelines are important to their
hospital. However, the study shows that these guidelines are not enough in the hospital.

4.3.2.9. Variable 2.2.9: I have enough time to comply with infection prevention
guidelines (N= 195): Table 4.12 indicates that although someparticipants n= 85 (43.6%)
agreed that they have enough time to comply with infection prevention guidelines, the
majority of participants n= 109 (55.9%) disagreed with the statement that they have enough
time to comply with infection prevention guidelines. While one participant n= 1 (0.5%)
thought it was no applicable.
The current study shows that n= 110 (56.4%) disagreed with the statement that they have
enough time to comply with infection prevention guidelines. In this regard, Cimiotti, Aiken,
Sloane and Wu (2012:486-490) revealed a significant relationship between staffing of nurses
and urinary tract infection as well as surgical site infection. The study indicated that reducing
stress among nurses is a tactic to help control hospital acquired infections in acute care
facilities.

4.3.2.10. Variable 2.2.10: I believe that following the prevention guidelines will reduce
rates of hospital-acquired infection (N= 195): According to table 4.12the majority of
participants n= 190 (97.4%) agreed that they believed that following the infection prevention
guidelines will reduce the rates of hospital acquired infection. While very few participants n=
5 (2.6%) did not believe (disagreed) that following infection prevention guidelines will reduce
the rates of hospital acquired infection.

4.3.2.11. Variable 2.2.11: I should follow the procedure guidelines of the

unit. (N= 195): According to table 4.12 the majority of participants n= 190 (97.4%)agreed
that they should follow the guidelines of the unit whereas very few participants n= 4 (2%)
disagreed that they should follow the guidelines of the unit. One participants n= 1 (0.5%)
thought it was not applicable.

Nurses are at risk of occupational exposure and can spread infection from one patient to the
other. Therefore, implementing relevant control measures whichinclude following the units
guidelines are key to successful infection control management. However, n= 4 (2%) indicated
that they should not follow infection control guidelines of the unit posing a risk of hospital
acquired infections.

4.3.2.12. Variable 2.2.12: I feel that needles should be recapped after use
and before disposal (N= 195): Table 4.12 indicates that the majority of participantsn= 181
(92.8%) disagreed with the statement that needles should be recapped after use and before
disposal. A few participants n= 13 (6.7%) agreed with the statement that needles should be
recapped after use and before disposal, while a participant n= 1 (0.5%) thought it was not
applicable.

According to OSEH (2010:2-3), recapping needles is a dangerous practice as many accidental

needle stick injuries occur when employees are recapping needles. This practice predisposes
health-care workers to infections like HIV and Hepatitis B virus infections. However, n= 14
(7.2%) still feel that needles should be recapped after use.

4.3.2.13. Summary of the extent agreement on attitudes towards infection prevention

and control among nurses.
Figure 4.2 shows the extent of agreement on attitudes among nurses in infection prevention
and control. The high or low level of agreement does not indicate the favourable answer. Each
variable is explained in section 4.3.2 above.

Figure 4.2. The results reflected within the graph below shows the extent of
agreement on attitudes among nurses in infection prevention and control.
 (y= Questions on attitudes 2.2.1-2.2.12)

4.3.2.14. Questions on attitudes

Feedback of responses on the y axis of fig 4.2 referring to attitudes

2.2.1. 3.1% of the nurses agreed that they do not have to wash their hands afterusing gloves.

2.2.2. 96.4% of nurses agreed that policies and procedures on infection controlshould be
adhered to at all times.

2.2.3. 96.4% of nurses agreed that they should attend in-service training/workshoprelated to
infection prevention and control regularly.

2.2.4. 66.2% of the nurses agreed that the workload affects their ability to applyinfection
prevention guidelines.

2.2.5. 77.4% of the agreed that they are aware that patients expect them to washhands before
touching them and after touching them.

2.2.6. 47.2% of the agreed that they feel that infection control policies andguidelines are
enough in the hospital.

2.2.7. 6.7% of the nurses agreed that it is not their responsibility to comply withhospital-
acquired infection guidelines.

2.2.8. 98.5% of the nurses agreed that Infection prevention guidelines are importantto their
hospital.
2.2.9. 43.6% of the nurses agreed that they have enough time to comply withinfection
prevention guidelines.

2.2.10. 97.4% of the nurses agreed that they believed that following the preventionguidelines
will reduce rates of hospital acquired infection.

2.2.11. 97.4% of the nurses agreed that they should follow the procedure guidelinesof the
unit.

2.2.12. 6.7% of the nurses agreed that they feel needles should be recapped afteruse and
before disposal.

4.3.3. Practice questions from 2.3.1 to 2.3.13

One participant did not complete the section on Practice questions from 2.3.1 to
2.3.13.Therefore this section was completed by N=195.

Table 4.13: Questions on practices regarding infection prevention and control

among nurses
Disagre Not
Variable Agree e applicable Total (N)

I always wash hands before and

2.3.1 after n=147 n=46 n=2 N=195
direct contact with the patients
(75.4%) (23.6%) (1%) (100%)
I always put on a mask and
2.3.2 glasses when n= 37 n= 147 n=11 N=195
performing invasive and body
fluid
procedures. (19%) (75.4%) (5.6%) (100%)

Knowledge of infection
2.3.3 prevention and n=155 n=38 n=2 N= 195
control are being monitored in
the hospital
(79.5%) (19.5%) (1%) (100%)
I attend in-service
2.3.4 training/workshop n=17 n=169 n=9 N=195
related to infection prevention
 and control
yearly. (8.7%) (86.7%) (4.6%) (100%)
Surgical operation sites are
2.3.5 shaved with n=100 n=90 n=5 N=195
razors.
(51.0%) (45.9) (2.6%) (100%)
The latest infection and
2.3.6 prevention n =78 n =53 n =64 N =195
guidelines date is between 2015
and 2013.
(40%) (27.2%) (32.8%) (100%)
Screening of patients is being
2.3.7 done to n =98 n=82 n=15 N=195
detect colonisation even if no
evidence of
infection. (50.3%) (42.1%) (7.7%) (100%)

Vaccination is provided to
2.3.8 staff. n=31 n=148 n=15 N=195
(15.8%) (76.4%) (7.7%) (100%)
Personal protective equipment
2.3.9 are always n=76 n=119 n=0 N= 195
accessible
(39.0%) (61%) (0%) (100%)
Our hospital monitors patients
2.3.10 with urinary n=35 n=154 n=6 N=195
catheters for urinary tract
infection and
gives feedback on urinary tract
infection (17.9%) (79%) (3.1%) (100%)
rates.

Infection prevention does not

2.3.11 improve n=36 n= 158 n=1 N=195
patient outcome
(18.5%) (81%) (0.5%) (100%)
We wear personal protective
2.3.12 equipment n=132 n=57 n=6 N=195
when handling linen.
(67.7%) (29.2%) (3.1%) (100%)
We shake linen out to release
2.3.13 dust from n=6 n=185 n=3 N=195
the linen.
(3.1%) (95.4%) (1.5%) (100%)
4.3.3.1. Variable 2.3.1: I always wash hands before and after direct contact with the
patients (N= 195): as per table 4.13 a large group of participants n= 147(75.4%) agreed that
they always wash hands before and after direct contact with the patients while some
participants n= 46 (23.6%) disagreed that they always wash hands before and after direct
contact with the patient. A small proportion of participants n= 2 (1%) indicated that it is not
applicable. Nurses should practice good infection prevention, the basis of which is effective
hand washing (Hillier 2015:34-36). However, the current study reviews that n= 48 (24.6%)
pose a risk to nosocomial infection as they do not always wash hands before and after direct
contact with the patient.

4.3.3.2. Variable 2.3.2: I always put on a mask and glasses when

performing invasive and body fluid procedures (N= 195): As indicated in Table4.13 the
majority of participants disagreed n= 147 (75.4%)with the statement that they always put on a
mask and goggles when performing invasive and body fluid procedures. Some participants n=
37 (19%) agreed that they always put on a mask and glasses when performing invasive and
body fluid procedures. A few participants n= 11 (5.6%) thought it was not applicable to
always put on a mask and goggles when performing invasive and body fluid procedures.

4.3.3.3. Variable 2.3.3: Knowledge of infection prevention and control are

being monitored in the hospital (N= 195): Table 4.13 Indicates that most of theparticipants
n= 155 (79.5%) agreed that knowledge of infection prevention and control are being
monitored in the hospital, while some participants n= 38 (19.5%) disagreed that knowledge of
infection prevention and control are being monitored in the hospital. Very few participants n=
2(1%) thought it is not applicable to monitor knowledge of infection prevention and control in
the hospital.

4.3.3.4. Variable 2.3.4: I attend in-service training/workshop related to

infection prevention and control yearly (N= 195): As per Table 4.13 most of
theparticipants n= 169 (86.7%) disagreed that they attend in-service training /workshop
related to infection prevention and control yearly. Some participants n= 17 (8.7%) agreed that
they attend in-service training/workshop related to infection prevention and control yearly. A
few participants n= 9 (4.6%) thought it is not applicable to
attend in-service training/workshop related to infection prevention and control yearly. A
significant proportion of nurses n= 178, (91.3%) do not update their knowledge regarding
infection prevention and control on a yearly basis hence posing a risk of spreading infection.

4.3.3.5. Variable 2.3.5: Surgical operation sites are shaved with razors (N=
195): from the results in table 4.13 most participants n= 100 (51.3%) agreed thatsurgical
operation sites are shaved with razors while the good number n= 90 (45.9%) of participants
disagreed that surgical operations sites are shaved with razors. A few participants n= 5 (2.6%)
thought it is not applicable to shave surgical operation sites with razors.

Also, n= 100 (51.3%) still shave with razor although literature shows that this practice
predisposes the patient to skin injuries and wound infection. In this regard Suvera, Vyas,
Patel, Varghese, Ahmed, Kashyap and Nair (2013:885-888), found that there was a
significant association between pre-operative skin injuries and post-operative wound
infection.

4.3.3.6. Variable 2.3.6: The latest infection and prevention guidelines date is between
2015 and 2013 (N= 195): As per table 4.13 a large number of participants(n= 78, 40%)
agreed that the latest infection control and prevention guidelines date is between 2015 and
2013. However, an alarming number of participants n= 64 (32.8%) thought it was not
applicable. Some participants n= 53 (27.2%) disagreed that the latest infection and prevention
guidelines date is between 2015 and 2013. However, n= 117 (60%) of the nurses indicate that
guidelines are not reviewed and updated regularly.

4.3.3.7. Variable 2.3.7: Screening of patients is being done to detect

colonisation even if no evidence of infection (N= 195): As indicated in table 4.13a large
number of participants n= 98 (50.3%) agreed that screening of patients to detect colonisation
even if no evidence of infection are done. Some participants n= 82 (42.1%) disagreed with a
screening of patients to detect colonisation even if no evidence of infection are being done,
while a minority of participants n= 15(7.7%) reported as not applicable to screen patients to
detect colonisation even if there is no evidence of colonisation.

4.3.3.8. Variable 2.3.8: Vaccination is provided to staff. (N= 195): As indicatedin Table
4.13 some nurses n= 31 (15.9%) agreed that vaccinations regarding infection control is being
provided to staff members. However, the large majority of participants n= 149 (76.4%)
disagreed that vaccinations regarding infection prevention is provided to members of staff. A
few participants n= 15, (7.7%) indicated that it is not applicable to provide vaccination to
members of staff.

Furthermore, high influenza vaccination rates of health care professionals (HCP) and patients
is an important step in preventing transmission of influenza from HCP to patients and the
other way round. Abeje and Azage (2015:1-6) indicated that out of N= 370 respondents, only
n=20 (5.4%) reported that they took three or more doses of hepatitis B vaccine. Indicating that
health care workers are at increased risk of acquiring hepatitis B infection due to occupational
exposure. In agreement, this study reviews that n= 164 (84.1 %) of nurses indicated that
vaccinations regarding infection control are not provided to members of staff.

4.3.3.9. Variable 2.3.9: Personal protective equipment are always accessible (N= 195):
Personal protective equipment (PPE) has to be accessible for nurses tocomply with infection
prevention measures. However, Table 4.13 indicates that the majority of nurses n= 119 (61%)
reported that personal protective equipment is not always accessible for them to comply with
infection prevention measures. Nevertheless some participants n= 76 (39%) agreed that
personal protective equipment is always accessible.

4.3.3.10. Variable 2.3.10: Our hospital monitors patients with urinary tract infection
and gives feedback on urinary tract infection rates. (N= 195):
According to Table 4.13 the majority of participants n= 154 (79%) disagreed with the
statement that their hospital monitors patients with urinary catheters for infection and gives
feedback on urinary tract infection rates. Some participants n= 35 (17.9%) agreed that their
hospital monitors patients with urinary catheters for infection and gives feedback on urinary
tract infection rates. A minority of participants n= 6 (3.1%) indicated that it is not applicable
for the hospital to monitor patients with urinary catheters for infection and give feedback on
urinary tract infection rates.

The current study reviews that the hospital does not monitor patients with urinary catheter for
infections and does not give feedback on urinary tract infection rates as indicated by n= 160
(82.1%)

4.3.3.11. Variable 2.3.11: Infection prevention does not improve patient

outcome (N= 195): Table 4.13 indicates that the majority of participants n= 158(81%)
disagreed with the statement that infection prevention does not improve patient outcome
while some participants n= 36 (18.5%) agreed with the statement that infection prevention
does not improve patient outcome. A participant n= 1 (0.5%) indicated that it was not
applicable. Literature has shown that infection prevention does improve patient outcome as it
reduces on days of patient hospitalization. However n= 37 (19%) of the nurses indicated that
infection prevention does not improve patient outcome hence posing a risk for hospital-
acquired infections.

4.3.3.12. Variable 2.3.12: We wear personal protective equipment when

handling linen. (N= 195): According to Table 4.13 the majority n= 132 (67.7%)agreed that
they wear personal protective equipment when handling linens, while some participants n= 57
(29.1%) disagreed that they wear personal protective equipment when handling linen. A few
participants n= 6 (3.1%) indicated that it is not applicable to wear personal protective
equipment when handling linen.

Some of the nurses n= 63 (32.2%) indicated that they do not wear personal protective
equipment when handling linen. According to MOH (2013:57), hospital linen may become
contaminated by blood, body fluids or excreta and by skin shedding. Hospital linen thus poses
an infection risk to staff during handling on the ward, during transport or processing at
laundry. Therefore safe handling of linen are required to prevent unnecessary exposure

4.3.3.13. Variable 2.3.13: We shake linen out to release dust from the linen (N= 195): As
per table 4.13 the large majority of participants n= 185 (95.4%)disagreed that they shake linen
out to release dust from the linen, while very few nurses n= 6 (3.1%) agreed that they shake
linen out to release dust from the linen. Fewer nurses n= 3 (1.5%) indicated that it is not
applicable to shake line out to release dust from linen.

The current study shows that n= 9 (4.6%) agreed that they shake linen out to release dust from
the linen hence posing a risk for transmission of infection. In this regard, Mathews (2015:1)
indicated that shaking soiled linen in the air can disseminate secretions, excretion and the
micro-organism they contain. Contamination of the environment and the people around
occurs.

4.3.3.14. Summary of the extent agreement on practices towards infection prevention

and control among nurses.
Figure 4.3 shows the extent agreement on practices towards infection prevention and control
among nurses. High or low level of agreement does not indicate a favourable answer. Each
variable is explained in section 4.3.3 above.

Figure 4.3. The results reflected within the graph below shows the extent of agreement
on practices towards infection prevention and control among nurses.
 (Y= Questions on practices 2.3.1.-2.3.13.)

3.3.3.15. Questions on practices

Feedback of responses on the y-axis of fig 4.2 referring to practice

2.3.1. 75.4% of the nurses agreed that they always wash hands before and afterdirect contact
with the patients.

2.3.2. 19% of the nurses agreed that they always put on a mask and glasses whenperforming
invasive procedures.

81
2.3.3. 79.5% of the nurses agreed that knowledge of infection prevention andcontrol are being
monitored in their hospital.

2.3.4. 8.7% of the nurses agreed that they attend in-service training/workshoprelated to
infection prevention and control yearly.

2.3.5. 51% of the nurses agreed that surgical operation sites are shaved withrazors.

2.3.6. 40% of the nurses agreed that the latest infection and prevention guidelinesdate is
between 2015 and 2013.

2.3.7. 50.3% of the nurses agreed that screening of patients is being done to
detectcolonisation even if no evidence of infection.

2.3.8. 15.8% of the nurses agreed that vaccination is provided to staff.

2.3.9. 39% of the nurses agreed that personal protective equipment (PPE) is alwaysaccessible.

2.3.10. 17.9% of the nurses agreed that their hospital monitors patients with urinarycatheters

for urinary tract infection and gives feedback on urinary tract infection rates.

2.3.11. 18.5% of the nurses agreed that infection prevention does not improvepatient outcome
which is incorrect.

2.3.12. 67.7% of the nurses agreed that they wear PPE when handling linen.

2.3.13. 3.1% of the nurses agreed that they shake linen out to release dust from thelinen.

4.4. GENERAL STATISTICAL ANALYSIS REGARDING THE THREE SET

VARIABLES AS STATED IN THE STUDY OBJECTIVES BELOW:

• To determine the knowledge of nurses in infection prevention and control within a

tertiary hospital in Nigeria.

• To determine the attitude of nurses in infection prevention and control within

a tertiary hospital in Nigeria.
• To determine the practices of nurses in infection prevention and control within a
tertiary hospital in Nigeria.

4.4.1 Descriptive statistics for the sample knowledge, attitudes and practices scores.
A summary of the descriptive statistics will be discussed which will be followed by graphic
representations of the distribution of the variable in figures 4.4.1 to 4.4.3

Table 4.14 below shows summary of descriptive statistics for the sample knowledge,
attitudes and practices scores.

Table 4.14: Descriptive statistic summary reflecting knowledge, attitude and practice
scores of nurses regarding infection prevention and control (n=196).

Knowledge score
% attitude_score practise_score
N Valid 196 195 195
Missing 0 1 1
Mean 83.2058 81.3675 48.8757
Median 83.3333 83.3333 46.1538
Std. Deviation 11.46272 10.82158 16.99165
Minimum 25.00 41.67 15.38
Maximum 100.00 100.00 92.31

The knowledge score show a mean of 83.33 a mean of 83.20 with a SD of 11.46 in a range of
25-100 where the minimum was 25 and the maximum was 100. It therefore indicate that
nurses has adequate knowledge on infection prevention and control.

The attitude score show a mean of 81.36 and a median of 83.33 with a SD of 10.82 in a range
of 41.67-100 where the minimum is 41 and maximum 100. It therefore indicate that the
nurses has positive attitudes towards infection prevention and control.

The practice score show a mean of 48.87 and a median of 46.15 with SD of 16.99 in a range
of 15.35-100 where the minimum is 15.35 and the maximum 100. It therefore indicate that
the nurses’ practices was poor with regard to infection prevention and control.
The distribution of the knowledge score on infection prevention and control shows a normal
distribution.

The figure 4.4.2 that follows shows the distribution of attitudes scores among nurses in
infection prevention and control.

Figure 4.4.2 Graphic representation of the distribution of the distribution of attitudes

scores
The distribution of the attitude score on infection prevention and control has a normal
distribution with N=195, mean 81.37 and SD=10.82.

The figure 4.4.3. that follows shows a graph of the distribution of practice score among
nurses in infection prevention and control. Based on the graph the mean attitude score
(48.88),

Graph 4.4.3 Graphic representation of the distribution of practice sores among nurses
in infection prevention and control

The distribution of the practice score on infection prevention and control has a normal
distribution with N=195, mean 48.887 and SD=16.99.

4.5 ASSOCIATION BETWEEN THE VARIABLES KNOWLEDGE,

ATTITUDES AND PRACTICES
The table 4.15 that follows, shows that the association between knowledge and attitudes is
0.136. The association between attitudes and practices is 0.23 while the association between
practice and knowledge is 0.09 .

Table 4.15: Association between the knowledge, attitudes and practice

Knowledge
VARIABLES score % attitude_score practise_score

Knowledge score
% Pearson Correlation 1 .136 .009

Sig. (2-tailed) .058 .905

N 196 195 195

attitude score Pearson Correlation .136 1 .227**

Sig. (2-tailed) .058 .001

N 195 195 195

practise score Pearson Correlation .009 .227** 1

Sig. (2-tailed) .905 .001

N 195 195 195

If the level of significance is 0.05 or less, the compared group is considered to be

significantly different (Burns & Grove, 2011:377)

4.6. SUMMARY OF RESEARCH FINDINGS

This chapter presents and describes the research data that was collected during the study. The
variables regarding knowledge, attitudes and practices of nurses with reference to infection
prevention and control were investigated and results analysed.

The findings analysed were presented in tables, histograms and graphs in order to interpret
the data collected.

4.7. CONCLUSION
Based on the study findings it was evident that nurses were knowledgeable in infection
prevention and control. The mean score for knowledge among nurses in infection prevention
and control were 83.21 and median; 83.33. The scores for attitude among nurses in infection
prevention and control were as follows; mean;81.37 and median; 83.33. Therefore nurses had
positive attitudes towards infection prevention and control. The scores for practices among
nurses in infection prevention and control were as follows; mean; 48.88 and median; 46.15.
Based on the mean and median practice scores among nurses in infection prevention and
control, it is evident that nurses had poor practices. All scores were found to be plausibly
normally distributed, and parametric correlation coefficients (Pearson’s correlation) were
calculated to assess the correlation between the three scores of knowledge, attitudes and
practices of infection prevention and control. The association between knowledge, attitude
and practice is not significant. The study results will be discussed in-depth in relation to the
objectives in chapter 5.
 CHAPTER 5
DISCUSSION, CONCLUSION AND RECOMMENDATION

5.1 INTRODUCTION
Within this chapter, the study findings will be discussed in terms of the study aim and
objectives along with the conceptual framework, study limitations, future recommendations
and the conclusion of the research study.

5.2 DISCUSSION
The aim of the study is to determine the knowledge, attitude and practices of nurses regarding
infection prevention and control within a tertiary hospital in Nigeria. Infection-related
diseases are still the main cause of death in Nigeria according to the 2013 health profile
acquired by World Health Organization (WHO) statistics.
According to WHO (2016:1) a huge gap still exists between the knowledge accumulated over
the past decades and implementation of infection control practices. This gap is even deeper in
poor-resource settings with devastating consequences. Every advance and investment in
health care is undermined by breaches in infection control measures (WHO, 2016:1).

The current study revealed that 76.4% (table 4.13) of nurses did not receive appropriate
vaccination regarding infection prevention and control. Furthermore, 61% (table 4.13) of the
nurses indicated that personal protective equipment is not always accessible. Therefore, both
patients and nurses are exposed to hospital acquired infections. The researcher has observed
that nurses do not apply infection prevention and control measures in the hospital setting
which is required to ensure patient safety. In agreement with the current study, 23.6% (table
4.13) of the nurses indicated that they do not wash their hands before and after direct contact
with the patients. According to WHO the prevalence of hospital acquired infection (HAI) in
Nigeria/Africa is high. However, 42.1% (table 4.13) of the nurses of the current study
indicated that screening of patients to detect colonization even when there is no evidence is
not done at the tertiary hospital. These findings are in agreement with Razine, Azzouzi,
Barkat, Khoudri, Hanssouni, Chefchaouni and Abouqua (2012:1) who determined the
prevalence of HAI in the University Medical Center of Rabat, Morocco. The study revealed
that HAI prevalence was 10.3%. Urinary tract infection
was the most common (35%) and 34.5% of hospital acquired infection were from critical care
units. However, 83.1% (table 4.13) participants of the current study revealed that the hospital
does not monitor patients with urinary catheters for urinary tract infections. Razine et al.
(2012:1) further revealed that Staphylococcus was the organism most commonly isolated
18.7% and was methicillin- resistance in 50% of cases. Stubblefield (2014:1-9) define
nosocomial infections as an infection acquired in a hospital or other health-care facilities
within 48 hours after admission that showed no signs of active or incubating infection.
Moreover, the patient could have presented with a different disease other than the infection
acquired in the hospital. These infections occur up to 3 days after discharge as well as 30 days
after an operation (Stubblefield, 2014:1-9). Determining knowledge, attitudes and practices in
infection prevention and control among nurses is vital to protect patients from acquiring
hospital acquired infections.

A descriptive, research design with a quantitative approach was applied to determine the level
of knowledge, attitudes and practices of nurses regarding infection prevention and control
within a tertiary hospital in Nigeria. The population for the study was nurses working in
clinical environment at a tertiary hospital in Nigeria. 312 nurses were the total population of
nurses at this tertiary hospital of which n= 140 (70%) were registered nurses, n= 80 (56%)
enrolled nurses, n= 47 (33%) registered midwives, n= 23 (16%) enrolled midwives, n= 10
(7%) certified midwives and n= 12 (8%) registered mental health nurses. According to table
3.1, n= 31 nurses participated in the pilot study (10% of N= 312) while n= 196 nurses
participated in the main study (70% of N= 281). The sampling method that was utilized in this
study was stratified simple random sampling. This method of sampling enabled the study
population to have an equal and independent chance of appearing in the study sample. Upon
completion of data collection, data was coded and captured on to excel spreadsheet as advised
by a qualified statistician employed by The Biostatistics Unit, Centre for Evidence Based
Health Care, Stellenbosch University. The statistician was further consulted for data analysis.
A statistical package (IBM SPSS version 22) was used to statistically analyse data. Data was
analysed and reported on by using descriptive and inferential statistics, such as frequency
tables
and relative frequencies, and graphically illustrated by using bar charts. Continuous variables
were summarised, using means and standard deviations.

5.3 LIMITATIONS OF THE STUDY

This study assessed the knowledge, attitude and practices of all categories of nurses in
infection prevention and control at federal government hospital,Maiduguri, which may limit
the generalisation of the findings to other hospitals in Nigeria.
5.4 CONCLUSIONS
Despite the nurses being knowledgeable (mean score 83%) and having a positive attitude
(mean score 81%) towards infection prevention and control the practices were very poor
(mean score 48.8%). However if nurses are knowledgeable and have a positive attitude
towards infection prevention and control, then the practices of nurses are expected to be good.

Furthermore, according to Florence Nightingale’s Environmental theory, the nurse plays an

important role in the translation of knowledge, attitude and practices to the clinical
environment, it is concluded that the patients are exposed to infection related diseases due to
poor infection prevention and control practices.

As a result of these findings the researcher has concluded that there could be barriers to good
practice in infection prevention and control which require further
research. In conclusion, the research question “what is the knowledge, attitudes and practices
of nurses in infection prevention and control at hospitals in Nigeria?” has been adequately
addressed in this setting.

5.5 RECOMMENDATIONS FOR FUTURE PRACTICE

Based upon the scientific evidence generated during the study, the following
recommendations are discussed below:

• The Minister of Health to lobby for sufficient funds from the government so that the
Permanent Secretary can allocate enough resources specifically for Infection
Prevention and Control. The economic recession that began in 2007 led to austerity
measures and public sector cut breaks in many European countries. Reduced resource
allocation to infection prevention and control (IPC) programmes is impeding
prevention and control of tuberculosis, HIV and vaccine-preventable infections. To
mitigate the negative effects of recession, there is need to educate our political leaders
about the economic benefits of IPC; better quantify the costs of health-care associated
infection; and evaluate the effects of budget cuts on health-care outcomes and IPC
activities (O’Riordan & Fitzpatricck, 2015:340-345)
• Permanent Secretary to ensure that the resources allocated for infection prevention and
control are not deviated to other things. This can be achieved by performing random
infection control spot checks of the hospitals.

• Resources should be allocated for Infection prevention and control conferences locally
and internationally. This will enable infection control team/committee to attend such
conferences so that they are updated with the latest evidence-based information.
According to the current study, (Variable 2.3.4) n= 169 (86.7%) of the nurses
indicated that they do not attend in-service training/workshops related to infection
prevention and control.

• Nursing schools should emphasise the importance of infection prevention and control
(Hospital acquired infections) in the syllabus. Ojulong, Mitonga and Lipinge
(2013:1071-1078) assessed students’ knowledge and attitudes of infection prevention
and control and their sources of information. The studyrevealed that medical
students had better overall scores 73% compared to nursing students 66% and
radiology students 61%. The study indicated that serious efforts are needed to improve
or review curriculum so that health science students’ knowledge on infection
prevention and control is imparted early before they are introduced to the wards.

• The General Nursing Council of Nigeria has introduced a Continuous Professional

Development Booklet for Nurses. The researcher recommends that training on
infection prevention and control be mandatory yearly and that it should be a
requirement for yearly nursing registration.

• The General Nursing Council of Nigeria through Ministry of Health should facilitate
training of trainers in infection prevention and control (IPC) for all health care centers
in Nigeria so that in-service training in IPC is provided to health care workers at the
institutional level. According to the current study (variable 2.3.6), n= 53 (27.2%) of
nurses indicated that the latest infection control and prevention guidelines date is not
between 2013-2015, while n= 64 (32.8%) indicated that it is not applicable to know
the latest guidelines.

• The General Nursing Council of Nigeria should come up with a policy indicating that
all nurses should be up to date with immunisation (Hepatitis B Vaccine) for
prevention of infection prior to registration. This will ensure compliance. The current
 study (variable 2.3.8) revealed that n= 148 (76.4%) of the nurses indicated that
vaccinations regarding infection prevention are not provided to staff, while 7.7%
thought it is not applicable.

• The infection control committee should be more proactive so that they can be able to
monitor the rate of Hospital Acquired infections as well as giving feedback to nurses
and relevant authorities. This will make problems visible and hence actionable. The
current study (Variable 2.3.10) revealed that n= 154 (79%) of the nurses who
participated in the study indicated that monitoring patients with urinary tract infection
and giving feedback on urinary tract infection rates is not done at their hospital

• Availability of personal protective equipment required for applying infection control

measures at all the times. According to the current study (variable 2.3.9), n=119 (61%)
of the nurses indicated that personal protective equipment are not always accessible.

• The institutions where the research study was done should ensure adequate facilities
for hand hygiene. For example hand basins with running water available as well as
disposable hand towels. This will help with compliance with hand hygiene. A study
conducted by Mearkle, Houghton, Bwonya and Lindfield (2016:1-6) in which current
hand washing practices, barriers to hand washing and available facilities in two
Ugandan Specialist eye hospital was assessed. The study revealed that facilities for
hand washing were inadequate in some key areas having no provisions for hand
hygiene. The study indicated that interventions to improve hand hygiene could include
increased provision of hand towels and running water as well as improve staff
education to challenge their views and perceived barriers to hand hygiene.

• The Tertiary Hospital should ensure that new members of staff (nurses) receive in-
service training in infection prevention and control as part of induction. The current
study revealed that 86.7% of nurses did not attend inservice training/workshop related
to infection prevention and control yearly.

5.5.1 Observation of nurse’ practice and correction of poor practice

According to the current study, it is evident that the practices of nurses in infection prevention
and control (mean score of 48.8) were poor. Therefore the infection control team should
strictly observe nurses as they practice. This includes auditing of hand hygiene practices,
observe the nurses as they perform invasive procedures, a procedure that requires aseptic
technique, isolation of infectious conditions to prevent the spread of infection and application
of barrier nursing. According to Gastmeier, Behnke, Reichardt and Geffers (2011:207-212),
hospitals should compare their own infection rates and find problems concerning specific
infection type which should motivate for a careful investigation of procedures of care and the
alternatives to improve the situation. Therefore, surveillance plans designed according to
exact requirements of the hospital are key component of good infection
5.5.2 Provision of vaccination to all health workers regarding infection prevention and
control e.g. Hepatitis B Vaccine
It is evident that, during the current study, most nurses (Table 4.5) indicated that they did not
receive vaccination regarding infection prevention and control. Hence a policy has to be
developed which will indicate the transmission of hepatitis B, the doses of Hepatitis B
Vaccine and complications of Hepatitis B infection. This standard operating procedure should
be made known and available to all health care workers and newly qualified nurses.

5.6 RECOMMENDATIONS FOR FUTURE RESEARCH

• Barriers affecting compliance to infection prevention and control measures among
nurses.

• The role of policy makers, stakeholders and government leaders in infection

prevention and control in a clinical setup.

• The impact of the shortage of nurses on infection prevention practices.

• The perceptions and knowledge of nurses against Hepatitis B vaccinations with regard
to infection prevention and control.

• The wrong usage of antibiotic and its impact on infection prevention and control.

5.7 CONCLUSION
Based on the findings, it is evident that lack of personal protective equipment is one of the
barriers to infection prevention and control (61%). The study further revealed that workshops
relating to infection prevention and control (IPC) are poorly organised as 86.7% of the nurses
did not attend workshops related to IPC yearly. Vaccination against preventable infections is
not a priority as 96.4% of the nurses did not receive any vaccinations. Therefore, it can be
concluded that nurses in the current study have a satisfactory level of knowledge and positive
attitude towards infectionprevention and control. However, the practice of infection
prevention and control scores were poor (Table 4.6), hence posing a risk of infection
transmission leading to increased rates of hospital acquired infections.
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QUESTIONNAIRE
SECTION A
Gender
Male [ ]
Female[ ]
Age group
20-29 [ ]
30-39 [ ]
40-49 [ ]
>50 [ ]
Marital Status
Single [ ] Married [ ] Other [ ]
Academic Qualification
FSLC [ ] WASSCE/GCE/NECO[ ]
OND/HND/BSC []MSC/PGD/PHD [ ]
OTHERS [ ]
Years of service
0-2years [ ] 3-5years [ ] 6-8years [ ]
9-11years [ ]
12-13years [ ] above 13years [ ]
Nursing Categories
RN [ ] EN[ ] RM[ ]
EM [ ] CM[ ] RMHN [ ]
Years practice
0-1[ ] 1-3[ ]
4 -10[ ] 10 and above years.[ ]
Employment status
Full-time [ ] Contract[ ] Agency[ ] Other [ ]
Years worked in current department
0-2 [ ]
2-4 [ ]
5-10 [ ]
>10 [ ]
SECTION B
Knowledge
Statements Agreed Disagreed Not
Applicable
Hospital acquired infection can be transmitted by
medical equipment such as syringes, needles,
catheters, stethoscopes, thermometers etc.
Nosocomial infection is an infection that the patient
comes with from home.
I know the worlds health organisation’s ‘5 moments of
hand hygiene.
Some instrument can be stored in an antiseptic solution
for up to36 hours.
If there is limited beds available, patients with
communicable diseases may be
Micro-organisms are destroyed by using clean water.
Bathing every day is a universal precaution.
Standard precautions apply to all patients regardless of
their diagnosis.
I am familiar with hospital-acquired infection
guidelines.
All staff and patients should be considered potentially
infectious.
You can handle body fluids with bare hands if gloves
are not available.
I know how to prevent and control hospital-acquired
infections.

ATTITUDES
Statements Agreed Disagreed Not
Applicable
I do not have to wash hands if I used gloves.
 Policies and procedures on infection control should be
adhered to at all times.
I should attend in-service training/workshop related to
infection prevention and control
regularly.
The workload affects my ability to apply infection
prevention guidelines.
I am aware that patients expect me to wash hands
before touching them and after
touching them.
I feel that infection control policies and guidelines are
enough in the hospital.
It is not my responsibility to comply with hospital-
acquired infection guidelines.
Infection prevention guidelines are important to this
hospital.
I have enough time to comply with infection
prevention guidelines.
I believe that following the prevention guidelines will
reduce rates of hospital-acquired
I should follow the procedure guidelines of the unit.
I feel that needles should be recapped after use and
before disposal.

Practices
Statements Agreed Disagreed Not
Applicable
I always wash hands before and after direct contact
with the patients.
I always put on a mask and glasses when performing
invasive and body fluid procedures.
Knowledge of infection prevention and control are
being monitored in the hospital.
I attend in-service training/workshop related to
infection prevention and control yearly.
Surgical operation sites are shaved with razors.
The latest infection and prevention guidelines date is
between 2015 and 2013.
Screening of patients is being done to detect
colonisation even if no evidence of infection.
Vaccination is provided to staff.
Personal protective equipment are always accessible.
Our hospital monitors patients with urinary catheters
for urinary tract infection and gives feedback on
urinary tract infection rates.
Infection prevention does not improve patient outcome.
We wear personal protective equipment when handling
linen.
We shake linen out to release dust from the linen.