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 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 21-28

A multicentric study to ascertain knowledge, attitude and practices for infection prevention and control amongst nurses

1 Department of Microbiology and Neuropsychopharmacology, Institute of Human Behaviour and Allied Sciences, Delhi, India
2 Department of Medicine, Guru Teg Bahadur Hospital, Delhi, India
3 Chief Quality Officer and Chief Executive Officer, Yashoda Super Speciality Hospital, Ghaziabad, Uttar Pradesh, India
4 Department of Microbiology and Director Office, Rajiv Gandhi Super Speciality Hospital, Delhi, India

Date of Submission22-May-2020
Date of Acceptance17-Jul-2020
Date of Web Publication4-Sep-2020

Correspondence Address:
Dr. Renu Gupta
Institute of Human Behaviour and Allied Sciences, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpsic.jpsic_10_20

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Background: Infection prevention and control (IPC) is the key component to curtail the spread of infections and combating rising antimicrobial resistance (AMR) amongst bacteria.
Objectives: The present study was conducted to assess the knowledge, attitude and practices (KAPs) for IPC amongst nurses.
Materials and Methods: A cross-sectional, multicentric, hospital-based survey was conducted on 328 nurses from January to November 2018 using a self-administered questionnaire from public and private quaternary-, tertiary- and secondary-level hospitals.
Results: The overall score for infection control practices was low, with knowledge score being 51%, attitude 73% and good practices score 57%. The gaps were identified across all components with major gaps in the knowledge of care of devices (74%), barrier nursing/isolation precautions (60%), indications of using hand rub (55%), understanding the meaning of healthcare-associated infections, AMR (50%) and optimum use of personnel protective equipment (44%). In attitude and practices, injection safety emerged as the weakest area, with >40% of nurses being neither aware nor practicing the correct techniques of reconstituting, administering injectable medicines and maintaining asepsis.
Conclusion: There is an urgent need of rigorous, regular, restructured, standardised training programmes focussing on the weak areas for nurses in healthcare settings. Training programmes need supervision and provision of enabling environment in healthcare settings to facilitate the implementation of evidence-based IPC guidelines.

Keywords: Healthcare-associated infections, infection prevention and control, knowledge, attitude, practices

How to cite this article:
Gupta R, Sharma S, Yadav A, Arora U, Bhattar S, Sherwal B L. A multicentric study to ascertain knowledge, attitude and practices for infection prevention and control amongst nurses. J Patient Saf Infect Control 2020;8:21-8

How to cite this URL:
Gupta R, Sharma S, Yadav A, Arora U, Bhattar S, Sherwal B L. A multicentric study to ascertain knowledge, attitude and practices for infection prevention and control amongst nurses. J Patient Saf Infect Control [serial online] 2020 [cited 2021 Jan 21];8:21-8. Available from: https://www.jpsiconline.com/text.asp?2020/8/1/21/294368

  Introduction Top

Healthcare-associated infections (HAIs) are the most common complications of unsafe hospital care and result in increased morbidity and mortality and escalation in the cost of treatment.[1] Impending fear of infections in hospitals is also the major determinant for overreliance on antibiotics for prophylactic, preventive and therapeutic use, thereby leading to increasing antimicrobial resistance (AMR).[2],[3] Infection prevention and control (IPC) is the key component to curtail the spread of infections and for combating rising AMR among bacteria.[1],[4] Simple IPC interventions play an unparalleled role in the reduction of infection rates, thereby decreasing the overall cost of treatment, morbidity and mortality in healthcare settings.[1],[5]

IPC has become even more relevant in the current pandemic due to SARS-CoV-2, and there is a threat of every patient becoming COVID-19 infected as the lockdown is withdrawn.[4] Many international and national healthcare organisations, professional associations, regulators and consumer advocacy groups have recognised sustained IPC activities as a cornerstone to achieve quality improvement in hospitals and as a core component for certification of health facilities.[6],[7] IPC has also been identified as a key priority (strategic priority 3) for combating AMR in the Global Action Plan as well as the National Action Plan to combat AMR (NAP).[8],[9] Initiatives such as Swatch Bharat Abhiyan (Clean India mission) and Kayakalp Award Scheme (Ministry of Health and Family Welfare, 2015) have kindled interest among hospital administrators to strengthen IPC by setting up of systems and policies and dedicating funds resulting in some perceivable improvement in cleanliness, hygiene and documentation.[10] However, sustained improvement in IPC requires rigorous efforts towards implementation of policies and guidelines through capacity building and behavioural modification of healthcare staff.[11]

Nurses are the largest workforce in hospitals and are in the unique position to improve the quality of patient care by serving as first-line defence for preventing and controlling the transmission of infections. It is a professional and ethical requirement that nurses have up-to-date knowledge and skills for preventing the transmission of infections and practice them safely and competently at all times.

Although several studies have been done globally to assess the levels of nurses' knowledge, attitude and practices (KAPs), some of the activities within IPC, especially palpating veins after antisepsis; mis/over/under use of personal protective equipment (PPE); non-adherence to isolation precautions; incorrectly collected, stored or handled patient specimens; injection safety – multidose vial handling and mixing the leftover drugs in ampoules have not received an equivalent amount of attention as the potential sources of infection spread such as hand hygiene, use of PPE and biomedical waste management (BMW).[12],[13],[14],[15],[16],[17],[18],[19],[20]

The present study was conducted to assess the gaps in the existing IPC practices using simulated clinical scenarios pertaining to KAPs of nurses working in public and private quaternary-, tertiary- and secondary-level healthcare facilities.

  Materials and Methods Top

Study design

A descriptive, cross-sectional, hospital-based survey was done.

Study settings

The study included nursing professionals from tertiary-, quaternary- and secondary-level hospitals. The sample size drawn was representative of the bed strength of each hospital. The study was conducted from June 2018 to November 2018. Only those nurses who were willing to participate in the study were included.

Study tool and scoring

A standard questionnaire comprising of 30 questions with 42 checkpoints was developed to elicit information of the nursing personnel about common IPC practices and validated through a pilot test on 44 nurses to determine the clarity of questions, effectiveness of instructions and time required to complete.

The questionnaire comprised questions on KAP domain. Knowledge questions consisted of 18 checkpoints with 5 points around general awareness about IPC, 5 points for isolation precautions, 4 points for appropriate use of PPE, 2 points for BMW and 1 each for hand hygiene and care of devices. The response to these was captured as true/false/don't know or choosing the most appropriate response from multiple options or choosing all the correct responses among multiple options.

Attitude questions consisted of 14 checkpoints to evaluate attitude towards patient care about well-established/known infection control principles in hospital settings. These checkpoints consisted of 5 points on correct practices while using PPE, 3 points each for needle-stick injury, 4 for injection safety and 2 for asepsis. The response to these was either captured by choosing the most appropriate response from multiple options or by choosing all the correct responses from multiple options.

Practice questions consisted of ten clinical scenario-based statements which were designed to evaluate nurses' perception of IPC practices in their work area. This domain consisted of four checkpoints concerning maintenance of asepsis, four for injection safety and two towards use/misuse of PPE. The response to these was collected on a 5-point Likert scale from 1 to 5 (always [1], frequently [2], sometimes (3), rarely (4), never (5)] with 5 depicting very good practices.

In addition, information pertaining to age, gender, qualification, year of working experience, area of work, nature of work and duties, working experience in infection control and any training in infection control was collected from all the participants.

Data collection and analysis

The questionnaire was self-administered and collected back on the spot after 20 min of distribution. Data were entered into MS excel spread sheet and analysed using the statistical software (BM® SPSS® Statistics, Chicago, USA), version 21.0. Descriptive statistics was applied, and the association between demographics and cumulative score was analysed by one-way ANOVA. P ≤ 0.05 was considered statistically significant.

The maximum score of KAP section was 18, 14 and 10, respectively, based on 1 score given for each correct response. The practice section was also evaluated by computing the mean score for each scenario with 5 being the maximum and 1 being the minimum score. To calculate the percentage of correct practices, the score of 1–4 was grouped together as wrong practices assuming them to be critical non-tolerant practices (scored 0) and 5 as correct practice (scored 1).

A score of <50% was considered poor, 50%–79% fair and 80% and above was considered good, as mentioned by Fashafsheh et al.[14]

  Results Top

A total of 358 questionnaires were distributed and 328 were collected back with 91% response rate. [Table 1], [Table 2], [Table 3] depict the KAPs about specific components of IPC, respectively. The overall score for knowledge was 51%. The knowledge score ranged from fair to poor in most areas of concern except for awareness of biohazard symbol where awareness was good (92%). The overall score in attitude was 74% with lowest scores in injection safety (69%). The overall good practice score was 57%, ranging from 38% to 73% with a total mean score of 3.8 ± 0.9 out of 5. There was no significant difference in KAP score by level of care provided or public/private healthcare facility.
Table 1: Nurses knowledge towards infection prevention and control

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Table 2: Applied knowledge of nurses towards infection prevention and control

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Table 3: Nurse practices towards infection prevention and control

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[Figure 1] and [Figure 2] depict the overall and site-specific KAP scores, respectively. Overall, KAP score was good only for 6%, fair for 65% and poor for 29% nurses. Only 9% of nurses scored above 80% (good) in knowledge section, with 47% scoring <50%. The score for attitude (36%) and practice (47%) section was good.
Figure 1: Nurses' level of knowledge, attitude and practices

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Figure 2: Site-wise knowledge, attitude and practices of nurses

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The demographic and professional details of the participants are depicted in [Table 4]. There was no difference in the demographic characteristics of the participants from different sites. There was no statistically significant association of any of the variables including working experience in infection control, training/course attended in infection control, area of work and working in private versus public or different levels of healthcare facility on the mean KAP score.
Table 4: Demographic characteristics and relationship with cumulative knowledge, attitude and practice score

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  Discussion Top

This multicentric study aimed to identify the critical gaps in the implementation of IPC practices amongst nurses working in different levels of health facilities. The overall KAP score was 60%, with the average score of knowledge being 51%, attitude 73% and practices 57%. The situation seems grim as nearly half of the nurses scored below 50% in knowledge section despite the increasing emphasis on training programmes amidst initiatives towards quality improvement in healthcare settings. Score was better in attitude as compared to knowledge, but still unacceptable as nearly one-third of the nurses scored poor in minimal requirements for IPC. More than 30% of nurses followed incorrect practices on one or more occasions despite realisation that these may be harmful to patients. Several studies published from India and outside have shown KAP scores varying from as low as 10% to as high as 90% depending on different study tools used, intensity of training and available infrastructure, indicating that this issue is widespread warranting national efforts.[11],[12],[13],[14],[15],[16],[17],[18]

Detailed analysis of the subsections to identify the major gap areas revealed that nearly 50% of the nurses did not know the meaning of HAI and AMR. More than half of the nurses misbelieved that any new-onset fever with deranged white blood cell count in a hospitalised patient is a confirmed HAI, and AMR means that the patient is resistant to drug rather than pathogen becoming resistant to drug. In addition, 40% of the nurses were not aware about the basic requirement of sample collection that the samples for culture should be collected before the initiation of antimicrobial therapy.

Hand rub is considered a substitute of hand washing, but more than half of the nurses were not aware of specific indications as when not to use hand rub. While hand hygiene has been extensively assessed in previous studies, indications for hand rub use have not been adequately evaluated earlier.[12],[14],[15],[17],[18] Hand rub though is very effective for destroying microorganisms, it is not effective in all circumstances.

Use of PPE was not fully understood. One-third of the nurses did not know that sterile gloves are not always required to attend to every patient care need and nearly 40% of the nurses believed that gloves are required for making patient bed and during patient transfer. More than 50% of the nurses believed that N95 masks are superior to surgical masks and if given to a patient with active tuberculosis will prevent the spread of infection leading to misuse of costly N95 mask. N95 is inconvenient for patients with already-compromised lung capacity.[21],[22] The participants revealed that it is quite a common practice for staff to roam around wearing PPE in common use areas such as corridors and staff rooms (40%) with masks lying in the nape of neck after use and reused as and when required (60%), leading to the spread of infections.

Similar to problems with PPE, the respondents had their own ideas and interpretation of requirements for isolation precautions and strict barrier nursing. More than half of the nurses believed that strict barrier nursing is required for handling HIV-positive patients and paradoxically, were unaware of its role in the prevention of transmission of drug-resistant pathogens. The reasons could be non-availability of isolation rooms in public sector and frequent turn over of nursing staff in private sector. Despite the widespread advocacy of routes of HIV transmission, exaggerated precautions were still taken for HIV patients.

Despite reasonable knowledge about the role of asepsis in preventing infections, injection safety emerged as a major area of concern with glaring gaps in the implementation of safe injection practices such as (1) palpating veins just after doing antiseptic cleaning before venepuncture,(2) keeping alcohol swabs pre-soaked in a bottle for subsequent injections, (3) doing venepuncture even before alcohol evaporates from the skin completely, (4) using one mixing needle to reconstitute several vials, (5) leaving needles in the septum of a multidose vial for subsequent drug withdrawals, (6) mixing of leftover medicines from multiple vials to complete the dose requirement of one patient, (7) adjusting antibiotic administration time as per convenience of the patient rather than adhering to the established time intervals required to maintain minimum inhibitory concentration of an antibiotic and (8) using sterile items even if they get contaminated.

Awareness about recent changes/advances in infection control practices was low. Day-to-day management of the devices such as intravenous lines, central lines and ventilator tubings is important to assess patency (that the device is open and unrestricted) and to detect any signs or symptoms of infection. Almost three-fourth of the nurses did not know the current indications for replacement of peripheral intravenous catheters, which require change only when there are local signs of inflammation or malfunction and they continue the practice of replacing catheter every 72 h.[23] Furthermore, half of the nurses did not know that the current BMW guidelines (2016) recommend discarding of blood bags in yellow liners after pre-treatment and continue discarding in red liners according to older policy.[24] These gaps between evidence and implementation were expected as IPC is a dynamic field, but it is equally important for healthcare workers to keep updated and align practice with emerging evidences and regulatory requirements.

No association of KAP was observed with demographic characteristics including previous trainings on IPC, work area, private versus public and level of healthcare facility (tertiary and quaternary care hospitals or secondary care level), unlike other published studies.[13],[18]

Most of the nursing practices have been adopted or copied from peers (right or wrong) and are deeply inculcated. Occasional training programmes are insufficient to address these misbeliefs. Non-structured, short-term random trainings (a session or 1- or 2-day programmes) without supervision can at best serve as a sensitiser but cannot bring sustainable behavioural changes and skill upgradation for patient safety and IPC. There is a urgent need of structured approach for aptitude enhancement of nurses based on baseline competency assessment and orientation, in-service training, refresher trainings and supervision.

In addition to training, deep insight and brainstorming is required to bring in human factor engineering to understand barriers towards implementation of well-known safe practices. Disciplinary actions may be needed in special circumstances in order to achieve minimum tolerable infection rate in developing countries.

  Conclusion Top

Nurses in all roles and settings can demonstrate leadership in IPC by using their knowledge, skills and judgment to initiate appropriate and immediate infection control measures. There is an urgent need of rigorous, regular, restructured, standardised training programmes focussing on the need–gap analysis in all healthcare settings. Training programmes need supervision and provision of enabling environment to facilitate the implementation of evidence-based IPC guidelines. Investments in building and nurturing nurse's competence and enthusiasm by educational interventions, certifications, appreciation and bringing in role models are important viable solutions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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