NURSING INTERVENTION FOR THE PROMOTION OF INFECTION CONTROL IN TWO TEACHING HOSPITALS IN OGUN STATE, NIGERIA

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ABSTRACT

Health care workers, particularly nurses are at risk of infection because they constantly come into contact with infected tissues, fluid, blood and blood products. By complying with infection control measures a lot of infections can be prevented. Some survey studies have been conducted in Nigeria on knowledge, perception attitude and practice of infection control and they concluded that there was inadequate adherence to infection control practices and this could be addressed by organizing training and retraining programmes. This study therefore examined the effects of a training programme in promoting infection control in two teaching hospitals in Ogun State.

The study adopted a pretest-posttest quasi experimental design.  The sample consisted of 87 participants. They were made up of experimental group which consisted of 42 registered nurses from Babcock University Teaching Hospital (BUTH). Ilishan-Remo, Ogun State. The control group was 45 nurses from Olabisi Onabanjo University Teaching Hospital. The training programme consisted of 4 modules on infection control. The programme lasted 4 weeks. The instruments used for data collection were Knowledge about Infection Control Questionnaire (r = 0.79); Perceptions about Infection Control Questionnaire (r = 0.80); Attitudes towards Components of Infection Control Questionnaire (r = 0.62); Practice of Infection Control Questionnaire (both self-reported and observation checklist) (r =0.62). Four research questions were answered and three hypotheses were tested at 0.05 alpha level. Data were analysed using descriptive statistics and Students’ T-test.

Findings showed that the mean age in the experimental group was 34.92 and SD 8.99 while the control group was 47.43 and SD 6.60. The mean for years of experience in the experimental group was 10.42 and SD 9.95 while in the control group was 21.89 and SD 8.72. On attitude, 30 participants (69.0%) had positive attitude in the experimental group compared to 21 participants (46.7%) in the control group. The mean difference was 4.02. On perception, 32 participants (76.0%) in the post intervention had good perception compared to nonein the control group. The mean difference was 8.36. On knowledge, 26 participants (62.9%) in the post intervention had high knowledge compared to none participant in the pre intervention. The mean difference was 7.24. On infection risk reduction in the intervention group, 28 participants (66.7%) have experienced sharp injury pre intervention and none post intervention. Significant differences were found between mean practice score of participants in the experimental and control (p = 0.001) and between self reported and observed practices (p = 0.000) but there was no significant difference between the mean knowledge score in the experimental and control group (p = 0.149).

The training programme was effective in improving the level of knowledge, attitude, perception and practice of infection control. Based on these findings, it is recommended that there should be adequate provision of facilities for infection control. Training and retraining should be organized for all nurses and other categories of healthcare workers to promote adherence to infection control.

       TABLE OF CONTENTS

Content                                                                                                              Page

Title Page                                                                                                          i

Certification                                                                                     ii

Dedication                                                                                                      iii

Acknowledgements                                                                                         iv

Abstract                                                                                                     v

Table of Contents                                                                                    vi

List of Tables                                                                                                            ix

List of Figures                                                                                   x

Appendices                                                                                                                 xi

List of Abbreviations                                                               xii                                                                                                                                                                   

CHAPTER ONE: INTRODUCTION

1.1    Background to the Study                                                              1         

1.2    Statement of the Problem                                                                  4

1.3    Objective of the Study                                                             5

1.4    Research Questions                                                                          5

1.5    Hypotheses                                                                                             6

1.6    Scope of the Study                                                                                   6

1.7     Significance of the Study                                                                   6

1.8    Justification for the Study                                                                  7

1.9    Operational Definition of Terms                                                             7

CHAPTER TWO: REVIEW OF LITERATURE

2.0    Introduction                                                                                               9

2.1    Overview of infection prevention and control                               9

2.2    Knowledge Attitude and Practice of Infection Control             13      

2.3    Standard Precautions                                                                     17

2.4    Empirical Studies on Infection Control Measures                                    22

2.5    Theoretical/Conceptual Framework Precede Model                              31

2.6   Appraisal of Literature Review                                                 34

CHAPTER THREE: METHODOLOGY

3.0   Introduction                                                                                                     36

3.1   Research Design                                                                      36

3.2   Population                                                                                            37

3.3   Sample size and sampling Technique                                                 38

3.4   Instrumentation                                                                                 42

3.5   Validity and Reliability of the Instrument                            43

 3.6 Data Collection Procedure                                                             44

 3.7 Method of Data Analysis                                                             46

 3.8 Ethical Consideration                                                                       46

CHAPTER FOUR: DATA ANALYSIS, RESULTS AND DISCUSSION

 OF FINDINGS

4.0:   Introduction                                                                                           47

4.1:   Demographic Data of Participants                                                    54

4.2:   Discussion ofEffects of Training Programme on Perception of Participants                55

4.3:   Discussion of Hypotheses                                                                         57

CHAPTER FIVE: SUMMARY, CONCLUSION AND

RECOMMENDATIONS

5.1:   Summary                                                                                             61

5.2:   Conclusion                                                                                    63

5.3:  Recommendations                                                                                63

5.4:   Limitation of Study                                                                64

5.5: Suggestion for Further Studies                                                                   64

REFERENCES                                                                                           65

APPENDICES                                                                                                 75

LIST OF TABLES

Table                                                                                           Page

3.1:  Sampling Distribution for Intervention Group                                   40

3.2:  Sampling Distribution for Control Group                                            41

4.1:  Demographic Data of Participants                                                          48

4.2: Descriptive statistics showing Effect of Training on Participants’ Attitudes in   the Experimental Group                                                                                                 49

4.3: Descriptive statistics showing Effects of Training on Participants’ perceptions  in the Experimental Group                                                                                              50

4.4: Descriptive statistics showing Effects of Training on Participants’ knowledge in   the Experimental group                                                                                                   51

4.5: Pre Intervention Responses of Participants on Exposure or Injury Experience in  Experimental Group and Control Group                                                                         51

4.6:Post Intervention Responses of Participants on Exposure or Injury Experience in Experimental and Control Group                                                                                  52

4.7: T-test Showing Differences between the Mean Knowledge Score of Participants in Experimental group and Control Group                                                                          53

4.8: T-test Showing Differences between the Mean Practice Score of Participants   in Experimental Group and Control Group                                                                         53

4.9:T-test Showing Differences between Self-reported and Observed Practices of Infection Control in the Experimental Group                                                                54

LIST OF FIGURES

2.1: The Chain of Infection                                                                                11

2.2: Precede Framework Adapted to Nursing Intervention to promote

Infection Control                                                                                            33

APPENDICES

I.                      Informed Consent

II.                    Questionnaire

III.                   Reliability of Instruments

IV.                   BUHREC Approval Letter

V.                    Letter of Introduction to the Teaching Hospitals

VI.                   Letter of Approval from OOUTH

VII.                 Training Programme for Participants

VIII-XI           Intervention Packages

XII.                 Pictures from Field Work

XIII                 Similarity Index (Turnitin)

LIST OF ABBREVIATIONS

BUTH-            Babcock University Teaching Hospital

CDC-              Center for Disease Control and prevention

CEU-               Continuous Education Unit

CHER-            Children Emergency

CMPC-            Community Medical Primary Care

COPD-            Casualty Outpatient Department

CSSD-             Central Sterile Supply Department

CVC-              Central Venous Catheter

HBV-              Hepatitis B Virus

HCV-              Hepatitis C Virus

HCW-             Healthcare Waste Management

HIV-               Human Immunodeficiency Virus

ICU-                Intensive Care Unit

NSIs-               Needle Stick Injuries

OOUTH-         Olabisi Onabanjo University Teaching Hospital

PEP-                Post Exposure Prophylaxis

PMTCT-          Prevention of Mother-to-Child Transmission

PRECEDE-     Predisposing, Reinforcing, Enabling, Constructs in

Educational Diagnosis and Evaluation

PPE-                Personal Protective Equipment

SP-                  Standard Precautions

WHO-             World Health Organisation

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Infection control is an aspect of healthcare delivery that deals with the curtailment of the spread of infection within the healthcare set-up, be it from patient-to-patient, patient-to-staff, staff-to-patients or staff to staff. According to World Health Organisation (WHO, 2011) the components of infection prevention and control are as follows: organisation, technical guidelines, human resources, surveillance, microbiology laboratory support, environment, evaluation and links with public health and other services. Organisation involves setting up a programme, formation of the infection control committee and inter-professional team, which should include physicians, nurses, microbiologists, epidemiologists, infection control specialists, information specialists and others. The committee must have a good working relationship with one another, because their work entails collaboration with other departments, staff and programmes. Technical guidelines involve developing, disseminating and implementing technical evidence-based information in preventing the risks of infection. Human resources involve training and re-training of health care personnel in preventing infections and the training of infection control professionals. It guarantees a pool of adequate staff responsible for infection prevention and control activities.

Surveillance is the tracking of demonstrated or suspected spread of infection. It involves the collection of data on epidemic and detection of outbreaks as well as the assessment of level of compliance with infection control practices, response to outbreaks and documentation of the situation of healthcare associated infection. Surveillance is important in that it causes early detection, identification, isolation and intervention, and results in effective infection prevention. Microbiology laboratory supports generate data, standardised laboratory techniques and promotes interaction between infection control activities. The environment refers to the minimum requirements for infection control. It includes water, ventilation, hand-hygiene equipment, placement of patient as well as isolation facilities, sterile supply storage, building conditions and renovation activities. Evaluation has to do with monitoring, assessment and report of infection prevention and control outcomes, processing and strategizing at national level and in healthcare facilities. It mirrors the impact of the infection control programmes. Links with public health and other services ensures proper coordination and collaboration between staff and departments in the events of mandatory reporting and activities such as waste management and sanitation, bio-safety, occupational health, patients and consumer’s care and the quality of health care (Hebden, 2015; Stempliuk & Eremin, 2015; WHO, 2011).

There are various sources of infections. Healthcare associated infections (HAI) are infections that develop in the course of healthcare and results in aggravating illnesses and may lead to deaths, extends the duration of hospital stay, and calls for more interventions at an added cost to the one already expended by the patient’s initial disease. Its occurrence is an indicator of the quality of patient care, adverse event and an issue of patient safety. The sources includes adverse drug events, surgical complications, microorganism isolates, antimicrobial resistance, decreasing trends in intensive care units, exogenous microorganisms such as bacteria, fungi, viruses, protozoan from other patients, endogenous flora of the patients- residual bacteria residing on the patient’s skin, mucous membrane, gastro intestinal tract, respiratory tract, inanimate environmental surfaces, contaminated objects, patient room touch, surfaces, equipment, medication, individual patient, medical equipment, devices, hospital environment, contaminated drugs and foods and hospital flora in the healthcare environment. Other sources include doctors’ white coats, nurses’ uniform, hospital garments, privacy drapes, stethoscopes, bed rails, common hospital surfaces, contaminated water, compromised immune system, negligence or poor attitude of hospital staff, hands of health care workers. It could be from patient to patient, patient to environment, staff to patient, renovation works in the hospital (Hans, 2012; Stubblefield, 2014; WHO, 2011).

Healthcare workers generally are at risk of infection, because they constantly come into contact with infected materials such as tissues, fluid, blood and blood products. There are several infection control measures aimed at controlling the spread of infectious diseases, such as hepatitis B and C, Human immunodeficiency virus (HIV) and other life threatening infections. Moreover, the hospital waste itself is a potential source of infection hence the need for proper infection control measures. It has been found that healthcare workers do not adhere strictly to the various infection control measures, probably because they do not recognise such, or they lack adequate knowledge, or could be due to poor attitude towards infection control measures, including non-availability of materials and equipment (Amoran & Onwube, 2013).In a study conducted at the Federal Medical Center (FMC), Gombe, in North Eastern Nigeria among nurses, it was found that some respondents were not aware that standard precautions is applied to all patients, and majority of the respondents have poor knowledge of the components of standard precautions (Saidu, Habu, Kever, Dathini, Inuwa, Maigari et al, 2015).

Standard precautions are infection control measures that are put forward by the United States Centre for Disease Prevention & Control (CDC), in 1996. By complying with standard precautions, a lot of infections can be avoided, such as occupational exposure to pathogens. While some health workers are familiar with the infection control measures, some are not. This may be due to lack of awareness or knowledge and moreover, the attitude that some who are familiar with the infection control measures, show towards practice is not encouraging. When one considers the importance of adequate knowledge and practice of infection control measures, by the healthcare workers, one cannot but think of what to do to improve on that knowledge and practice. Jain, Dogra, Mishra, Thakur and Loomba (2012), in their study among doctors and nurses in a tertiary care hospital, found that there is lack of knowledge and practice regarding basic infection control measures. This deficit in knowledge can be improved through educational intervention. Wasswa, Nalwadda, Buregyoya, Gitta, Anguzu and Nuwama (2015), in their study on implementation of infection control in health facilities in Uganda, found that with prior training on infection control, the respondents were more likely to wash their hands. Level of education and a prior nosocomial infection experience will have a role in the practice of infection control measures. In-service training on infection control measures will boost the practice of infection control measures.

Amoran and Onwube (2013) found that inadequate workers’ knowledge on infection control and environment related problems are crucial issues that need urgent attention. According to Gebresilassie, Kumei, and Yemane (2014) in their study, “there is suboptimal and inconsistent practice of standard precautions in the healthcare setting that put patients and healthcare workers at significant risk of acquiring infections”. They also emphasized the need for in-service training for the healthcare workers on infection control. Adly, Amin and Abd El-aziz, (2014) found that intervention influenced the compliance of nurses with infection control measures, because of the knowledge gained during the intervention or training programme. There is a standard of infection control measures that can guarantee infection safety among health workers and patients.

 1.2 Statement of the Problem

Healthcare workers generally are at risk of infection. WHO (2006), reported that among the 35million health workers worldwide, about 3 million sustain percutaneous exposures to the blood borne pathogens each year, including 2 million to Hepatitis B virus (HBV), 0.9 million to Hepatitis C virus (HCV) and 170,000 to Human Immunodeficiency virus (HIV). These injuries may result in 70,000 HBV; 15,000 HCV and 5,000 HIV infections. Nurses are at higher risk of being infected with blood-borne pathogens from clinical blood exposure through injuries with sharp instruments and needle-stick injuries if infection control measures are not strictly followed. This is because they are usually the first contact with a patient on arrival in the hospital and provide 24 hour patient care. Studies have also shown evidence of clinical nurses becoming infected due to occupational exposure (Centers for Disease Control & Prevention, 2012).  Abdulraheem, Amodu, Saka, Bolarinwa & Uthman (2012), in their study, among health workers in North Eastern Nigerian found that the level of knowledge and implementation of standard precautions is below standard to guarantee infection safety. They concluded that there is still much to learn and implement when it comes to infection control measures. 

Furthermore, in some health institutions, the researcher observed that some nurses do not adhere to the components of standard precautions while providing nursing care. For example, few nurses were observed not to wash their hand after removing gloves and before commencing another procedure. In some of the wash hand basins in the outpatient department, liquid soap is not available for health workers and patients to wash their hands. When blood or body fluids are spilled on the floor, the house keepers do not decontaminate with hypochlorite solution before mopping with soap and water. The health institutions infection control units are not well equipped to function effectively to ensure compliance to standard precautions. It is in the light of the gaps that the researcher became interested in planning a training programme on knowledge, perception, attitude and practice of infection control for nurses at Babcock University Teaching Hospital (BUTH), Ilisan-Remo, Ogun state.

1.3 Objective of the Study

The main objective of this study is to determine the effects of a training programme on infection control among nurses. The specific objectives are to:

NURSING INTERVENTION FOR THE PROMOTION OF INFECTION CONTROL IN TWO TEACHING HOSPITALS IN OGUN STATE, NIGERIA