Original Article

VOLUME: 39 | ISSUE: 4 | Dec 25, 2023 | PAGE: (161 - 167) | DOI: 10.24911/BioMedica/5-916

Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore


Authors: Amir aftab , Mansoor Ghani , Samina Kausar , Tanzeel Ur Rahman , Tahira Bibi , Gulnaz Bano


Authors

Amir aftab

MS Nursing Student, University of Health Sciences, Lahore, Pakistan.

Mansoor Ghani

Former Program Coordinator, Institute of Nursing University of Health Sciences, Lahore, Pakistan.

Samina Kausar

Head, Institute of Nursing University of Health Sciences, Lahore, Pakistan.

Tanzeel Ur Rahman

Nursing Instructor, Regional Training Institute Lahore Population Welfare Department, Lahore, Pakistan.

Tahira Bibi

Nursing Instructor, College of Nursing Government Teaching Hospital Shahdara, Lahore, Pakistan.

Gulnaz Bano

MS Nursing Student, University of Health Sciences, Lahore, Pakistan

Publication History

Received: April 24, 2023

Revised: August 19, 2023

Accepted: December 10, 2023

Published: December 25, 2023


Abstract


Background and objective: Severely ill patients are at a higher risk of carrying nosocomial infections especially when admitted to the intensive care units (ICUs). Therefore, it is the professional obligation of all health workers to adhere to the scientifically accepted criteria for infection control in clinical settings. This study was conducted to assess intensive care nurses’ adherence to standard precautions (SPs) and to assess the practices of SPs in intensive care.

Methods: This cross-sectional study was carried out at ICUs of two public sector hospitals in Lahore, Pakistan, from March to September, 2022. A total of 150 nurses were selected for the study who worked in the medical-surgical, general, and specialized ICUs. The extent to which the behavior of a worker coincides with the prescribed standard (Adherence) and performing work repeatedly till it becomes a routine competency (Practice) was assessed using a structured questionnaire. The chi-square test was used to determine the link between adherence to SPs and the practice carried out by nurses. Data were analyzed and a p-value ≤ 0.05 was taken as significant.

Results: A total of 84.7% of nurses showed adherence while practice was demonstrated by 52.7% of nurses. No significant correlation (p-value:0.95) was however found between the practice and adherence to the SPs, despite the fact that a notable gap was observed between the practice and adherence to SPs among ICU nurses.

Conclusion: It is concluded that a compromised adherence to SPs of infection control in ICUs of public sector hospitals in Lahore is exhibited by the nurses.


Keywords: Standard Precautions, Adherence, Practice, Critical Care Nurses, Hospital acquired infections, Health care associated infections, nosocomial infections


Pubmed Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano. Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore. BioMedica. 2023; 25 (December 2023): 161-167. doi:10.24911/BioMedica/5-916

Web Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano. Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore. https://biomedicapk.com/articles/online_first/916 [Access: April 21, 2024]. doi:10.24911/BioMedica/5-916

AMA (American Medical Association) Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano. Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore. BioMedica. 2023; 25 (December 2023): 161-167. doi:10.24911/BioMedica/5-916

Vancouver/ICMJE Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano. Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore. BioMedica. (2023), [cited April 21, 2024]; 25 (December 2023): 161-167. doi:10.24911/BioMedica/5-916

Harvard Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano (2023) Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore. BioMedica, 25 (December 2023): 161-167. doi:10.24911/BioMedica/5-916

Chicago Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano. "Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore." 25 (2023), 161-167. doi:10.24911/BioMedica/5-916

MLA (The Modern Language Association) Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano. "Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore." 25.December 2023 (2023), 161-167. Print. doi:10.24911/BioMedica/5-916

APA (American Psychological Association) Style

Amir aftab, Mansoor Ghani, Samina Kausar, Tanzeel Ur Rahman, Tahira Bibi, Gulnaz Bano (2023) Practices and Adherence of Nurses with Standard Precautions of Infection Control in Intensive Care Units of Public Sector Hospitals in Lahore. , 25 (December 2023), 161-167. doi:10.24911/BioMedica/5-916


Biomedica - Official Journal of University of Health Sciences, Lahore, Pakistan

Volume 39(4):161-167

ORIGINAL ARTICLE

Practices and adherence of nurses with standard precautions of infection control in intensive care units of public sector hospitals in Lahore

Amir Aftab1*, Mansoor Ghani2, Samina Kausar3, Tanzeel Ur Rahman4, Tahira Bibi5, Gulnaz Bano1

Received: 24 April 2023 First Revisions: 19 August 2023 Second Revisions: 16 November 2023 Accepted: 10 December 2023

Correspondence to: Amir Aftab

*MS Nursing Student, University of Health Sciences, Lahore, Pakistan.

Email: amiraftab1697@gmail.com

Full list of author information is available at the end of the article.


ABSTRACT

Background and Objective:

Severely ill patients are at a higher risk of carrying nosocomial infections especially when admitted to the intensive care units (ICUs). Therefore, it is the professional obligation of all health workers to adhere to the scientifically accepted criteria for infection control in clinical settings. This study was conducted to assess intensive care nurses’ adherence to standard precautions (SPs) and to assess the practices of SPs in intensive care.


Methods:

This cross-sectional study was carried out at ICUs of two public sector hospitals in Lahore, Pakistan, from March to September, 2022. A total of 150 nurses were selected for the study who worked in the medical-surgical, general, and specialized ICUs. The extent to which the behavior of a worker coincides with the prescribed standard (Adherence) and performing work repeatedly till it becomes a routine competency (Practice) was assessed using a structured questionnaire. The chi-square test was used to determine the link between adherence to SPs and the practice carried out by nurses. Data were analyzed and a p-value ≤ 0.05 was taken as significant.


Results:

A total of 84.7% of nurses showed adherence while practice was demonstrated by 52.7% of nurses. No significant correlation (p-value:0.95) was however found between the practice and adherence to the SPs, despite the fact that a notable gap was observed between the practice and adherence to SPs among ICU nurses.


Conclusion:

It is concluded that a compromised adherence to SPs of infection control in ICUs of public sector hospitals in Lahore is exhibited by the nurses.


Keywords:

Precautions, adherence, practice, critical care nurses, hospital acquired infections, nosocomial infections.


Introduction

Standard precautions (SPs) are a collection of guidelines intended to limit the threat of obtaining hospital-acquired contamination from both identified and unknown causes within healthcare settings and its goal is to safeguard healthcare personnel from percutaneous wounds and avoid the spread of nosocomial infections. It must be applied to all patients being treated in all hospitals, irrespective of whether an infectious agent is suspected or confirmed 1.

In hospitals around the globe, healthcare-related infections have become a problem nowadays. Acquisition of infections in hospitals affects an estimated 1.4 million individuals worldwide 2. In comparison to industrialized countries, the risk of hospital-acquired illness has increased significantly in developing countries 3. According to a recent study, hospital-acquired illness is 5 times more common in developing countries. In underdeveloped nations, the rate of device-associated infection ranges from 8.2 to 16.1 per 1,000 device-exposed days 2.

The Center for Disease Control established universal precautions as a new prevention approach called "standard precaution" in 1996. The two goals of SPs are to safeguard healthcare personnel from the occurrence of percutaneous wounds and to avoid nosocomial infection spread. Hand hygiene, routine working habits, and the use of individual protective equipment (using rubber gloves, gown, mask, face shield, or eye protection as per the anticipated exposure) are all examples of SPs 4.

In healthcare environments, health personnel are open to a range of occupational dangers, such as biological, chemical, ergonomic, physical, and stress/violence. Blood-borne infections including hepatitis B and C virus, and the human immunodeficiency virus pose the greatest risk to healthcare workforces, predominantly those who are dealing with blood and body fluids or come across sharps or needle stick injuries while caring for patients 5.

Hence, this study aims to assess practice and adherence to standard precautionary measures of infection control among nurses working in intensive care units. It has the potential to yield data that will promote the understanding and importance of SPs with a strong positive attitude, which will prevent nurses, patients, and all medical staff from getting infected and will decrease healthcare costs by enhancing the standard of nursing practice regarding hospital infection control.


Methods

This cross-sectional study was conducted at the University of Health Sciences (UHS) Lahore, Pakistan, with the collaboration of ICUs of Jinnah Hospital and Sheikh Zaid Hospital, Lahore, from March to September, 2022. Data were collected from 150 ICU nurses selected by simple random sampling technique according to the inclusion criteria, i.e., nurses involved in direct patient care working in tertiary care hospital medical-surgical, general, and specialized ICUs. Nurses having a minimum of 1 year or above working experience in the ICUs of local or foreign hospitals were included. Head nurses or nurse managers or those nurses who were not involved in direct patient care at the ICUs were excluded.

A structured questionnaire 6 was used to collect data for adherence, i.e., the extent to which the behaviors of a worker coincide with the prescribed standards 7 and practice, i.e., to perform work repeatedly so as it becomes a routine competency 8 of ICU nurses to standardized precautions of infection control, i.e., a set of practices carried out while dealing with all patients irrespective of infection status to prevent infections, which is centered on the belief that every blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes can potentially transmit contagious agents 9. The subjects were guided for proper understanding and response to the questionnaire according to their own experience and knowledge. The confidentiality and anonymity of the respondents were maintained according to the declaration of Helsinki. The study was approved by the Ethical Review Committee of the UHS, Lahore, and written permission from the Medical Superintendent of both hospitals was taken before conducting the study.

Statistical Analysis: The data were analyzed using Statistical Package for the Social Sciences (SPSS) 23.0. Mean and standard deviation were calculated for the age and frequency and percentage was given for the gender, qualification, experience, adherence, and practice status. The chi-square test was used to determine the association between adherence to SPs and the practice of SPs among nurses. A p-value ≤ 0.05 was taken as significant.


Results

The demographic profile of the participant nurses is given in Table 1 which shows that the majority (94.7%) of nurses were females with a comparable number of nurses with Diplomas and Bachelors of Science in Nursing (BSN) Generic or Registered nurses (Post RN BSN).

Descriptive statistics related to the questionnaire for “Adherence” to the standard precautions’ are shown in Table 2 which depicts that most of the nurses (76%) practice hand washing immediately after contact with potentially contaminated biological materials while 61.4% perform hand hygiene after removing the gloves.

The lowest value (33.3%) was observed for the knowledge regarding putting on the gloves while changing dressing.

Descriptive statistics related to the practice of SPs according to the validated checklist are shown in Table 3

Table 3 revealed that most of the nurses (95.3%) were washing hands before and after contacting the impaired skin of patients followed by 94.7% of nurses practicing hand washing or disinfecting techniques immediately after contacting blood, any other body fluid, secretion, or excreta. Only 50.0% of the respondents had a practice of hand washing after using second-hand sharps such as needles and blades.

Table 1. Socio-demographic characteristics of the nurses (n = 150).

Demographic variables Category Frequency Percentage
Age 21-30 years 88 58.7
31-40 years 54 36.0
More than 40 years 8 5.3
Gender Male 8 5.3
Female 142 94.7
Hospital Jinnah hospital Lahore 75 50
Sheikh Zaid hospital Lahore 75 50
Qualification Diploma in nursing 73 48.7
Generic BSN 40 26.7
Post RN BSN 37 24.7
Experience in ICU 1-5 years
5-10 years
More than 10 years
64
54
32
42.7
36.0
21.3

Table 2. Descriptive statistics of the questionnaire for adherence to SPs6.

S. No. Question Never Rarely Sometimes Often Always
1. I perform hand hygiene in the interval between providing care to different patient 3 1 10 40 96
2.0% 7% 6.7% 26.7% 64.0%
2. I perform hand hygiene after removing the gloves 4 4 11 39 92
2.7% 2.7% 7.3% 26.0% 61.3%
3. I wash my hands immediately after contact with potentially contaminated biological materials 0 0 12 24 114
0.0% 0.0% 8.0% 16.0% 76.0%
Frequency of glove use in procedures where there is a possibility of contact with potentially contaminated biological materials:
4. Blood collection 1 2 14 39 94
7% 1.3% 9.3% 26.0% 62.7%
5. Procedures involving the possibility of contact with urine or feces 1 2 21 32 94
7% 1.3% 14.0% 21.3% 62.7%
6. Procedures involving the possibility

of contact with the patient’s nonintegral skin

2 9 11 14 114
1.3% 6.0% 7.3% 9.3% 76.0%
7. Procedures involving the possibility of contact with the patient’s mucosa 3 5 18 37 87
2.0% 3.3% 12.0% 24.7% 58.0%
8. Procedures involving the possibility of contact with secretions of the

airway of patient

2 3 21 23 101
1.3% 2.0% 14.0% 15.3% 67.3%
9. Intramuscular or subcutaneous injection 0 4 15 25 106
0.0% 2.7% 10.0% 16.7% 70.7%
10. Dressing change 0 12 32 56 50
0.0% 8.0% 21.3% 37.3% 33.3%
11. Cleaning for blood and body fluid when there is possibility of contact with blood splash, body fluid, secretion, or excretion 2 5 15 17 111
1.3% 3.3% 10.0% 11.3% 74.0%
12. Venous puncture 0 1 11 25 113
0.0% .7% 7.3% 16.7% 75.3%
13. Contact with blood samples 2 4 25 47 72
1.3% 2.7% 16.7% 31.3% 48.0%
14. I use protective mask when there is possibility of contact with blood splash, body fluid, secretion, or excretion 1 2 24 31 92
0.7% 1.3% 16.0% 20.7% 61.3%
15. I wear protective glasses when there is a possibility of contact with blood splash, body fluid, secretion, or excretion. 1 0 13 23 113
0.7% 0.0% 8.7% 15.3% 75.3%
16. I use protective apron when there is possibility of contact with blood splash, body fluid, secretion, or excretion 19 15 17 35 64
12.7% 10.0% 11.3% 23.3% 42.7%
17. I use disposable hats and surgical shoe when there is the possibility of contact with blood splash, body fluid, secretion, or excretion 8 12 17 34 79
5.3% 8.0% 11.3% 22.7% 52.7%
18. I do not perform active encapsulation of used needles or perform passive encapsulation of needles with only one hand. 13 9 23 37 68
8.7% 6.0% 15.3% 24.7% 45.3%
19. Discard needles, blades, and other sharps materials in specific waste containers 17 15 26 24 68
11.3% 10.0% 17.3% 16.0% 45.3%
20. After work accidents with potentially contaminated sharping materials, immediately squeeze the site, then perform the antisepsis and put on a dressing 0 4 8 24 114
0.0% 2.7% 5.3% 16.0% 76.0%

Table 3. Descriptive statistics of checklist for practice of SPs (6,10).

S. No. Question Yes No
1. Washing hands/disinfecting hands if contacting with different patients 140 10
93.3% 6.7%
2. Washing hands/ disinfecting hands if taking off the gloves 131 19
87.3% 12.7%
3. Washing or disinfecting hands immediately if contacting any blood, body fluid, secretion, excretion, or dirty substances 142 8
94.7% 5.3%
92.0% 8.0%
4. Wearing gloves during blood collection 138 12
92.0% 8.0%
5. Wearing gloves during disposal of urine and stool 138 12
92.0% 8.0%
6. Wearing gloves while contacting the impaired skin of patients. 143 7
95.3% 4.7%
7. Wearing gloves during contact with the mucosa of patients 140 10
93.3% 6.7%
8. Wearing gloves when even not dealing with the patients. 85 65
56.7% 43.3%
9. Wearing gloves while giving intramuscular or subcutaneous injection 89 61
59.3% 40.7%
10. Wearing gloves during dressing change 134 16
89.3% 10.7%
11. Wearing gloves and apron during cleaning blood trace 133 17
88.7% 11.3%
12. Wearing gloves and apron during venous puncture 99 51
66.0% 34.0%
13. Wearing apron and gloves during contact with blood samples 119 31
79.3% 20.7%
14. Wearing gloves during recapping and reusing of syringes 84 66
56.0% 44.0%
15. Wearing protective gown in the procedures that might induce the spraying of blood, body fluid, secretion, or excretions. 112 38
74.7% 25.3%
16. Wearing protective cap or shoes to protect hair or shoes where necessary 119 31
79.3% 20.7%
17. Wearing face mask in the procedures as it might induce the spraying of blood, body fluid, and secretion 121 29
80.7% 19.3%
18. Wearing gloves and apron using second-hand sharps such as needles and blades 75 75
50.0% 50.0%
19. If the skin is injured by contaminated sharps, it is going to be thoroughly cleaned and taped up by nurse. 141 9
94.0% 6.0%
20. Wearing gloves while performing active encapsulation of used needles or passive encapsulation of needles with only one hand. 128 22
85.4% 14.6%

Applying the chi-square test, a comparison of adherence and practice of SPs among nurses was calculated (Table 4).

Table 4 depicts that there is no significant difference in the practice of SPs between the nurses with or without adequate adherence patterns. A total of 52.8% of nurses with adequate adherence to SPs had adequate practices while quite a similar number (52.2%) of nurses with adequate adherence to SPs had inadequate practices.

Table 4. Comparison of “Adherence” and “Practice” of SPs among nurses.

Adherence Practice p-value
Adequate Inadequate
Adequate 67 60 0.959
52.8% 47.2%

Discussion

Adherence is the extent to which someone follows an approved set of actions in accordance with a specified standard. In our study, the results regarding the level of adherence with the SPs show that 127 (84.7%) nurses have adequate adherence while only 23 (15.3%) nurses have inadequate adherence (Table 4). These results are parallel with the research conducted by Hessels and colleagues 11 where most of the nurses (94%) reported. On the other hand, our results are dissimilar from the outcomes of research carried out in Italy 12 which reported a lower level (15.3%) of adherence to SPs of nurses and documented a gap among health care providers regarding adherence with standard precautions. Frequent ongoing infection control training sessions on standard precautions and proper equipment availability within the hospital are the potential factors behind the higher percentage of nurses having adequate adherence 13.

Adherence to hand hygiene, in case of more likelihood of interaction with possibly contaminated biological materials, is a key precaution to prevent the spread of infection. The findings of this study reflect that 96% of nurses have adherence to standard precautions regarding hand hygiene, 92% and 76%, respectively, by removing gloves and after contact with biologically contaminated material (Table 3). The results of this study are congruent with that of research conducted for the assessment of knowledge and practice of medical students trained in the ICU at a Singapore hospital. A total of 66.3% of students demonstrated positive scores regarding practice and 48.9% had good knowledge about hand hygiene. On the other hand, our study results were different from the results of a Nigerian study 14 where only 45 % of nurses had adequate adherence to standard precautions regarding hand hygiene and used proper protocol in hand washing and putting gloves when handling blood samples, bandages, and venipuncture to control the spread of infection. This nonadherence to proper protocols leads to an increase in nosocomial infection rate. In our study, the results reflect that the nurses of the public sector have frequent training sessions on hand washing and hygiene by the infection control department of the respective hospital.

As per the results of the present study regarding the use of personal protective equipment (PPE), the usage of gloves has the highest percentage among all the nurses studied (ranging from 75% to 80 %), except when using intramuscular and/or subcutaneous injections for which only 70% of the nurses stated that they used the gloves and the lowest has been the usage of apron, which is merely 40%. These results were parallel with one previous study conducted in Misurata Teaching Hospital, Libya 15, where most of the nurses (67.8%) were adherent with the usage of all PPEs (gloves, mask, apron, and so on) to perform different procedures and also changed their gloves from patient to patient to prevent nosocomial infections. Another Nigerian study16, however, reported contrary findings where the majority of the healthcare workers were not adherent to the usage of PPE and complained of inadequate resources.

A task that is performed repeatedly, becomes a practice in nursing. In our study 79 (52.8%) nurses had adequate practice of standard precautions while 71 (47.2%) had inadequate practice. The practices of standard precautions in most of the developing countries remain either ineffective or nonexistent. Research has proved that the absence of knowledge is the major cause of noncompliance with the standard precautions 17. The outcomes of the current study were similar to the findings of one earlier study published 14 where 50 % of nurses had good practices regarding the application of protective measures. On the other hand, findings as reported by the investigators at Kyrenia University, Dr. Suat Günsel Hospital, Kyrenia, were not congruent to the present study which revealed the majority of nurses showed poor practices in using protective measures. The dearth of resources has been reported as a major factor for the failure to adhere to or practice in all the above-mentioned studies. Factors that negatively influence the practice of standard precautions are amendable through reinforcement and continuous education of the health care workers. s modification This refinement in standard precautions may subsequently play a pivotal role in the control of nosocomial infections within intensive care units ICUs at public hospitals in Pakistan.


Conclusion

A significant gap exists between the adherence and practice of standard precautions by the nurses working in ICUs at the public sector hospitals of Lahore city. The most influencing factor on adherence and practice of standard precaution was found to be the workload followed by the unavailability of protective devices.


Limitations of the Study

This study has several limitations. First, it was questionnaire-based data which has the potential of respondents’ bias. Interviews or in-depth analysis could be more reliable for reporting the findings. Second, a large sample size with the inclusion of more hospitals is needed to validate the findings of this study.


Acknowledgement

The authors would like to acknowledge the management and related staff of Jinnah and Sheikh Zaid Hospitals Lahore, Pakistan, for support in data collection. The authors would also like to thank Tahira Bibi, Assistant Nursing Instructor at the College of Nursing, Government Teaching Hospital Shahdra, Lahore, for her help in compiling the article.


List of Abbreviations

BSN Bachelors of Science in Nursing
ICUs Intensive care units
PPE Personal protective equipment
SPs Standard precautions
UHS University of Health Sciences

Grant support and financial disclosure

None to disclose.


Conflict of interest

None to declare.


Ethical approval

The study was approved by the Ethical Review Committee of the University of Health Sciences Lahore, Pakistan, vide Letter no. UHS/EAPC-22/ERC/22 dated 10-05-22.


Authors’ Detail

Amir Aftab1*, Mansoor Ghani2, Samina Kausar3, Tanzeel Ur Rahman4, Tahira Bibi5, Gulnaz Bano1

  1. MS Nursing Student, University of Health Sciences, Lahore, Pakistan
  2. Former Program Coordinator, Institute of Nursing University of Health Sciences, Lahore, Pakistan
  3. Head, Institute of Nursing University of Health Sciences, Lahore, Pakistan
  4. Nursing Instructor, Regional Training Institute Lahore Population Welfare Department, Lahore, Pakistan.
  5. Nursing Instructor, College of Nursing Government Teaching Hospital Shahdara, Lahore, Pakistan

Authors’ contributions

AA: Conception and design of the study, drafting of the manuscript, analysis and interpretation of data.

AA,MG: Conception and design of the study, data collection, and drafting of the manuscript.

AA,MG,SK,TB,TR, GB: Data collection, analysis and interpretation of data, and drafting of the manuscript with critical intellectual input.

All Authors: Approval of the final version of the manuscript to be published.


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