RESEARCH doi: 10.1111/nicc.12078

Infection control practices among intensive care unit registered nurses: a Jordanian national study Omar M AL-Rawajfah ABSTRACT Aims: This study aimed to evaluate infection control (IC) practices among Jordanian registered nurses (RNs) working in intensive care unit (ICU) settings. Background: The Centers for Disease Control and Prevention (CDC) recommends periodic assessment of IC practices for health care workers as an effective strategy to control infections. Design: Cross-sectional descriptive design. Methods: A stratified, cluster random sampling technique was used. The sample consisted of ICU RNs from all major health care service providers and from all geographical areas in Jordan. The IC-Practices Tool (Cronbach α = 0·88) a self-report instrument was used. Results: A total of 21 hospitals participated in the study, of which, 8 were governmental, 7 military, 4 private and 2 university-affiliated. The final sample consisted of 247 RNs from 56 critical care units. Of the total sample, 36% of RNs were from governmental hospitals. Of the total sample, 51% were female with a mean age of 28·5 years (SD = 5·2), and 54·7% worked in general ICUs. The mean overall IC practice score was 122·6 (SD = 13·2). Nurses who reported that they had been trained about IC procedures in their hospital scored higher on the IC practice scale (M = 124·3, SD = 12·3) than nurses who never received any IC training in the hospital (M = 117·3, SD = 14·6, p < 0·001). Conclusion: This study demonstrated the importance of conducting IC educational programmes as an effective strategy to increase staff compliance with standard IC practices. Relevance to clinical practice: Educational role of IC nurse is important to enhance RNs compliance with standard IC practices. Key words: ICU infections • Infection control practices • Infection prevention • Staff education • Standard precautions

BACKGROUND AND AIMS OF THE STUDY Health care-associated infections (HCAIs) are a major challenge for hospitals, especially in intensive care units (ICUs). Studies have demonstrated that the prevalence of HCAIs in ICUs is greater than in other units (Suljagic et al., 2005; Nagao, 2013), resulting in a substantial increase in hospital mortality, (Ylipalosaari et al., 2006; Al-Rawajfah et al., 2009; Al-Rawajfah et al., 2012; Nagao, 2013) length of stay and overall cost (Al-Rawajfah et al., 2012; Al-Rawajfah et al., 2013b). Exposure to pathogenic microorganisms by seriously ill patients with impaired immunity, and invasive procedures for ICU patients are factors associated with

Author: OM AL-Rawajfah, RN, PhD, Assistant Professor of Acute Care Nursing, Faculty of Nursing, AL AL-Bayt University, Mafraq, Jordan Address for correspondence: OM AL-Rawajfah, Assistant Professor of Acute Care Nursing, Faculty of Nursing, AL AL-Bayt University, P.O. Box 130040, Mafraq 25113, Jordan E-mail: [email protected]

© 2014 British Association of Critical Care Nurses

the increased risk of HCAIs in the ICU (McCusker et al., 2002; Gastmeier et al., 2007; Vandijck et al., 2010; Venet et al., 2011). The problem of HCAIs becomes more challenging in developing countries such as Jordan (AL-Rawajfah et al., 2013a). A 2008 report suggests that the incidence of HCAIs in developing countries is approximately five times higher than international standards.(Rosenthal, 2008) Jordan is a Middle Eastern country with a population of about 6 million and an estimated per capita income in 2011 of 4624 USD (Jordanian National Department of Statistics, 2010). The Ministry of Health budget in Jordan comprises 6·3% of the total national budget (The Hashemite Kingdom of Jordan Ministry of Health, 2011). Health care services are primarily provided through the Ministry of Health, the military and private and university-affiliated health care facilities. Few studies have been conducted in Jordan regarding infection control (IC) practices among health care workers (Qudeimat et al., 2006; Al-Dwairi, 2007). 1

A Jordanian ICU study

However, none has targeted registered nurses (RNs) in critical care units as an independent population. Numerous studies have demonstrated that educating health care workers about proper practices of IC results in a substantial decrease of HCAIs (Berenholtz et al., 2004; Warren et al., 2004, Lobo et al., 2005; Labeau et al., 2009). The Centers for Disease Control and Prevention (CDC) recommends periodic assessment of IC practices among health care workers as an effective strategy to control HCAIs (O’Grady et al., 2002). Different methods have been used to assess IC practice among ICU staff, including self-report (Kennedy et al., 2004; Verdier et al., 2006; Labeau et al., 2009; Parmeggiani et al., 2010) and observational methods (Creedon, 2008; Chau et al., 2010; Korniewicz and El-Masri, 2010). The purpose of this national study was to evaluate IC practices among Jordanian staff nurses working in critical care areas.

METHOD AND SAMPLING For the purpose of this study, an intensive care unit (ICU) was conceptually defined as: ‘section within a hospital that looks after patients whose conditions are life-threatening and need constant, close monitoring and support from equipment and medication to keep normal body functions going’ (The Intensive Care Society, 2013). Operationally, critical care unit was defined any unit from the following list: general ICU, neonatal intensive care unit (NICU), burn ICU, cardiac care unit, cardiac catheterization, intermediate care unit and recovery unit. A group of three doctorally prepared critical care nurses validated and agreed on this operational definition. This study is part of a larger Jordanian national study that aimed to evaluate the compliance of RNs with IC guidelines. The design was cross-sectional and descriptive. A stratified, cluster, random sampling technique was used to obtain the final sample. Geographically, Jordan was divided into North, Middle and South regions. Complete list of hospitals in each geographical area was established. In each region, hospitals were also stratified according to the health care providers (governmental, military, private and university affiliated hospitals). The total sampling frame consisted of 103 hospitals of which 29·1% were governmental, 10·7% military, 58·3% private and 1·9% university affiliated hospitals. Randomly, 21 hospitals were selected to participate in the study from all types of health care provider and from all geographical areas. A 10% simple random sample was obtained from the total RNs in each of the selected hospitals. The hospitals with fewer than 60 beds were excluded to ensure the availability of adequate numbers of 2

RNs on the duty schedule. Institutional Review Board approval was obtained from each of the participating hospitals as well as from Al al-Bayt University. Moreover, participating nurses were asked to give their consent before completing the required data collection forms.

INSTRUMENT AND DATA COLLECTION This study adopted a self-report instrument to assess IC practices among ICU nurses. The IC-Practices Tool (ICPT) was developed through an in-depth literature review regarding IC practices. The original version of the instrument was used in various international studies (Askarian et al., 2004; Askarian et al., 2005; Askarian et al., 2006b, Askarian et al., 2006a; Askarian et al., 2007; Paudyaly et al., 2008). The reported reliability coefficient of the original instrument was 0·76 (Askarian et al., 2005). To develop an Arabic version of the ICPT, the standard procedure of translation and back translation of the original version of the instrument was followed. The Arabic version was validated by IC experts and pilot tested (Kim et al., 1995). The reliability coefficient of the Arabic version in the current sample was 0·83. The 29 items of the ICPT are rated using a 5-point Likert scale with scores ranging from never to always. Total practice scores range from 29 to 145, with higher total scores reflecting greater compliance with standard IC practices. Demographic data were collected using a demographic data sheet. Demographic data obtained included age, gender, level of education, experience and working unit. After providing consent, potential participants were asked to complete the ICPT and the data collection sheet and return them to a box located in their department for this purpose.

DATA ANALYSIS The analyses in this study were conducted using ® SPSS -PC Version 20. Forms with more than 20% missing data were excluded from the final analyses. On the item level, missing data did not exceed 3% for any item. To replace missing data, the expectationmaximization (EM) maximum likelihood algorithm was used (Dempster et al., 1977). Independent t-test and one-way analysis of variance (ANOVA) were used to compare practice mean scores in relation to variables of more than two levels.

RESULTS A total of 21 hospitals participated in the study; of these, 8 were governmental, 7 military, 4 private © 2014 British Association of Critical Care Nurses

A Jordanian ICU study

and 2 university affiliated. The final sample consisted of 247 RNs from 56 critical care units. Of the total participating nurses, 51% were female with a mean age of 28·5 years (SD = 5·2). The majority of the sample (84·6%) held a bachelor’s degree with mean years of experience of 6·2 years (SD = 5·1). More than half (54·7%) of participating RNs were working in general ICUs; 17·8% worked in NICUs; only about 2·8% were working in cardiac catheterization units. (See Table 1 for detailed demographic data.) Approximately one fourth of participating RNs (24·7%) reported that they received no IC training in their hospital, and the majority (83%) had not received IC training outside the hospital. About 9% of participating RNs reported that there was no IC nurse in their hospital or they did not know if their hospital employed an IC nurse. Of the total participating RNs, 14·2% answered that there was no IC manual in their unit or they did know if there was an IC manual in the unit (Table 1). The overall IC practice score ranged from 78 to 145, with a mean score of 122·6 (SD = 13·2). Of the total participating RNs, 25·5% scored below the 75th percentile of the total score for the ICPT. Of the participating RNs, 78·9% reported that they always wash their hands before and after giving care to patients, and 63·2% reported that they always wash their hands before and after using gloves. About one fourth (23·5%) of the RNs reported that they always perform needle recapping, and fewer than one third (29·6%) reported that they always use eye protection when required (Table 2). Table 3 shows the results of running independent t-tests conducted to compare overall practice mean scores in relation to different factors. Nurses who reported that they were trained about IC guidelines in their hospital scored higher on the IC practice scale (M = 124·3, SD = 12·3) than nurses who reported that they received no IC training in the hospital (M = 117·3, SD = 14·6), p < 0·001. Nurses who received IC training outside the hospital also reported higher practice scores (M = 126·2, SD = 11·7) than nurses who had received no such training (M = 121·8, SD = 13·4), p = 0·05. Although knowing about an IC manual in the unit was associated with higher practice scores, this finding did not reach the statistical difference (p = 0·11). To compare IC practices among different types of critical care units, one-way ANOVA procedure was used. The mean total IC practice score was not statistically different across all types of critical care units, F(6, 246) = 0·80, p < 0·90. Similarly, one-way ANOVA showed that mean total IC practice score was not significantly different across the four health care providers in Jordan, F(3, 246) = 0·60, p < 0·70. © 2014 British Association of Critical Care Nurses

Table 1 Sample characteristics

Characteristic Gender Female Male Age group 20–30 31–40 41–50 Level of education 3-year diploma BSN MSN Experience

Infection control practices among intensive care unit registered nurses: a Jordanian national study.

This study aimed to evaluate infection control (IC) practices among Jordanian registered nurses (RNs) working in intensive care unit (ICU) settings...
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