American Journal of Infection Control 42 (2014) 254-9
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American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Knowledge, perceptions, and practices of methicillin-resistant Staphylococcus aureus transmission prevention among health care workers in acute-care settings Dorothy J. Seibert PhD, RN a, *, Karen Gabel Speroni PhD, RN b, Kyeung Mi Oh PhD, RN a, Mary C. DeVoe RN b, Kathryn H. Jacobsen PhD c a b c
School of Nursing, George Mason University, Fairfax, VA Inova Fair Oaks Hospital, Fairfax, VA Department of Global & Community Health, George Mason University, Fairfax, VA
Key Words: Attitudes Health personnel Infection control Inpatients Health care-associated infection Nursing personnel
Background: Health care workers (HCWs) play a critical role in prevention of health care-associated infections such as methicillin-resistant Staphylococcus aureus (MRSA), but glove and gown contact precautions and hand hygiene may not be consistently used with vulnerable patients. Methods: A cross-sectional survey of MRSA knowledge, attitudes/perceptions, and practices among 276 medical, nursing, allied health, and support services staff at an acute-care hospital in the eastern United States was completed in 2012. Additionally, blinded observations of hand hygiene behaviors of 104 HCWs were conducted. Results: HCWs strongly agreed that preventive behaviors reduce the spread of MRSA. The vast majority reported that they almost always engage in preventive practices, but observations of hand hygiene found lower rates of adherence among nearly all HCW groups. HCWs who reported greater comfort with telling others to take action to prevent MRSA transmission were significantly more likely to self-report adherence to recommended practices. Conclusions: It is important to reduce barriers to adherence with preventive behaviors and to help all HCWs, including support staff who do not have direct patient care responsibilities, to translate knowledge about MRSA transmission prevention methods into consistent adherence of themselves and their coworkers to prevention guidelines. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Drug-resistant health care-associated infections (HAIs) such as methicillin-resistant Staphylococcus aureus (MRSA) are a growing concern in acute-care settings. HAIs cause a significant burden on the health care system as a result of extended hospital stays, expensive treatments, and increased mortality rates.1,2 For example, the costs and length of stays doubled for MRSA infections.2,3 Health care workers (HCWs) may contribute to the spread of MRSA and other HAIs within a hospital and to the community through failure to adhere to recommended practice guidelines. Prevention efforts in a variety of patient care units, including outpatient clinics and intensive care units, have been shown to * Address correspondence to Dorothy J. Seibert, PhD, RN, School of Nursing, George Mason University, 4400 University Dr, MS 3C4, Fairfax, VA 22030-4444. E-mail address: [email protected] (D.J. Seibert). This project was supported by a grant from the Epsilon Zeta chapter of Sigma Theta Tau, the Honor Society of Nursing. Conflicts of interest: None to report.
significantly reduce HAI-related MRSA.4-7 However, the frequency of hand hygiene (washing with soap and water or using alcohol-based hand sanitizers) and the consistent use of contact precautions, such as the use of gloves and gowns, are often found to be suboptimal.8,9 The US Centers for Disease Control and Prevention guidelines recommend contact precautions for all interactions that may involve contact with MRSA-infected or MRSA-colonized patients or with potentially contaminated areas in a patient’s environment.10 The World Health Organization also recommends consistent performance of hand hygiene before and after contact with the each patient and his or her environment.11 Observed adherence of HCWs with these prevention practices has been found to be about 68%-82% for use of gloves, about 68%-77% for use of gowns, and about 48%69% for hand hygiene after patient contact.8,9,12 HCWs may become vectors of infection, transferring the infectious agent from 1 patient to another via contamination of skin, clothing, or equipment.13-15 HCWs may also become colonized with MRSA, and asymptomatic
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carriers may inadvertently transmit the bacterium to patients.16-19 (About 4.6% of HCWs in the United States are MRSA carriers.13) HCWs can play a critical role in preventing HAIs caused by MRSA.20,21 HCWs’ knowledge of and perceptions about MRSA may strongly influence their willingness to routinely engage in preventive practices.10,22,23 Once knowledge gaps, barriers to adherence, and other factors that may inhibit adherence are identified, interventions to reduce MRSA transmission can be implemented.23-25 The goal of our study was to evaluate knowledge, perceptions, and practices related to MRSA among a diverse sample of HCWsd medical, nursing, allied health, and support services staffdat an acute care hospital. Understanding these factors will contribute to action plans that include all HCWs in efforts to reduce MRSA transmission in the acute care setting. METHODS Study population As part of a comprehensive evaluation of HCW knowledge, attitudes/perceptions, and practices/behaviors (KAP) about MRSA, we conducted a cross-sectional survey of HCWs at a 182-bed hospital in the mid-Atlantic region of the United States from September through November 2012. All HCWs with direct patient care and those who enter patient care areas were asked to complete a questionnaire, including medical staff (physicians, physician assistants, and nurse practitioners on medical staff), nurse staff (registered nurses and other types of nurses), allied health professionals (such as cardiopulmonary therapists; physical therapists; occupational therapists; speech therapists; social workers; and laboratory, medical imaging, and pharmacy staff), and support staff from environmental services, foodservices, engineering, security, and patient registration. Data collection HCWs were recruited via e-mail, staff newsletters, posters displayed in employee locker rooms, and announcements on the hospital’s research Web page. Department managers were informed about the survey at administrative meetings and asked to promote the survey to their colleagues and distribute the e-mail invitation. Additionally, HCWs were informed about the survey during visits by the research team to clinical departments. Responses to the 33-item survey, which included 3 open-ended and 49 close-ended questions, could be submitted on paper forms deposited in survey collection boxes located in the mailroom or could be submitted electronically via a Zoomerang Web survey. Characteristics of participants are described in Table 1.
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Table 1 Demographic characteristics of survey participants by health care worker (HCW) group
HCW group*
Medical
Nurses
Allied health
Support staff
Total
No. of participants 49 129 48 50 276 Proportion of total 17.8 46.7 17.4 18.1 100 sample (%) Age in years (%) 18-25 6.1 14.8 6.2 8.3 10.6 26-35 16.3 24.2 29.2 22.9 23.4 36-45 26.5 25.8 29.2 18.8 25.3 46-55 24.5 25.0 25.0 25.0 24.9 56 26.5 10.2 10.4 25.0 15.8 Sex (%) Women 47.8 91.3 72.9 77.1 78.0 Men 52.2 8.7 27.1 22.9 22.0 Education (%) Doctoral degree 85.4 0.8 10.6 2.0 17.6 Master’s degree 8.3 11.7 19.1 10.0 12.1 Bachelor’s degree 6.2 57.0 29.8 20.0 36.6 0 27.4 38.3 38.3 26.3 Associate’s degree/ diploma/ certificate High school or less 0 3.1 2.1 30.0 7.3 Experience in years Range 0-45 0-43 0-33 0-30 0-45 Mean standard 17.5 11.7 14.0 11.1 14.5 9.8 8.3 7.7 13.7 10.8 deviation Work status (%) Full time 82.6 66.1 70.2 78.7 71.9 Part time 17.4 21.3 23.4 12.8 19.5 As needed 0 12.6 6.4 8.5 8.6 *HCW included medical staff: medical doctors (n ¼ 41); other medical staff, such as physician assistants and nurse practitioners (n ¼ 8); nurses: registered nurses (n ¼ 112); other nursing staff, including certified nursing assistants and emergency medical technicians (n ¼ 17); allied health: medical imaging staff (n ¼ 15); physical medicine and rehabilitation: physical therapists, occupational therapists, and speech therapists (n ¼ 10); laboratory staff (n ¼ 10); other allied health staff, including dietitians, pharmacists, respiratory therapists, and social services (n ¼ 13); support staff: patient registration/clerical (n ¼ 27); environmental services (n ¼ 10); and other support staff (n ¼ 13).
education methods, and suggestions for reducing transmission of MRSA. To improve the validity of the survey instrument, the questionnaire included 17 questions about contact precautions, colonization, mode of transmission, bacterial viability, and hand hygiene efficacy previously used by Burkitt et al24 in a large study of HCWs at Veterans’ Administration health care facilities; 9 questions from the study by Trigg et al25 of HCWs at a National Health Systems hospital in the United Kingdom; and 3 questions regarding concern about transmission, knowing someone with MRSA, and community-acquired MRSA adapted from a study of HCWs in North Dakota by Koltes.22 The specific wording of the questions is provided in Tables 2-4.
Survey instrument Survey validity The questionnaire included 7 demographic questions; 4 multiple choice and 2 true/false questions about knowledge; 12 ordinal questions about perceptions of MRSA; and a series of 6 yes/no questions about practice adherence by self and other HCWs. The perceptions of MRSA questions (with a 5-point Likert scale ranging from strongly disagree to strongly agree) rated susceptibility, severity, the benefit of practice adherence, self-efficacy, and cues to take action. Additional questions included 7 yes-or-no questions about barriers to adherence with recommended practices related to time management, communication, access to equipment, the environment, and patient characteristics. Also included were12 yes-or-no questions about resources and preferred education methods and 3 open-ended questions for reporting barriers, other
A pilot test of the survey by 6 HCWs from another hospital in the same part of the country was conducted. Additionally, 12 infection preventionists, 2 nurse educators, and 6 HCW members of the hospital’s research council rated the relevance and clarity of each item on a 4-point scale (from not relevant to highly relevant and from not clearly written to clearly written). A content validity index was calculated from these scores. A content validity index score of 0.80 (on a scale of 0 to 1) is desirable, and the assessors rated the relevance of the questions at 0.98 and the clarity at 0.97. After the questionnaires were completed, Cronbach’s a was used to evaluate the internal consistency of the survey items. The scores for internal consistency of the perception variables, the knowledge scores, and
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Table 2 Methicillin-resistant Staphylococcus aureus (MRSA) knowledge by health care worker (HCW) group Selected correct answer (%) Statement Which of the following precautions should be taken before contact with MRSA patients/items in their room? (Check all that apply)
People who have (or carry) MRSA but do not have symptoms can spread MRSA How is MRSA most often spread to patients? How long can MRSA live outside the body on surfaces? Which hand hygiene method is most effective in killing MRSA?
Correct answer
Medical
Nurses
Allied health
Support staff
Total
Hand hygiene Gloves Gown All of the above True Health care worker hands Days Alcohol-based hand rub
100.0 100.0 95.8 95.8 97.9 89.6 47.9 35.4
98.4 100.0 100.0 98.4 86.5 75.4 40.5 38.9
100.0 100.0 100.0 100.0 95.6 71.1 33.3 33.3
98.0 98.0 98.0 98.0 74.0 64.0 42.0 24.0
98.9 99.6 98.9 98.1 87.7** 75.1* 40.9 34.6
*P < .05 for statistically significant differences in correct responses by HCW type. **P < .005 for statistically significant differences in correct responses by HCW type.
Table 3 Methicillin-resistant Staphylococcus aureus (MRSA) perceptions by health care worker (HCW) group Strongly agree or agree (%) Category
Statement
Medical
Nurses
Allied health
Support staff
Total
Severity
MRSA is a national problem MRSA is a problem in this hospital If I clean my hands and wear gowns and gloves as recommended, I will decrease my risk of getting MRSA If I clean my hands and wear gowns and gloves as recommended, I will decrease my patients’ risk of getting MRSA When staff on this unit do not gown and glove before touching a patient with MRSA, I feel comfortable reminding them When staff on this unit do not clean their hands, I feel comfortable reminding them I am comfortable with educating patients and their families about MRSA I am concerned that I will transmit MRSA to my family and/or friends at home When we are short staffed on my unit, MRSA is spread more than when we are fully staffed I have received meaningful education regarding MRSA The news media influenced my attitude toward MRSA. Someone I know had MRSA and the experience influenced my attitude toward MRSA
95.9 55.1 91.8
91.4 52.0 96.1
95.8 41.3 97.8
80.8 36.0 96.0
90.9 47.8* 95.6
93.9
92.9
95.7
94.0
93.8
85.7
83.7
89.6
84.0
85.1
77.6 83.3 41.7 44.9 71.4 20.4 26.5
76.6 78.3 48.1 34.6 72.7 22.7 18.6
78.7 69.6 46.8 34.0 82.6 21.3 24.4
86.0 48.0 60.0 18.0 66.0 35.4 22.0
78.8 72.2** 48.9 33.3* 72.9 24.3 21.6
Benefit
Self-efficacy
Susceptibility Cues to action
*P < 0.05 for statistically significant differences in agreement level by HCW type. **P < .001 for statistically significant differences in agreement level by HCW type.
the practice scores were 0.602, 0.624, and 0.788, respectively. A Cronbach’s a value of 0.7 or greater (on a scale of 0-1) indicates that questions within a series measured highly related constructs. Hand hygiene observations To complement the self-reported measures in the survey, a hand hygiene observation study was conducted during September 2012. Blinded observations of hand hygiene behavior were conducted according to recommendations from the World Health Organization.11 Trained observers stationed in the corridors of inpatient and outpatient service areas for 15 minutes to 2 hours took notes about HCWs’ hand hygiene compliance at unannounced randomly selected times and places. (Because of patient security concerns, verbal permission from the area manager was obtained before observations.) HCWs were expected to engage in hand hygiene at 3 times: before touching a patient, after touching a patient, and after touching a patient’s surroundings. For each observed opportunity to practice appropriate hand hygienedwhether with soap and water or with alcohol hand rubsdthe observer noted if a hand hygiene action was performed or missed. To minimize the risk of Hawthorne effect biasdthat is, increased adherence to recommended practice due to awareness of observations26dparticipants in the hand hygiene study were not aware that they were being observed.
variance were used to compare responses to KAP questions by HCW type. The associations of HCW group membership with knowledge, perceptions, and self-reported practices were analyzed. Logistic regression models were fit to identify the demographic and other variables that were the strongest predictors of KAP responses. All statistical analyses were conducted with SPSS version 20 (IBM-SPSS Inc, Armonk, NY) and a significance level of a ¼ 0.05 was set. Ethical considerations The protocol was reviewed and approved by the study hospital’s institutional review board and the associated university institutional review board. Survey participants were provided with an informed consent statement outlining the purposes and benefits of participation. Participation was voluntary and no incentives were offered. To ensure anonymity of hand hygiene program participants, observations were categorized by HCW group with no identifiers related to observation unit. Because patient safety must be prioritized, brief verbal reports of hand hygiene adherence were provided to department managers immediately after hand hygiene observations were completed. RESULTS Participants
Statistical analysis Descriptive statistics were used to compare individual selfreport and observed behavior. Two-sided c2 tests and analysis of
Surveys were received from 276 HCWs of the potential 1,200 HCWs, including 49 medical, 129 nurse, 48 allied health, and 50 support staff. The participants are described in Table 1. In total,
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Table 4 Self-reported adherence to use of gloves, gowns, and hand hygiene, by health care worker (HCW) group HCW group Self-report survey participants reporting all practices, n HCWs reporting all practices of peers, n Personnel observed, n Consistently wear gloves when entering a MRSA isolation room, % Self-report Report on peers Self-rated their compliance as higher than that of their peers Consistently wear gowns when entering a MRSA isolation room, % Self-report Report on peers Self-rated their compliance as higher than that of their peers Consistently perform hand hygiene before and after touching patients, % Self-report Report on peers Self-rated their compliance as higher than that of their peers Consistently perform all 3 practices, % Self-report Report on peers Self-rated their compliance as higher than that of their peers
Medical 48 44 17
Nurses 123 121 70
Allied health 44 43 6
Support staff 47 47 11
Total 262 258 104
97.9 86.4 13.6
95.2 82.9 14.6
100.0 86.4 14.0
89.8 90.0 10.2
95.5 85.4 13.5
87.5 75.6 11.1
87.0 70.5 18.2
97.7 86.4 14.0
87.5 82.0 10.4
89.0 76.2 14.8
95.8 71.1 24.4
93.5 71.5 23.6
95.5 77.3 18.6
97.9 94.0 6.2
95.1 76.7 19.7
85.4 65.9 20.5
79.7 58.2 24.0
95.5 70.5 25.6
85.1 78.0 12.8
84.4 65.4 21.6
MRSA, Methicillin-resistant Staphylococcus aureus.
183 (66.3%) of the surveys were submitted on paper and 93 (33.7%) via the Zoomerang Web site. A response rate of 55% of 330 paper surveys distributed and 23% of the potential population was realized. To be included in the analysis of preventive practices, all 3 of the practice questionsdasking about consistency in gowning and gloving for MRSA patients and performing hand hygiene before and after touching patientsdhad to be answered. In total, 262 surveys met this criterion. Additionally, 104 HCWs were observed for adherence with hand hygiene recommendations, including 17 medical, 70 nurse, 6 allied health, and 11 support staff. Knowledge Nearly every HCW correctly identified appropriate precautions for preventing the spread of MRSA (Table 2). Most HCWs also correctly identified that asymptomatic persons can spread MRSA, that MRSA is most often spread by hands, and that MRSA can occur in the community as well as in the hospital. However, more than half of HCWs, including more than half of medical and nursing staff, did not know that MRSA can live on surfaces for days and did not know that alcohol rubs are the most effective hand hygiene method for killing MRSA. There were significant differences in knowledge across HCW types, with medical staff demonstrating higher levels of MRSA knowledge and support staff expressing lower levels of knowledge (P < .001). Perceptions The questions about attitudes toward MRSA were grouped by theme: severity of and susceptibility to MRSA, the benefit of behaviors for preventing MRSA spread, comfort with educating others about MRSA and encouraging MRSA prevention, and cues to action (Table 3). More than 90% of participants agreed that MRSA was a national problem, but fewer than half believed that MRSA is a problem in the hospital where they work. Support staff and allied health staff were much less likely to think of MRSA as a local problem than medical and nursing staff. Nearly all HCWs reported believing that preventive measures would reduce their risk of contracting MRSA and would protect their patients. The majority of HCWs reported feeling comfortable reminding others to glove, gown, and practice hand hygiene. About three-quarters of HCWs reported having received meaningful MRSA education and feeling comfortable educating patients and their families about MRSA.
About half of participants were concerned about bringing MRSA home from work. Only about one-third believed that being understaffed increased the spread of MRSA in the hospital. Fewer than one-quarter reported that media reports or knowing someone with MRSA had influenced their attitude toward MRSA. Observed and reported practices More than 100 HCWs were observed for adherence to hand hygiene recommendations. There were significant differences by HCW type: consistent performance of hand hygiene before and after touching patients was observed for 94.1% of medical staff, 88.6% of nurses, and 83.3% of allied health staff, but only 45.5% of support staff. Alcohol rubs were used in 84.1% of the observed hand hygiene actions; soap and water were used for only 15.9%. Because the surveys were submitted anonymously, we could not determine if an HCW under observation had submitted a completed questionnaire. That means that it is not possible to make a direct comparison between these onsite workplace observations and the self-reported practices recorded by survey participants. However, the observed hand hygiene adherence rate appears to be intermediate between the high rates of self-reported hand hygiene adherence and the lower rates reported for peers (Table 4). (HCWs also reported high rates of adherence to glove and gown use by themselves and their coworkers, with self-adherence rates reported to be higher than those of peers.) The direct observations noted that support staff had significantly lower adherence to hand hygiene recommendations, but the self-reported rates were higher for support staff and their peers than for any other HCW group. Predictors of recommended practice Logistic regression models showed that the MRSA knowledge score (out of 6 points) and most perceptions of MRSA were not statistically significant predictors of self-reported adherence to MRSA transmission prevention guidelines. However, those who reported greater self-efficacydthat is, a greater comfort with telling others to take action to prevent MRSA transmissiondwere significantly more likely to report self-adherence to recommended practices (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.011.40); P ¼ .04). When all variables with significance of P < .2 in bivariate analysis were included in 1 multiple logistic regression model, 6 variables were found to have significant relationships
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with adherence to recommended practices. These predictors of high adherence included being a man, being in the allied HCW group, having a high school education, believing that adherence to the recommended practices is beneficial, being influenced by the experience of others with MRSA, and feeling comfortable reminding others to perform hand hygiene. Barriers to recommended practice The survey asked about 6 items that might influence transmission, and asked follow-up questions about potential barriers to adherence to recommended practices. The 2 most commonly selected items that influence transmission were patient nonadherence to contact precautions (59.3%) and communication issues (48.9%). The other items included in the list were lack of time to engage in hand hygiene and to put on gowns and gloves (36.9%), lack of environmental cleanliness (29.1%), workload issues (27.6%), and not having alcohol rubs or soap within easy reach (11.2%). When asked to identify 1 of the 6 items as the most influential barrier, communication was the most common response (30.2%). The responses to the open-ended question about barriers yielded 15 communication-related comments, 11 of which focused on the need for better communication about which patients have MRSA. Besides these comments, 25 education-related comments noted a lack of knowledge or experience and the need for additional educational opportunities. Additionally, 24 comments about contact precautions mentioned the need for more gowns and gloves to be in stock and conveniently located (n ¼ 10), more equipment to be available and more time allotted for cleaning equipment (n ¼ 6), and more isolation signs to be posted (n ¼ 5) and 11 comments about hand hygiene requested more alcohol hand rub stations (n ¼ 3) and more sinks (n ¼ 5). DISCUSSION The HCWs who participated in this study strongly agreed that glove, gown, and hand hygiene precautions prevent the spread of MRSA and rated the benefit of engaging in these actions as very high for both HCWs and patients. The vast majority of participants reported that they almost always engaged in these practices, but our study’s observations of hand hygiene found lower rates of adherence among nearly all HCW groups. This gap between reported and observed preventive practices has been found in previous studies that concluded that HCWs tended to overestimate how well they apply their prevention knowledge to daily work activities.27,28 This may be the result of HCWs not understanding when particular preventive actions should be taken. For example, in a study from the Netherlands, 87% of participating HCWs had a strong knowledge of MRSA prevention measures but only 45% correctly identified the scenarios in which such actions should be taken.28 Additionally, failure to engage in preventive behaviors may result from lack of knowledge or experience with recognizing appropriate actions or from barriers to adhering to recommended practices, such as having inconveniently located hand hygiene supplies, insufficient time, or poorly placed signs about which patients have MRSA and require special precautions. Reducing barriers and making contact precautions and hand hygiene convenient for staff will improve MRSA prevention.20,21,29 Two results from this part of our study may point to action items for improving adherence to recommended practice. First, the observed rates of hand hygiene were particularly low among support staff, such as janitorial staff, who have critical roles in patient safety and MRSA prevention but are not involved in direct patient care. Support staff also had lower knowledge of MRSA than other HCW groups. However, they reported high rates of self- and peer
adherence to good practices, which means that they did not recognize that they were not following current best-practice protocols. Working with these essential personnel to improve their knowledge of MRSA may be helpful in improving routine prevention practices, especially because support staff expressed willingness to remind other staff to engage in these practices. Previous studies have found that health education increases comfort of HCWs with reminding other staff and visitors about prevention behaviors.24,28 Second, survey participants perceived their peers to be considerably less vigilant at prevention practices than themselves. This is similar to the results from the study by Koltes,22 in which 80% of participants reported that they consistently used precautions but only 52% reported that their colleagues did.22 Posting more reminders about recommended practices that highlight this discrepancy might improve personal practices as well as increase peer pressure to use contact precautions and engage in frequent hand hygiene. All groups of HCWs in our study had limited knowledge about the lengthy duration of time that MRSA can live on surfaces and about the effectiveness of alcohol rubs at removing MRSA from the hands. Additionally, few HCWs reported that knowing someone with MRSA had influenced their attitudes toward the infection, and less than half believed that MRSA was a problem in their workplace or worried about bringing MRSA home from the hospital. The perception that they are not at riskdbecause they believe MRSA organisms die quickly in the environment or because they do not know people who have been seriously affected by MRSAdmay contribute to failure of some HCWs to practice hand hygiene or contact precautions. Previous studies have found that HCWs who believe HAIs cause severe illness engage in better preventive behaviors.22,23 Misperceptions about risk and severity could be changed with appropriate educational outreach from infection control specialists. Multimedia resources that allow for participative, interactive, and engaging learning experiences may be most effective for improving patient care practices.29-33 The strengths of our study include the use of both survey and observational methods, the use of validated survey items for all of the KAP areas, and the inclusion of all types of HCWs rather than limiting participation to 1 group such as nurses. However, the results must be interpreted conservatively because the participation rate suggests that self-selection bias may have occurred. Because HCWs who were not confident about their MRSA knowledge may have been less likely than others to submit a completed questionnaire, the knowledge levels reported in the Results section may be overestimates of the levels in the HCW population as a whole. Also, because the study was conducted at only 1 health care facility, the findings may not be generalizable to other HCW populations. Our findings point to the importance of helping all HCWsd medical, nursing, allied health, and support staffdtranslate knowledge of HAIs such as MRSA into consistent adherence of themselves and their coworkers to guidelines for contact precautions and hand hygiene. Multidisciplinary educational interventions to increase awareness of personal and patient risks paired with reductions of barriers to adherence may help to reduce MRSA transmission in acute-care settings.
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D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 254-9 3. Cummings KL, Anderson DJ, Kaye KS. Hand hygiene noncompliance and the cost of hospital-acquired methicillin-resistant Staphylococcus aureus infection. Infect Control Hosp Epidemiol 2010;34:357-64. 4. Ahmed SS, McCaskey MS, Bringman S, Eigen H. Catheter-associated bloodstream infection in the pediatric intensive care unit: a multidisciplinary approach. Pediatr Crit Care Med 2012;13:e69-72. 5. Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. Am J Infect Control 2011;39:640-6. 6. Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med 2011;39:2218-24. 7. Wheeler DS, Giaccone MJ, Hutchinson N, Haygood M, Bondurant P, Demmel K, et al. A hospital-wide quality-improvement collaborative to reduce catheterassociated bloodstream infections. Pediatrics 2011;128:e995. 8. Clock S, Cohen B, Behta M, Ross B, Larson E. Contact precautions for multidrugresistant organisms: current recommendations and actual practice. Am J Infect Control 2010;38:105-11. 9. Huskins WC, Huckabee CM, O’Grady NP, Murray P, Kopetskie H, Zimmer L, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011;364:1407-18. 10. Siegel J, Rhinehart E, Jackson M, Chiarello L. Healthcare Infections Control Practices Advisory Committee. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control 2007;35(10 Suppl 2):S165-93. 11. World Health Organization. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. 2009. Available from: http:// www.who.int/gpsc/en/. Accessed October 14, 2013. 12. Manian F, Ponzillo J. Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions. Infect Control Hosp Epidemiol 2007;28:337-40. 13. Albrich WC, Harbarth S. Health-care workers: source, vector, or victim of MRSA? Lancet Infect Dis 2008;8:289-301. 14. Ben-David D, Mermel LA, Parenteau S. Methicillin-resistant Staphylococcus aureus transmission: the possible importance of unrecognized health care worker carriage. Am J Infect Control 2008;36:93-7. 15. Snyder G, Thorn K, Furuno JP, Perencevich EN, Roghmann M-C, Strauss S, et al. Detection of methicillin-resistant Staphylococcus aureus and vancomycinresistant enterococci on the gowns and gloves of healthcare workers. Infect Control Hosp Epidemiol 2008;29:583-9. 16. Cimolai N. The role of healthcare personnel in the maintenance and spread of methicillin-resistant Staphylococcus aureus. J Infect Public Health 2008;1: 78-100. 17. Haill C, Fletcher S, Archer R, Jones G, Jayarajah M, Frame J, et al. Prolonged outbreak of meticillin-resistant Staphylococcus aureus in a cardiac surgery unit linked to a single colonized healthcare worker. J Hosp Infect 2013;83:219-25. 18. Kassis C, Hachem R, Raad II, Perego CA, Dvorak T, Hulten KG, et al. Outbreak of community-acquired methicillin-resistant Staphylococcus aureus skin infections among health care workers in a cancer center. Am J Infect Control 2011;39:112-7.
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19. Eveillard M, Martin Y, Hidri N, Boussougant Y, Joly-Guillou M. Carriage of methicillin-resistant Staphylococcus aureus among hospital employees: prevalence, duration, and transmission to households. Infect Control Hosp Epidemiol 2004;25:114-20. 20. Cheng VC, Tai JW, Chan WM, Lau EH, Chan JF, To KK, et al. Sequential introduction of single room isolation and hand hygiene campaign in the control of methicillin-resistant Staphylococcus aureus in intensive care unit. BMC Infect Dis 2010;10:263. 21. Cromer AL, Latham SC, Bryant KG, Hutsell S, Gansauer L, Bendyk HA, et al. Monitoring and feedback of hand hygiene compliance and the impact on facility-acquired methicillin-resistant Staphylococcus aureus. Am J Infect Control 2008;36:672-7. 22. Koltes LA. Healthcare workers’ attitudes, understanding and perceived risk of methicillin-resistant Staphylococcus aureus [dissertation]. Fargo (ND): North Dakota State University; 2009. 23. Sax H, Uçkay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol 2007;28:1267-74. 24. Burkitt K, Sinkowitz-Cochran R, Obrosky D, Cuerdon T, Miller L, Jain R, et al. Survey of employee knowledge and attitudes before and after a multicenter Veterans’ Administration quality improvement initiative to reduce nosocomial methicillin-resistant Staphylococcus aureus infections. Am J Infect Control 2010;38:274-82. 25. Trigg D, Timmons S, Pynegar C. An audit of healthcare workers’ knowledge of meticillin resistant Staphylococcus aureus (MRSA) against current infection control standards. Br J Infect Control 2008;9:30-3. 26. Maury E, Moussa N, Lakermi C, Barbut F, Offenstadt G. Compliance of health care workers to hand hygiene: awareness of being observed is important. Intensive Care Med 2006;32:2088-9. 27. McLaughlin AC, Walsh F. Individual differences in judgments of hand hygiene risk by health care workers. Am J Infect Control 2011;39:456-63. 28. Van Gemert-Pijnen J, Hendrix MG, van der Palen J, Schellens PJ. Performance of methicillin-resistant Staphylococcus aureus protocols in Dutch hospitals. Am J Infect Control 2005;33:377-84. 29. Carboneau C, Benge E, Jaco MT, Robinson M. A Lean Six Sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. J Healthc Qual 2010;32:61-70. 30. Engum SA, Jeffries PR. Interdisciplinary collisions: bringing healthcare professionals together. Collegian 2012;19:145-51. 31. Levett-Jones T, Gilligan C, Lapkin S, Hoffman K. Interprofessional education for the quality use of medicines: designing authentic multimedia learning resources. Nurse Educ Today 2012;32:934-8. 32. Mikkelsen J, Reime MH, Harris AK. Nursing students’ learning of managing cross-infectionsdscenario-based simulation training versus study groups. Nurse Educ Today 2008;28:664-71. 33. Lee T, Moore C, Raboud J, Muller M, Green K, Tong A, et al. Impact of a mandatory infection control education program on nosocomial acquisition of methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2009;30:249-56.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Knowledge, perceptions, and practices of methicillin-resistant Staphylococcus aureus transmission prevention among health care workers in acute-care settings Dorothy J. Seibert PhD, RN a, *, Karen Gabel Speroni PhD, RN b, Kyeung Mi Oh PhD, RN a, Mary C. DeVoe RN b, Kathryn H. Jacobsen PhD c a b c
School of Nursing, George Mason University, Fairfax, VA Inova Fair Oaks Hospital, Fairfax, VA Department of Global & Community Health, George Mason University, Fairfax, VA
Key Words: Attitudes Health personnel Infection control Inpatients Health care-associated infection Nursing personnel
Background: Health care workers (HCWs) play a critical role in prevention of health care-associated infections such as methicillin-resistant Staphylococcus aureus (MRSA), but glove and gown contact precautions and hand hygiene may not be consistently used with vulnerable patients. Methods: A cross-sectional survey of MRSA knowledge, attitudes/perceptions, and practices among 276 medical, nursing, allied health, and support services staff at an acute-care hospital in the eastern United States was completed in 2012. Additionally, blinded observations of hand hygiene behaviors of 104 HCWs were conducted. Results: HCWs strongly agreed that preventive behaviors reduce the spread of MRSA. The vast majority reported that they almost always engage in preventive practices, but observations of hand hygiene found lower rates of adherence among nearly all HCW groups. HCWs who reported greater comfort with telling others to take action to prevent MRSA transmission were significantly more likely to self-report adherence to recommended practices. Conclusions: It is important to reduce barriers to adherence with preventive behaviors and to help all HCWs, including support staff who do not have direct patient care responsibilities, to translate knowledge about MRSA transmission prevention methods into consistent adherence of themselves and their coworkers to prevention guidelines. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Drug-resistant health care-associated infections (HAIs) such as methicillin-resistant Staphylococcus aureus (MRSA) are a growing concern in acute-care settings. HAIs cause a significant burden on the health care system as a result of extended hospital stays, expensive treatments, and increased mortality rates.1,2 For example, the costs and length of stays doubled for MRSA infections.2,3 Health care workers (HCWs) may contribute to the spread of MRSA and other HAIs within a hospital and to the community through failure to adhere to recommended practice guidelines. Prevention efforts in a variety of patient care units, including outpatient clinics and intensive care units, have been shown to * Address correspondence to Dorothy J. Seibert, PhD, RN, School of Nursing, George Mason University, 4400 University Dr, MS 3C4, Fairfax, VA 22030-4444. E-mail address: [email protected] (D.J. Seibert). This project was supported by a grant from the Epsilon Zeta chapter of Sigma Theta Tau, the Honor Society of Nursing. Conflicts of interest: None to report.
significantly reduce HAI-related MRSA.4-7 However, the frequency of hand hygiene (washing with soap and water or using alcohol-based hand sanitizers) and the consistent use of contact precautions, such as the use of gloves and gowns, are often found to be suboptimal.8,9 The US Centers for Disease Control and Prevention guidelines recommend contact precautions for all interactions that may involve contact with MRSA-infected or MRSA-colonized patients or with potentially contaminated areas in a patient’s environment.10 The World Health Organization also recommends consistent performance of hand hygiene before and after contact with the each patient and his or her environment.11 Observed adherence of HCWs with these prevention practices has been found to be about 68%-82% for use of gloves, about 68%-77% for use of gowns, and about 48%69% for hand hygiene after patient contact.8,9,12 HCWs may become vectors of infection, transferring the infectious agent from 1 patient to another via contamination of skin, clothing, or equipment.13-15 HCWs may also become colonized with MRSA, and asymptomatic
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carriers may inadvertently transmit the bacterium to patients.16-19 (About 4.6% of HCWs in the United States are MRSA carriers.13) HCWs can play a critical role in preventing HAIs caused by MRSA.20,21 HCWs’ knowledge of and perceptions about MRSA may strongly influence their willingness to routinely engage in preventive practices.10,22,23 Once knowledge gaps, barriers to adherence, and other factors that may inhibit adherence are identified, interventions to reduce MRSA transmission can be implemented.23-25 The goal of our study was to evaluate knowledge, perceptions, and practices related to MRSA among a diverse sample of HCWsd medical, nursing, allied health, and support services staffdat an acute care hospital. Understanding these factors will contribute to action plans that include all HCWs in efforts to reduce MRSA transmission in the acute care setting. METHODS Study population As part of a comprehensive evaluation of HCW knowledge, attitudes/perceptions, and practices/behaviors (KAP) about MRSA, we conducted a cross-sectional survey of HCWs at a 182-bed hospital in the mid-Atlantic region of the United States from September through November 2012. All HCWs with direct patient care and those who enter patient care areas were asked to complete a questionnaire, including medical staff (physicians, physician assistants, and nurse practitioners on medical staff), nurse staff (registered nurses and other types of nurses), allied health professionals (such as cardiopulmonary therapists; physical therapists; occupational therapists; speech therapists; social workers; and laboratory, medical imaging, and pharmacy staff), and support staff from environmental services, foodservices, engineering, security, and patient registration. Data collection HCWs were recruited via e-mail, staff newsletters, posters displayed in employee locker rooms, and announcements on the hospital’s research Web page. Department managers were informed about the survey at administrative meetings and asked to promote the survey to their colleagues and distribute the e-mail invitation. Additionally, HCWs were informed about the survey during visits by the research team to clinical departments. Responses to the 33-item survey, which included 3 open-ended and 49 close-ended questions, could be submitted on paper forms deposited in survey collection boxes located in the mailroom or could be submitted electronically via a Zoomerang Web survey. Characteristics of participants are described in Table 1.
255
Table 1 Demographic characteristics of survey participants by health care worker (HCW) group
HCW group*
Medical
Nurses
Allied health
Support staff
Total
No. of participants 49 129 48 50 276 Proportion of total 17.8 46.7 17.4 18.1 100 sample (%) Age in years (%) 18-25 6.1 14.8 6.2 8.3 10.6 26-35 16.3 24.2 29.2 22.9 23.4 36-45 26.5 25.8 29.2 18.8 25.3 46-55 24.5 25.0 25.0 25.0 24.9 56 26.5 10.2 10.4 25.0 15.8 Sex (%) Women 47.8 91.3 72.9 77.1 78.0 Men 52.2 8.7 27.1 22.9 22.0 Education (%) Doctoral degree 85.4 0.8 10.6 2.0 17.6 Master’s degree 8.3 11.7 19.1 10.0 12.1 Bachelor’s degree 6.2 57.0 29.8 20.0 36.6 0 27.4 38.3 38.3 26.3 Associate’s degree/ diploma/ certificate High school or less 0 3.1 2.1 30.0 7.3 Experience in years Range 0-45 0-43 0-33 0-30 0-45 Mean standard 17.5 11.7 14.0 11.1 14.5 9.8 8.3 7.7 13.7 10.8 deviation Work status (%) Full time 82.6 66.1 70.2 78.7 71.9 Part time 17.4 21.3 23.4 12.8 19.5 As needed 0 12.6 6.4 8.5 8.6 *HCW included medical staff: medical doctors (n ¼ 41); other medical staff, such as physician assistants and nurse practitioners (n ¼ 8); nurses: registered nurses (n ¼ 112); other nursing staff, including certified nursing assistants and emergency medical technicians (n ¼ 17); allied health: medical imaging staff (n ¼ 15); physical medicine and rehabilitation: physical therapists, occupational therapists, and speech therapists (n ¼ 10); laboratory staff (n ¼ 10); other allied health staff, including dietitians, pharmacists, respiratory therapists, and social services (n ¼ 13); support staff: patient registration/clerical (n ¼ 27); environmental services (n ¼ 10); and other support staff (n ¼ 13).
education methods, and suggestions for reducing transmission of MRSA. To improve the validity of the survey instrument, the questionnaire included 17 questions about contact precautions, colonization, mode of transmission, bacterial viability, and hand hygiene efficacy previously used by Burkitt et al24 in a large study of HCWs at Veterans’ Administration health care facilities; 9 questions from the study by Trigg et al25 of HCWs at a National Health Systems hospital in the United Kingdom; and 3 questions regarding concern about transmission, knowing someone with MRSA, and community-acquired MRSA adapted from a study of HCWs in North Dakota by Koltes.22 The specific wording of the questions is provided in Tables 2-4.
Survey instrument Survey validity The questionnaire included 7 demographic questions; 4 multiple choice and 2 true/false questions about knowledge; 12 ordinal questions about perceptions of MRSA; and a series of 6 yes/no questions about practice adherence by self and other HCWs. The perceptions of MRSA questions (with a 5-point Likert scale ranging from strongly disagree to strongly agree) rated susceptibility, severity, the benefit of practice adherence, self-efficacy, and cues to take action. Additional questions included 7 yes-or-no questions about barriers to adherence with recommended practices related to time management, communication, access to equipment, the environment, and patient characteristics. Also included were12 yes-or-no questions about resources and preferred education methods and 3 open-ended questions for reporting barriers, other
A pilot test of the survey by 6 HCWs from another hospital in the same part of the country was conducted. Additionally, 12 infection preventionists, 2 nurse educators, and 6 HCW members of the hospital’s research council rated the relevance and clarity of each item on a 4-point scale (from not relevant to highly relevant and from not clearly written to clearly written). A content validity index was calculated from these scores. A content validity index score of 0.80 (on a scale of 0 to 1) is desirable, and the assessors rated the relevance of the questions at 0.98 and the clarity at 0.97. After the questionnaires were completed, Cronbach’s a was used to evaluate the internal consistency of the survey items. The scores for internal consistency of the perception variables, the knowledge scores, and
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Table 2 Methicillin-resistant Staphylococcus aureus (MRSA) knowledge by health care worker (HCW) group Selected correct answer (%) Statement Which of the following precautions should be taken before contact with MRSA patients/items in their room? (Check all that apply)
People who have (or carry) MRSA but do not have symptoms can spread MRSA How is MRSA most often spread to patients? How long can MRSA live outside the body on surfaces? Which hand hygiene method is most effective in killing MRSA?
Correct answer
Medical
Nurses
Allied health
Support staff
Total
Hand hygiene Gloves Gown All of the above True Health care worker hands Days Alcohol-based hand rub
100.0 100.0 95.8 95.8 97.9 89.6 47.9 35.4
98.4 100.0 100.0 98.4 86.5 75.4 40.5 38.9
100.0 100.0 100.0 100.0 95.6 71.1 33.3 33.3
98.0 98.0 98.0 98.0 74.0 64.0 42.0 24.0
98.9 99.6 98.9 98.1 87.7** 75.1* 40.9 34.6
*P < .05 for statistically significant differences in correct responses by HCW type. **P < .005 for statistically significant differences in correct responses by HCW type.
Table 3 Methicillin-resistant Staphylococcus aureus (MRSA) perceptions by health care worker (HCW) group Strongly agree or agree (%) Category
Statement
Medical
Nurses
Allied health
Support staff
Total
Severity
MRSA is a national problem MRSA is a problem in this hospital If I clean my hands and wear gowns and gloves as recommended, I will decrease my risk of getting MRSA If I clean my hands and wear gowns and gloves as recommended, I will decrease my patients’ risk of getting MRSA When staff on this unit do not gown and glove before touching a patient with MRSA, I feel comfortable reminding them When staff on this unit do not clean their hands, I feel comfortable reminding them I am comfortable with educating patients and their families about MRSA I am concerned that I will transmit MRSA to my family and/or friends at home When we are short staffed on my unit, MRSA is spread more than when we are fully staffed I have received meaningful education regarding MRSA The news media influenced my attitude toward MRSA. Someone I know had MRSA and the experience influenced my attitude toward MRSA
95.9 55.1 91.8
91.4 52.0 96.1
95.8 41.3 97.8
80.8 36.0 96.0
90.9 47.8* 95.6
93.9
92.9
95.7
94.0
93.8
85.7
83.7
89.6
84.0
85.1
77.6 83.3 41.7 44.9 71.4 20.4 26.5
76.6 78.3 48.1 34.6 72.7 22.7 18.6
78.7 69.6 46.8 34.0 82.6 21.3 24.4
86.0 48.0 60.0 18.0 66.0 35.4 22.0
78.8 72.2** 48.9 33.3* 72.9 24.3 21.6
Benefit
Self-efficacy
Susceptibility Cues to action
*P < 0.05 for statistically significant differences in agreement level by HCW type. **P < .001 for statistically significant differences in agreement level by HCW type.
the practice scores were 0.602, 0.624, and 0.788, respectively. A Cronbach’s a value of 0.7 or greater (on a scale of 0-1) indicates that questions within a series measured highly related constructs. Hand hygiene observations To complement the self-reported measures in the survey, a hand hygiene observation study was conducted during September 2012. Blinded observations of hand hygiene behavior were conducted according to recommendations from the World Health Organization.11 Trained observers stationed in the corridors of inpatient and outpatient service areas for 15 minutes to 2 hours took notes about HCWs’ hand hygiene compliance at unannounced randomly selected times and places. (Because of patient security concerns, verbal permission from the area manager was obtained before observations.) HCWs were expected to engage in hand hygiene at 3 times: before touching a patient, after touching a patient, and after touching a patient’s surroundings. For each observed opportunity to practice appropriate hand hygienedwhether with soap and water or with alcohol hand rubsdthe observer noted if a hand hygiene action was performed or missed. To minimize the risk of Hawthorne effect biasdthat is, increased adherence to recommended practice due to awareness of observations26dparticipants in the hand hygiene study were not aware that they were being observed.
variance were used to compare responses to KAP questions by HCW type. The associations of HCW group membership with knowledge, perceptions, and self-reported practices were analyzed. Logistic regression models were fit to identify the demographic and other variables that were the strongest predictors of KAP responses. All statistical analyses were conducted with SPSS version 20 (IBM-SPSS Inc, Armonk, NY) and a significance level of a ¼ 0.05 was set. Ethical considerations The protocol was reviewed and approved by the study hospital’s institutional review board and the associated university institutional review board. Survey participants were provided with an informed consent statement outlining the purposes and benefits of participation. Participation was voluntary and no incentives were offered. To ensure anonymity of hand hygiene program participants, observations were categorized by HCW group with no identifiers related to observation unit. Because patient safety must be prioritized, brief verbal reports of hand hygiene adherence were provided to department managers immediately after hand hygiene observations were completed. RESULTS Participants
Statistical analysis Descriptive statistics were used to compare individual selfreport and observed behavior. Two-sided c2 tests and analysis of
Surveys were received from 276 HCWs of the potential 1,200 HCWs, including 49 medical, 129 nurse, 48 allied health, and 50 support staff. The participants are described in Table 1. In total,
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257
Table 4 Self-reported adherence to use of gloves, gowns, and hand hygiene, by health care worker (HCW) group HCW group Self-report survey participants reporting all practices, n HCWs reporting all practices of peers, n Personnel observed, n Consistently wear gloves when entering a MRSA isolation room, % Self-report Report on peers Self-rated their compliance as higher than that of their peers Consistently wear gowns when entering a MRSA isolation room, % Self-report Report on peers Self-rated their compliance as higher than that of their peers Consistently perform hand hygiene before and after touching patients, % Self-report Report on peers Self-rated their compliance as higher than that of their peers Consistently perform all 3 practices, % Self-report Report on peers Self-rated their compliance as higher than that of their peers
Medical 48 44 17
Nurses 123 121 70
Allied health 44 43 6
Support staff 47 47 11
Total 262 258 104
97.9 86.4 13.6
95.2 82.9 14.6
100.0 86.4 14.0
89.8 90.0 10.2
95.5 85.4 13.5
87.5 75.6 11.1
87.0 70.5 18.2
97.7 86.4 14.0
87.5 82.0 10.4
89.0 76.2 14.8
95.8 71.1 24.4
93.5 71.5 23.6
95.5 77.3 18.6
97.9 94.0 6.2
95.1 76.7 19.7
85.4 65.9 20.5
79.7 58.2 24.0
95.5 70.5 25.6
85.1 78.0 12.8
84.4 65.4 21.6
MRSA, Methicillin-resistant Staphylococcus aureus.
183 (66.3%) of the surveys were submitted on paper and 93 (33.7%) via the Zoomerang Web site. A response rate of 55% of 330 paper surveys distributed and 23% of the potential population was realized. To be included in the analysis of preventive practices, all 3 of the practice questionsdasking about consistency in gowning and gloving for MRSA patients and performing hand hygiene before and after touching patientsdhad to be answered. In total, 262 surveys met this criterion. Additionally, 104 HCWs were observed for adherence with hand hygiene recommendations, including 17 medical, 70 nurse, 6 allied health, and 11 support staff. Knowledge Nearly every HCW correctly identified appropriate precautions for preventing the spread of MRSA (Table 2). Most HCWs also correctly identified that asymptomatic persons can spread MRSA, that MRSA is most often spread by hands, and that MRSA can occur in the community as well as in the hospital. However, more than half of HCWs, including more than half of medical and nursing staff, did not know that MRSA can live on surfaces for days and did not know that alcohol rubs are the most effective hand hygiene method for killing MRSA. There were significant differences in knowledge across HCW types, with medical staff demonstrating higher levels of MRSA knowledge and support staff expressing lower levels of knowledge (P < .001). Perceptions The questions about attitudes toward MRSA were grouped by theme: severity of and susceptibility to MRSA, the benefit of behaviors for preventing MRSA spread, comfort with educating others about MRSA and encouraging MRSA prevention, and cues to action (Table 3). More than 90% of participants agreed that MRSA was a national problem, but fewer than half believed that MRSA is a problem in the hospital where they work. Support staff and allied health staff were much less likely to think of MRSA as a local problem than medical and nursing staff. Nearly all HCWs reported believing that preventive measures would reduce their risk of contracting MRSA and would protect their patients. The majority of HCWs reported feeling comfortable reminding others to glove, gown, and practice hand hygiene. About three-quarters of HCWs reported having received meaningful MRSA education and feeling comfortable educating patients and their families about MRSA.
About half of participants were concerned about bringing MRSA home from work. Only about one-third believed that being understaffed increased the spread of MRSA in the hospital. Fewer than one-quarter reported that media reports or knowing someone with MRSA had influenced their attitude toward MRSA. Observed and reported practices More than 100 HCWs were observed for adherence to hand hygiene recommendations. There were significant differences by HCW type: consistent performance of hand hygiene before and after touching patients was observed for 94.1% of medical staff, 88.6% of nurses, and 83.3% of allied health staff, but only 45.5% of support staff. Alcohol rubs were used in 84.1% of the observed hand hygiene actions; soap and water were used for only 15.9%. Because the surveys were submitted anonymously, we could not determine if an HCW under observation had submitted a completed questionnaire. That means that it is not possible to make a direct comparison between these onsite workplace observations and the self-reported practices recorded by survey participants. However, the observed hand hygiene adherence rate appears to be intermediate between the high rates of self-reported hand hygiene adherence and the lower rates reported for peers (Table 4). (HCWs also reported high rates of adherence to glove and gown use by themselves and their coworkers, with self-adherence rates reported to be higher than those of peers.) The direct observations noted that support staff had significantly lower adherence to hand hygiene recommendations, but the self-reported rates were higher for support staff and their peers than for any other HCW group. Predictors of recommended practice Logistic regression models showed that the MRSA knowledge score (out of 6 points) and most perceptions of MRSA were not statistically significant predictors of self-reported adherence to MRSA transmission prevention guidelines. However, those who reported greater self-efficacydthat is, a greater comfort with telling others to take action to prevent MRSA transmissiondwere significantly more likely to report self-adherence to recommended practices (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.011.40); P ¼ .04). When all variables with significance of P < .2 in bivariate analysis were included in 1 multiple logistic regression model, 6 variables were found to have significant relationships
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with adherence to recommended practices. These predictors of high adherence included being a man, being in the allied HCW group, having a high school education, believing that adherence to the recommended practices is beneficial, being influenced by the experience of others with MRSA, and feeling comfortable reminding others to perform hand hygiene. Barriers to recommended practice The survey asked about 6 items that might influence transmission, and asked follow-up questions about potential barriers to adherence to recommended practices. The 2 most commonly selected items that influence transmission were patient nonadherence to contact precautions (59.3%) and communication issues (48.9%). The other items included in the list were lack of time to engage in hand hygiene and to put on gowns and gloves (36.9%), lack of environmental cleanliness (29.1%), workload issues (27.6%), and not having alcohol rubs or soap within easy reach (11.2%). When asked to identify 1 of the 6 items as the most influential barrier, communication was the most common response (30.2%). The responses to the open-ended question about barriers yielded 15 communication-related comments, 11 of which focused on the need for better communication about which patients have MRSA. Besides these comments, 25 education-related comments noted a lack of knowledge or experience and the need for additional educational opportunities. Additionally, 24 comments about contact precautions mentioned the need for more gowns and gloves to be in stock and conveniently located (n ¼ 10), more equipment to be available and more time allotted for cleaning equipment (n ¼ 6), and more isolation signs to be posted (n ¼ 5) and 11 comments about hand hygiene requested more alcohol hand rub stations (n ¼ 3) and more sinks (n ¼ 5). DISCUSSION The HCWs who participated in this study strongly agreed that glove, gown, and hand hygiene precautions prevent the spread of MRSA and rated the benefit of engaging in these actions as very high for both HCWs and patients. The vast majority of participants reported that they almost always engaged in these practices, but our study’s observations of hand hygiene found lower rates of adherence among nearly all HCW groups. This gap between reported and observed preventive practices has been found in previous studies that concluded that HCWs tended to overestimate how well they apply their prevention knowledge to daily work activities.27,28 This may be the result of HCWs not understanding when particular preventive actions should be taken. For example, in a study from the Netherlands, 87% of participating HCWs had a strong knowledge of MRSA prevention measures but only 45% correctly identified the scenarios in which such actions should be taken.28 Additionally, failure to engage in preventive behaviors may result from lack of knowledge or experience with recognizing appropriate actions or from barriers to adhering to recommended practices, such as having inconveniently located hand hygiene supplies, insufficient time, or poorly placed signs about which patients have MRSA and require special precautions. Reducing barriers and making contact precautions and hand hygiene convenient for staff will improve MRSA prevention.20,21,29 Two results from this part of our study may point to action items for improving adherence to recommended practice. First, the observed rates of hand hygiene were particularly low among support staff, such as janitorial staff, who have critical roles in patient safety and MRSA prevention but are not involved in direct patient care. Support staff also had lower knowledge of MRSA than other HCW groups. However, they reported high rates of self- and peer
adherence to good practices, which means that they did not recognize that they were not following current best-practice protocols. Working with these essential personnel to improve their knowledge of MRSA may be helpful in improving routine prevention practices, especially because support staff expressed willingness to remind other staff to engage in these practices. Previous studies have found that health education increases comfort of HCWs with reminding other staff and visitors about prevention behaviors.24,28 Second, survey participants perceived their peers to be considerably less vigilant at prevention practices than themselves. This is similar to the results from the study by Koltes,22 in which 80% of participants reported that they consistently used precautions but only 52% reported that their colleagues did.22 Posting more reminders about recommended practices that highlight this discrepancy might improve personal practices as well as increase peer pressure to use contact precautions and engage in frequent hand hygiene. All groups of HCWs in our study had limited knowledge about the lengthy duration of time that MRSA can live on surfaces and about the effectiveness of alcohol rubs at removing MRSA from the hands. Additionally, few HCWs reported that knowing someone with MRSA had influenced their attitudes toward the infection, and less than half believed that MRSA was a problem in their workplace or worried about bringing MRSA home from the hospital. The perception that they are not at riskdbecause they believe MRSA organisms die quickly in the environment or because they do not know people who have been seriously affected by MRSAdmay contribute to failure of some HCWs to practice hand hygiene or contact precautions. Previous studies have found that HCWs who believe HAIs cause severe illness engage in better preventive behaviors.22,23 Misperceptions about risk and severity could be changed with appropriate educational outreach from infection control specialists. Multimedia resources that allow for participative, interactive, and engaging learning experiences may be most effective for improving patient care practices.29-33 The strengths of our study include the use of both survey and observational methods, the use of validated survey items for all of the KAP areas, and the inclusion of all types of HCWs rather than limiting participation to 1 group such as nurses. However, the results must be interpreted conservatively because the participation rate suggests that self-selection bias may have occurred. Because HCWs who were not confident about their MRSA knowledge may have been less likely than others to submit a completed questionnaire, the knowledge levels reported in the Results section may be overestimates of the levels in the HCW population as a whole. Also, because the study was conducted at only 1 health care facility, the findings may not be generalizable to other HCW populations. Our findings point to the importance of helping all HCWsd medical, nursing, allied health, and support staffdtranslate knowledge of HAIs such as MRSA into consistent adherence of themselves and their coworkers to guidelines for contact precautions and hand hygiene. Multidisciplinary educational interventions to increase awareness of personal and patient risks paired with reductions of barriers to adherence may help to reduce MRSA transmission in acute-care settings.
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