- Email: [email protected]
Compliance of Jordanian registered nurses with infection control guidelines: A national population-based study
American Journal of Infection Control 41 (2013) 1065-8
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Compliance of Jordanian registered nurses with infection control guidelines: A national population-based study Omar M. AL-Rawajfah RN, PhD a, *, Issa M. Hweidi RN, DNSc b, Murad Alkhalaileh RN, PhD c, Yousef Saleh Khader PhD d, Suhaila A. Alshboul PhD e a
Department of Acute Care Nursing, Faculty of Nursing, AL AL-Bayt University, Mafraq, Jordan Department of Adult Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan Department of Adult Health Nursing, Faculty of Nursing, AL AL-Bayt University, Mafraq, Jordan d Department of Epidemiology and Biostatistics, Department of Public Health, Community, Family Medicine/Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan e Department of Molecular Microbiology and Bacterial Genetics, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan b c
Key Words: Infection prevention Standard precautions Infection control practices Adherence
Background: This national study aims to evaluate compliance of Jordanian staff nurses with infection control guidelines. Methods: Cross-sectional, descriptive design was used. Proportional-multistage, probability sampling was used to obtain a sample of 10% of all staff nurses working in Jordanian hospitals. Standardized selfreported instruments were used to evaluate the compliance. Results: The total sample consisted of 22 hospitals, of which 8 were governmental, 7 military, 5 private, and 2 university-affiliated hospitals. Of the total 889 participating nurses, 52.6% were females, 81.9% holding a bachelor degree. The mean age was 29.0 years (standard deviation [SD] ¼ 5.9) with a mean of experience of 6.9 years (SD ¼ 5.8). According to the scale categories, 65.0% of participants demonstrated “high compliance,” 32.3% “weak compliance,” and 2.7% “unsafe compliance.” Nurses who received infection control training in the hospital demonstrated higher compliance (mean ¼ 120.2, SD ¼ 13.6); than those who never received such training (mean ¼ 115.8, SD ¼ 15.2), P < .001. Nurses who work in university affiliated hospitals demonstrated higher compliance than other types of hospital (P < .001). Conclusion: This study provides information about infection control practices in various health care sectors in Jordan. Results from this study expected to guide efforts to develop educational tools, programs, and curricula to improve infection control practices in Jordan. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
The Centers for Disease Control and Prevention (CDC) recommends the education of health care workers regarding infection control measures as a major strategy for preventing and controlling infection.1 It recommends periodic assessment of knowledge and adherence to infection control (IC) guidelines as a high priority.2 A number of self-report studies have examined compliance of health care workers with IC guidelines,3-5 whereas observational methods were used in other studies.6-8 These published studies have identified different factors that affect compliance with IC guidelines including knowledge about the latest IC guidelines,9 availability and accessibility of IC equipment,10 and availability of IC training programs in the hospital.11 * Address correspondence to Omar M. AL-Rawajfah, RN, PhD, Faculty of Nursing, AL AL-Bayt University, PO Box 130040, Mafraq, Jordan 25113. E-mail address: [email protected] (O.M. AL-Rawajfah). Supported by the Scientific Research Support Fund at the Jordanian Ministry of Higher Education and Scientific Research (grant ID: 2010/03/1). Conflicts of interest: None to report.
In Jordan, with a population of about 6 million12 and a per capita income in 2010 of $4,505 US, studies have shown low compliance of health care workers with IC guidelines.13,14 No studies have targeted registered nurses (RNs) in Jordanian hospitals, and none were conducted at the national level. Health care services in Jordan are provided primarily through governmental, military, private, and university-affiliated hospitals. In 2010, the Ministry of Health budget comprised 7.4% of the total national budget.12 The purpose of this national study was to assess the compliance of Jordanian RNs with standard IC guidelines. METHODS Sample This study used a descriptive cross-sectional design. Proportional, multistage, probability sampling was used to obtain the final
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.05.008
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sample of nurses. The sampling frame consisted of all Jordanian hospitals listed by the Ministry of Health annual statistical report.15 For the purpose of this study, Jordan was divided into 3 main geographical regions, the North, Middle, and South, and a complete list of all hospitals from each health care sector (governmental, military, private, and university affiliated) in each region was established. The number of RNs working in each hospital was determined based on direct contact with nursing directors. Hospitals with a bed capacity of less than 60 beds were excluded from the study because of the small number of RNs on their duty schedules. The final sampling frame consisted of 30 governmental, 11 military, 60 private, and 2 university-affiliated hospitals. A 10% proportional random sample of RNs was obtained from hospitals in each health care sector in each geographical area. Ethical approval was obtained from AL AL-Bayt University as well as from the participating hospitals. Informed consent was obtained from participating nurses. Participated nurses were asked to return the completed self-reported data collection forms to a special closed box in their department. Instrument The original version of the instrument has been used in various studies16-18 and had a reported reliability coefficient of 0.76.16 The original version was modified based on an in-depth literature review regarding compliance with IC guidelines and entitled as “Infection Control Practices Tool.” For the purpose of this study, the instrument was translated into Arabic and then back translated according to standard translation procedures.19 In the current study, the reliability coefficient of the Arabic version was 0.88. The instrument has 29 items and uses a 5-point Likert scale with scores ranging from 5 (always) to 1 (never). For this study, total compliance scores were categorized as follows: total scores less than the 50th percentile (range, 29-87) were classified as “unsafe compliance”; scores between the 50th and 75th percentiles (range, 88-116) were classified as “weak compliance”; scores exceeding the 75th percentile (range, 117-145) were classified as “high compliance.” The compliance categories were validated by IC experts who agreed on the categorization and the corresponding terms. Statistical analysis SPSS-PC version 20 (SPSS Inc, Chicago, IL) was used to compute frequencies, percentages, means, and standard deviations (SD) in describing the responses to the survey. Missing data for the 29 practice items ranged from 1% to 3%. The expectationmaximization (EM) maximum likelihood algorithm was used to impute missing data for all practice items. Cases of missing data of 20% or greater were deleted from the final analysis. RESULTS A total of 22 hospitals participated in the study: 8 were governmental, 7 military, 5 private, and 2 university affiliated. Of the total 1,000 distributed data collection forms, 894 (89.4%) were returned. Of these, 5 were excluded from the final analysis because they had more than 50% missing data, resulting in a total sample of 889 RNs. Of the total 889 participating nurses, 52.6% were female with a mean age of 29.0 years (SD ¼ 5.9). Of the sample, 81.9% held a bachelor’s degree; their mean years of experience was 6.9 (SD ¼ 5.8). More than one-third of the sample (37.6%) worked in medical and surgical floors, and about 20% worked in critical care units. About 28% of participating RNs had never attended an IC
Table 1 Sample characteristics
Characteristic Type of hospital Governmental Military Private University Sex Female Male Age group, y 20-30 31-40 41-50 More than 51 Level of education 3-year diploma BSN MSN Experience, y <2 2 and <5 5 and <10 10 Working unit Medical-surgical Critical care units Operation room Emergency room Neonate and pediatric Maternity and gynecology Other units Receiving infection control training inside the hospital Yes No Receiving infection control training outside the hospital Yes No Is there an infection control nurse in the hospital Yes No Not sure Receive hepatitis B virus vaccine Yes No Not sure
Number of nurses (%) (N ¼ 889)* 344 250 181 114
(38.7) (28.1) (20.4) (12.8)
470 (52.6) 419 (46.8) 631 192 41 5
(71) (21.6) (4.6) (0.6)
139 (15.6) 728 (81.9) 21 (2.4) 204 229 209 174
(22.9) (25.8) (23.5) (19.6)
334 176 61 74 92 22 129
(37.6) (19.8) (6.9) (8.3) (10.3) (2.5) (14.9)
637 (71.7) 252 (28.3) 198 (22.3) 687 (77.3) 789 (83.7) 59 (6.6) 40 (4.5) 744 (83.9) 135 (15.2) 9 (1.0)
BSN, Bachelor of science nursing degree; MSN, master of science nursing degree. *Missing data were as follows: 20 case for age groups, 5 for sex, 73 for experience groups, 1 for level of education, 4 for receiving training outside the hospital, and 1 for receiving hepatitis B virus vaccine.
workshop or educational program inside the hospital in which they worked; the majority (77.8%) had never attended an IC workshop outside the hospital in which they worked. About 11% answered that their hospital employed no IC nurse or that they did not know whether an IC nurse was employed by the hospital. Of the total participants, 20.5% reported having no IC manual in the unit in which they worked, or they did not know whether the unit had an IC manual (Table 1). The overall mean IC compliance score for the total sample was 119.9 (SD ¼ 14.3). According to the 3 compliance levels, 65.0% of participants were categorized as “high compliance”; 32.3% as “weak compliance”; and 2.7% as “unsafe compliance.” The majority of nurses (72.5%) reported that they always washed their hands before giving care to patients; and 81% always used gloves before contact with any mucus membrane (data not shown). On the other hand, more than half of participating nurses (55.9%) reported that they always shared patients’ tools and equipment with other patients, and less than one-third (30.3%) always used eye protection to
O.M. AL-Rawajfah et al. / American Journal of Infection Control 41 (2013) 1065-8 Table 2 Compared means compliance score in relation to selected factors
Available of infection control nurse Available of infection control manual in the unit Receive infection control training in the hospital Receive infection control training outside the hospital Received hepatitis B vaccine
Yes
No or not sure
M (SD)
M (SD)
120.6 (13.9)
114.1 (16.5)
4.3 (886) <.001
121.0 (14.1)
115.3 (14.3)
4.8 (883) <.001
121.2 (13.8)
116.4 (15.0)
4.5 (887) <.001
121.7 (14.3)
119.4 (14.3)
2.0 (883)
.045
120.4 (14.1)
117.1 (15.0)
2.4 (877)
.02
t (df)
P value
df, Degrees of freedom; M, mean; SD, standard deviation.
protect their eyes when they performed activities or nursing care that might lead to a spout of blood and body fluids (data not shown). Independent t test was used to compare compliance mean scores in relation to different factors (Table 2). Nurses who reported that they received IC educational training in their working hospital reported higher compliance scores (mean [M] ¼ 121.2, SD ¼ 13.8) than nurses who reported that they never received such training (M ¼ 116.4, SD ¼ 15.0), P < .001. Moreover, nurses who reported having an IC manual in the unit reported higher compliance score (M ¼ 120.0, SD ¼ 14.1) than nurses who reported having no such a manual in the unit (M ¼ 115.3, SD ¼ 14.3), P < .001. One-way analysis of variance was used to test for total compliance score differences among the 4 health care sectors represented by the participating hospitals. Total compliance scores were significantly different across the 4 types, F3,885 ¼ 9.3, P < .001. Tukey post hoc comparisons of the 4 types indicated that universityaffiliated hospitals (M ¼ 123.8, SD ¼ 13.7) scored significantly higher with regard to compliance level than military hospitals (M ¼ 116.6, SD ¼ 14.5, P < .001) and governmental hospitals (M ¼ 119.6, SD ¼ 15.0, P ¼ .03). However, compliance scores for university-affiliated hospitals (M ¼ 123.8, SD ¼ 13.7) were not statistically different from scores for private hospitals (M ¼ 122.4, SD ¼12.2, P ¼ .84). Moreover, Tukey post hoc comparisons showed that private hospitals had significantly higher compliance levels (M ¼ 122.4, SD ¼ 12.2) than military hospitals (M ¼ 116.6, SD ¼ 14.5, P < .001), but differences with governmental hospitals (M ¼ 119.6, SD ¼ 15.0, P ¼ .14) were not statistically significant. Finally, Tukey post hoc comparisons demonstrated that there was no statistically significant difference between total compliance scores of governmental hospitals (M ¼ 119.6, SD ¼ 15.0) and military hospitals (M ¼ 116.6, SD ¼ 14.5, P < .051). DISCUSSION As per the available literature, this is the first Jordanian national study that evaluated IC practices among RNs. The strength of this study was the inclusion of hospitals representing all health care sectors in Jordan and all geographic regions. Moreover, the study used a proportional probability sample. Because of these factors, the results of the current study are very likely generalizable and reflect the nursing population in Jordan. The major limitation of this study is the use of a self-report method. Different studies have demonstrated that the self-report method overestimates the compliance rate with IC practices in comparison with the observation of actual practice.20,21 The selfreport method used in this study demonstrated that more than one-third of participating RNs were weak in terms of compliance with IC guidelines. The use of observation would give greater
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insight regarding level of compliance with these guidelines. Moreover, this study did not examine the relationship between nursing workload and level of compliance. Previous research demonstrated that excessive nursing workload was a risk factor for health care-associated infection.22 Exploring this issue is highly recommended in future studies. This study revealed that about 28% of total participating nurses had not received IC training in the hospitals in which they worked. Post hoc analysis revealed that the majority of untrained nurses (63.7%) worked in governmental and military hospitals; similarly, 74% of nurses with weak compliance also worked in governmental and military hospitals. These findings reflect an absence of formal IC educational programs in these hospitals. The study also demonstrated that 52.4% of participating RNs performed needle recapping at least most of time. This ratio is higher than reported in developing countries such as India (40%)23 and Nigeria (31.9).24 The authors believe that the major reason for the high rate of this practice in Jordan is the absence of IC educational programs that increase the awareness of unsafe practices. These findings raise questions about orientation and teaching programs conducted in hospitals for newly employed RNs, especially in the governmental and military sectors. The majority of RNs in governmental and military hospitals start their work without any formal training program regarding general hospital policies and procedures, specifically IC guidelines. Guidelines published by the CDC for the prevention of health care-related infections state that the education of health care workers about infection control measures is strongly recommended. Furthermore, the CDC strongly recommends well-designed experimental, clinical, or epidemiologic studies as effective strategies to reduce the incidence of health care-related infection.25 This study showed that more than one-third of staff nurses in Jordan reported weak compliance with IC guidelines. This finding is similar to results reported in Kuwait,20 India,23 Korea,11 and Turkey.26 Moreover, results from this study are congruent with findings from a previous Jordanian study conducted to evaluate IC knowledge and practices among dentists and dental nurses,14 which found weak compliance with IC standards. One of the challenges regarding compliance with IC guidelines is the availability of resources.2,27 In our study, 36.5% of the participating RNs reported that they always or most of the time shared equipment between patients without sterilization. One major reason given for sharing equipment between patients is insufficient resources. Moreover, this study demonstrated that less than onethird of RNs always used eye protection when such protection was indicated. Similar results were reported in developing countries such as India (32%)23 and Nigeria (16.3%).24 The availability of IC resources such as handwashing facilities and personal protective equipment in health care facilities in Jordan represents a real challenge. This study demonstrated that having an infection control nurse in the hospital facility positively influenced compliance with IC guidelines. A study of the Efficacy of Nosocomial Infection Control Project (SENIC) demonstrated that 1 infection control nurse per 250 beds was associated with a 32% lower rate of HCRIs.28 In a more recent study that used the Delphi technique to assess staffing requirements for infection control programs in health care facilities in the United States, researchers recommended a ratio of 0.8 to 1.0 IC nurses per 100 occupied acute care beds as an appropriate level of staffing.29 CONCLUSION This study demonstrated the need for legislation to ensure the availability of an IC nurse in each hospital in Jordan to advance safe IC practices. Proper guidelines for the qualifications and training of IC nurses should be clearly delineated within the proposed legislation,
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and the role and authority of IC nurses must be established. The IC nurse needs to be a major part of an audit system that ensures high compliance with IC standards. Results from this study convey a clear and explicit message to all health care sectors in Jordan and similar countries about the necessity of establishing need-based IC training programs, especially for newly employed nurses. The availability of an IC procedure manual in all care units that embraces IC standards pertinent to RN practice is essential to ensure correct utilization of IC practices. Resources facilitating the safe practice of infection control (eg, handwashing facilities, protective equipment) should be readily available to enhance compliance with IC standards by RNs. To counteract the issue of limited resources, a multifaceted, collaborative approach that is based on improved health care structures, increased knowledge, effective guidelines, behavioral change, attitude adjustment, and efficient exploitation of existing resources to the maximum potential is indispensable. References 1. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51:1-29. 2. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35:S65-164. 3. Knoll M, Lautenschlaeger C, Borneff-Lipp M. The impact of workload on hygiene compliance in nursing. Br J Nurs 2010;19:S18-22. 4. Akyol AD. Hand hygiene among nurses in Turkey: opinions and practices. J Clin Nurs 2007;16:431-7. 5. Adinma ED, Ezeama C, Adinma JI, Asuzu MC. Knowledge and practice of universal precautions against blood borne pathogens amongst house officers and nurses in tertiary health institutions in Southeast Nigeria. Niger J Clin Pract 2009;12:398-402. 6. Korniewicz DM, El-Masri M. Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Appl Nurs Res 2010;23:86-90. 7. Creedon SA. Hand hygiene compliance: exploring variations in practice between hospitals. Nurs Times 2008;104:32-5. 8. Chau JP, Thompson DR, Lee DT, Twinn S. Infection control practices among hospital health and support workers in Hong Kong. J Hosp Infect 2010;75:299-303. 9. Luo Y, He GP, Zhou JW, Luo Y. Factors impacting compliance with standard precautions in nursing, China. Int J Infect Dis 2010;14:e1106-14. 10. Naing L, Nordin R, Musa R. The prevalence of, and factors related to, compliance with glove utilization among nurses in Hospital Universiti Sains Malaysia. Southeast Asian J Trop Med Public Health 2001;32:636-42.
11. Jeong I, Cho J, Park S. Compliance with standard precautions among operating room nurses in South Korea. Am J Infect Control 2008;36:739-42. 12. Jordanian National Department of Statistics. Selected Indicators. 2010. Available from: http://www.dos.gov.jo/dos_home_a/main/jorfig/2010/1.pdf. Accessed May 20, 2010. 13. Al-Dwairi ZN. Infection control procedures in commercial dental laboratories in Jordan. J Dent Educ 2007;71:1223-7. 14. Qudeimat MA, Farrah RY, Owais AI. Infection control knowledge and practices among dentists and dental nurses at a Jordanian University Teaching Center. Am J Infect Control 2006;34:218-22. 15. Ministry of Health. Annual statistical book. Amman: Ministry of Health; 2008. 16. Askarian M, Mirzaei K, Mundy LM, McLaws ML. Assessment of knowledge, attitudes, and practices regarding isolation precautions among Iranian healthcare workers. Infect Control Hosp Epidemiol 2005;26:105-8. 17. Paudyaly P, Simkhada P, Bruce J. Infection control knowledge, attitude, and parctice among Nepalese health care workers. Am J Infect Control 2008;36: 595-7. 18. Askarian M, Memish ZA, Khan AA. Knowledge, practice, and attitude among Iranian nurses, midwives, and students regarding standard isolation precautions. Infect Control Hosp Epidemiol 2007;28:241-4. 19. Kim HS, Schwartz-Barcott D, Holter IM, Lorensen M. Developing a translation of the McGill pain questionnaire for cross-cultural comparison: an example from Norway. J Adv Nurs 1995;21:421-6. 20. Al-Wazzan B, Salmeen Y, Al-Amiri E, Abul A, Bouhaimed M, Al-Taiar A. Hand hygiene practices among nursing staff in public secondary care hospitals in Kuwait: self-report and direct observation. Med Princ Pract 2011;20: 326-31. 21. Jenner EA, Fletcher BC, Watson P, Jones FA, Miller L, Scott GM. Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. J Hosp Infect 2006;63:418-22. 22. Daud-Gallotti RM, Costa SF, Guimaraes T, Padilha KG, Inoue EN, Vasconcelos TN, et al. Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PLoS One 2012;7. e52342. 23. Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford SM. Compliance with Universal/Standard Precautions among health care workers in rural north India. Am J Infect Control 2005;33:27-33. 24. Sadoh WE, Fawole AO, Sadoh AE, Oladimeji AO, Sotiloye OS. Practice of universal precautions among healthcare workers. J Natl Med Assoc 2006;98:722-6. 25. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2002;30:476-89. 26. Hosoglu S, Akalin S, Sunbul M, Otkun M, Ozturk R. Occupational Infections Study G. Healthcare workers’ compliance with universal precautions in Turkey. Med Hypotheses 2011;77:1079-82. 27. Yassi A, Lockhart K, Copes R, Kerr M, Corbiere M, Bryce E, et al. Determinants of healthcare workers’ compliance with infection control procedures. Healthc Q 2007;10:44-52. 28. Hughes JM. Study on the efficacy of nosocomial infection control (SENIC Project): results and implications for the future. Chemotherapy 1988;34: 553-61. 29. O’Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control 2002; 30:321-33.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Compliance of Jordanian registered nurses with infection control guidelines: A national population-based study Omar M. AL-Rawajfah RN, PhD a, *, Issa M. Hweidi RN, DNSc b, Murad Alkhalaileh RN, PhD c, Yousef Saleh Khader PhD d, Suhaila A. Alshboul PhD e a
Department of Acute Care Nursing, Faculty of Nursing, AL AL-Bayt University, Mafraq, Jordan Department of Adult Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan Department of Adult Health Nursing, Faculty of Nursing, AL AL-Bayt University, Mafraq, Jordan d Department of Epidemiology and Biostatistics, Department of Public Health, Community, Family Medicine/Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan e Department of Molecular Microbiology and Bacterial Genetics, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan b c
Key Words: Infection prevention Standard precautions Infection control practices Adherence
Background: This national study aims to evaluate compliance of Jordanian staff nurses with infection control guidelines. Methods: Cross-sectional, descriptive design was used. Proportional-multistage, probability sampling was used to obtain a sample of 10% of all staff nurses working in Jordanian hospitals. Standardized selfreported instruments were used to evaluate the compliance. Results: The total sample consisted of 22 hospitals, of which 8 were governmental, 7 military, 5 private, and 2 university-affiliated hospitals. Of the total 889 participating nurses, 52.6% were females, 81.9% holding a bachelor degree. The mean age was 29.0 years (standard deviation [SD] ¼ 5.9) with a mean of experience of 6.9 years (SD ¼ 5.8). According to the scale categories, 65.0% of participants demonstrated “high compliance,” 32.3% “weak compliance,” and 2.7% “unsafe compliance.” Nurses who received infection control training in the hospital demonstrated higher compliance (mean ¼ 120.2, SD ¼ 13.6); than those who never received such training (mean ¼ 115.8, SD ¼ 15.2), P < .001. Nurses who work in university affiliated hospitals demonstrated higher compliance than other types of hospital (P < .001). Conclusion: This study provides information about infection control practices in various health care sectors in Jordan. Results from this study expected to guide efforts to develop educational tools, programs, and curricula to improve infection control practices in Jordan. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
The Centers for Disease Control and Prevention (CDC) recommends the education of health care workers regarding infection control measures as a major strategy for preventing and controlling infection.1 It recommends periodic assessment of knowledge and adherence to infection control (IC) guidelines as a high priority.2 A number of self-report studies have examined compliance of health care workers with IC guidelines,3-5 whereas observational methods were used in other studies.6-8 These published studies have identified different factors that affect compliance with IC guidelines including knowledge about the latest IC guidelines,9 availability and accessibility of IC equipment,10 and availability of IC training programs in the hospital.11 * Address correspondence to Omar M. AL-Rawajfah, RN, PhD, Faculty of Nursing, AL AL-Bayt University, PO Box 130040, Mafraq, Jordan 25113. E-mail address: [email protected] (O.M. AL-Rawajfah). Supported by the Scientific Research Support Fund at the Jordanian Ministry of Higher Education and Scientific Research (grant ID: 2010/03/1). Conflicts of interest: None to report.
In Jordan, with a population of about 6 million12 and a per capita income in 2010 of $4,505 US, studies have shown low compliance of health care workers with IC guidelines.13,14 No studies have targeted registered nurses (RNs) in Jordanian hospitals, and none were conducted at the national level. Health care services in Jordan are provided primarily through governmental, military, private, and university-affiliated hospitals. In 2010, the Ministry of Health budget comprised 7.4% of the total national budget.12 The purpose of this national study was to assess the compliance of Jordanian RNs with standard IC guidelines. METHODS Sample This study used a descriptive cross-sectional design. Proportional, multistage, probability sampling was used to obtain the final
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.05.008
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sample of nurses. The sampling frame consisted of all Jordanian hospitals listed by the Ministry of Health annual statistical report.15 For the purpose of this study, Jordan was divided into 3 main geographical regions, the North, Middle, and South, and a complete list of all hospitals from each health care sector (governmental, military, private, and university affiliated) in each region was established. The number of RNs working in each hospital was determined based on direct contact with nursing directors. Hospitals with a bed capacity of less than 60 beds were excluded from the study because of the small number of RNs on their duty schedules. The final sampling frame consisted of 30 governmental, 11 military, 60 private, and 2 university-affiliated hospitals. A 10% proportional random sample of RNs was obtained from hospitals in each health care sector in each geographical area. Ethical approval was obtained from AL AL-Bayt University as well as from the participating hospitals. Informed consent was obtained from participating nurses. Participated nurses were asked to return the completed self-reported data collection forms to a special closed box in their department. Instrument The original version of the instrument has been used in various studies16-18 and had a reported reliability coefficient of 0.76.16 The original version was modified based on an in-depth literature review regarding compliance with IC guidelines and entitled as “Infection Control Practices Tool.” For the purpose of this study, the instrument was translated into Arabic and then back translated according to standard translation procedures.19 In the current study, the reliability coefficient of the Arabic version was 0.88. The instrument has 29 items and uses a 5-point Likert scale with scores ranging from 5 (always) to 1 (never). For this study, total compliance scores were categorized as follows: total scores less than the 50th percentile (range, 29-87) were classified as “unsafe compliance”; scores between the 50th and 75th percentiles (range, 88-116) were classified as “weak compliance”; scores exceeding the 75th percentile (range, 117-145) were classified as “high compliance.” The compliance categories were validated by IC experts who agreed on the categorization and the corresponding terms. Statistical analysis SPSS-PC version 20 (SPSS Inc, Chicago, IL) was used to compute frequencies, percentages, means, and standard deviations (SD) in describing the responses to the survey. Missing data for the 29 practice items ranged from 1% to 3%. The expectationmaximization (EM) maximum likelihood algorithm was used to impute missing data for all practice items. Cases of missing data of 20% or greater were deleted from the final analysis. RESULTS A total of 22 hospitals participated in the study: 8 were governmental, 7 military, 5 private, and 2 university affiliated. Of the total 1,000 distributed data collection forms, 894 (89.4%) were returned. Of these, 5 were excluded from the final analysis because they had more than 50% missing data, resulting in a total sample of 889 RNs. Of the total 889 participating nurses, 52.6% were female with a mean age of 29.0 years (SD ¼ 5.9). Of the sample, 81.9% held a bachelor’s degree; their mean years of experience was 6.9 (SD ¼ 5.8). More than one-third of the sample (37.6%) worked in medical and surgical floors, and about 20% worked in critical care units. About 28% of participating RNs had never attended an IC
Table 1 Sample characteristics
Characteristic Type of hospital Governmental Military Private University Sex Female Male Age group, y 20-30 31-40 41-50 More than 51 Level of education 3-year diploma BSN MSN Experience, y <2 2 and <5 5 and <10 10 Working unit Medical-surgical Critical care units Operation room Emergency room Neonate and pediatric Maternity and gynecology Other units Receiving infection control training inside the hospital Yes No Receiving infection control training outside the hospital Yes No Is there an infection control nurse in the hospital Yes No Not sure Receive hepatitis B virus vaccine Yes No Not sure
Number of nurses (%) (N ¼ 889)* 344 250 181 114
(38.7) (28.1) (20.4) (12.8)
470 (52.6) 419 (46.8) 631 192 41 5
(71) (21.6) (4.6) (0.6)
139 (15.6) 728 (81.9) 21 (2.4) 204 229 209 174
(22.9) (25.8) (23.5) (19.6)
334 176 61 74 92 22 129
(37.6) (19.8) (6.9) (8.3) (10.3) (2.5) (14.9)
637 (71.7) 252 (28.3) 198 (22.3) 687 (77.3) 789 (83.7) 59 (6.6) 40 (4.5) 744 (83.9) 135 (15.2) 9 (1.0)
BSN, Bachelor of science nursing degree; MSN, master of science nursing degree. *Missing data were as follows: 20 case for age groups, 5 for sex, 73 for experience groups, 1 for level of education, 4 for receiving training outside the hospital, and 1 for receiving hepatitis B virus vaccine.
workshop or educational program inside the hospital in which they worked; the majority (77.8%) had never attended an IC workshop outside the hospital in which they worked. About 11% answered that their hospital employed no IC nurse or that they did not know whether an IC nurse was employed by the hospital. Of the total participants, 20.5% reported having no IC manual in the unit in which they worked, or they did not know whether the unit had an IC manual (Table 1). The overall mean IC compliance score for the total sample was 119.9 (SD ¼ 14.3). According to the 3 compliance levels, 65.0% of participants were categorized as “high compliance”; 32.3% as “weak compliance”; and 2.7% as “unsafe compliance.” The majority of nurses (72.5%) reported that they always washed their hands before giving care to patients; and 81% always used gloves before contact with any mucus membrane (data not shown). On the other hand, more than half of participating nurses (55.9%) reported that they always shared patients’ tools and equipment with other patients, and less than one-third (30.3%) always used eye protection to
O.M. AL-Rawajfah et al. / American Journal of Infection Control 41 (2013) 1065-8 Table 2 Compared means compliance score in relation to selected factors
Available of infection control nurse Available of infection control manual in the unit Receive infection control training in the hospital Receive infection control training outside the hospital Received hepatitis B vaccine
Yes
No or not sure
M (SD)
M (SD)
120.6 (13.9)
114.1 (16.5)
4.3 (886) <.001
121.0 (14.1)
115.3 (14.3)
4.8 (883) <.001
121.2 (13.8)
116.4 (15.0)
4.5 (887) <.001
121.7 (14.3)
119.4 (14.3)
2.0 (883)
.045
120.4 (14.1)
117.1 (15.0)
2.4 (877)
.02
t (df)
P value
df, Degrees of freedom; M, mean; SD, standard deviation.
protect their eyes when they performed activities or nursing care that might lead to a spout of blood and body fluids (data not shown). Independent t test was used to compare compliance mean scores in relation to different factors (Table 2). Nurses who reported that they received IC educational training in their working hospital reported higher compliance scores (mean [M] ¼ 121.2, SD ¼ 13.8) than nurses who reported that they never received such training (M ¼ 116.4, SD ¼ 15.0), P < .001. Moreover, nurses who reported having an IC manual in the unit reported higher compliance score (M ¼ 120.0, SD ¼ 14.1) than nurses who reported having no such a manual in the unit (M ¼ 115.3, SD ¼ 14.3), P < .001. One-way analysis of variance was used to test for total compliance score differences among the 4 health care sectors represented by the participating hospitals. Total compliance scores were significantly different across the 4 types, F3,885 ¼ 9.3, P < .001. Tukey post hoc comparisons of the 4 types indicated that universityaffiliated hospitals (M ¼ 123.8, SD ¼ 13.7) scored significantly higher with regard to compliance level than military hospitals (M ¼ 116.6, SD ¼ 14.5, P < .001) and governmental hospitals (M ¼ 119.6, SD ¼ 15.0, P ¼ .03). However, compliance scores for university-affiliated hospitals (M ¼ 123.8, SD ¼ 13.7) were not statistically different from scores for private hospitals (M ¼ 122.4, SD ¼12.2, P ¼ .84). Moreover, Tukey post hoc comparisons showed that private hospitals had significantly higher compliance levels (M ¼ 122.4, SD ¼ 12.2) than military hospitals (M ¼ 116.6, SD ¼ 14.5, P < .001), but differences with governmental hospitals (M ¼ 119.6, SD ¼ 15.0, P ¼ .14) were not statistically significant. Finally, Tukey post hoc comparisons demonstrated that there was no statistically significant difference between total compliance scores of governmental hospitals (M ¼ 119.6, SD ¼ 15.0) and military hospitals (M ¼ 116.6, SD ¼ 14.5, P < .051). DISCUSSION As per the available literature, this is the first Jordanian national study that evaluated IC practices among RNs. The strength of this study was the inclusion of hospitals representing all health care sectors in Jordan and all geographic regions. Moreover, the study used a proportional probability sample. Because of these factors, the results of the current study are very likely generalizable and reflect the nursing population in Jordan. The major limitation of this study is the use of a self-report method. Different studies have demonstrated that the self-report method overestimates the compliance rate with IC practices in comparison with the observation of actual practice.20,21 The selfreport method used in this study demonstrated that more than one-third of participating RNs were weak in terms of compliance with IC guidelines. The use of observation would give greater
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insight regarding level of compliance with these guidelines. Moreover, this study did not examine the relationship between nursing workload and level of compliance. Previous research demonstrated that excessive nursing workload was a risk factor for health care-associated infection.22 Exploring this issue is highly recommended in future studies. This study revealed that about 28% of total participating nurses had not received IC training in the hospitals in which they worked. Post hoc analysis revealed that the majority of untrained nurses (63.7%) worked in governmental and military hospitals; similarly, 74% of nurses with weak compliance also worked in governmental and military hospitals. These findings reflect an absence of formal IC educational programs in these hospitals. The study also demonstrated that 52.4% of participating RNs performed needle recapping at least most of time. This ratio is higher than reported in developing countries such as India (40%)23 and Nigeria (31.9).24 The authors believe that the major reason for the high rate of this practice in Jordan is the absence of IC educational programs that increase the awareness of unsafe practices. These findings raise questions about orientation and teaching programs conducted in hospitals for newly employed RNs, especially in the governmental and military sectors. The majority of RNs in governmental and military hospitals start their work without any formal training program regarding general hospital policies and procedures, specifically IC guidelines. Guidelines published by the CDC for the prevention of health care-related infections state that the education of health care workers about infection control measures is strongly recommended. Furthermore, the CDC strongly recommends well-designed experimental, clinical, or epidemiologic studies as effective strategies to reduce the incidence of health care-related infection.25 This study showed that more than one-third of staff nurses in Jordan reported weak compliance with IC guidelines. This finding is similar to results reported in Kuwait,20 India,23 Korea,11 and Turkey.26 Moreover, results from this study are congruent with findings from a previous Jordanian study conducted to evaluate IC knowledge and practices among dentists and dental nurses,14 which found weak compliance with IC standards. One of the challenges regarding compliance with IC guidelines is the availability of resources.2,27 In our study, 36.5% of the participating RNs reported that they always or most of the time shared equipment between patients without sterilization. One major reason given for sharing equipment between patients is insufficient resources. Moreover, this study demonstrated that less than onethird of RNs always used eye protection when such protection was indicated. Similar results were reported in developing countries such as India (32%)23 and Nigeria (16.3%).24 The availability of IC resources such as handwashing facilities and personal protective equipment in health care facilities in Jordan represents a real challenge. This study demonstrated that having an infection control nurse in the hospital facility positively influenced compliance with IC guidelines. A study of the Efficacy of Nosocomial Infection Control Project (SENIC) demonstrated that 1 infection control nurse per 250 beds was associated with a 32% lower rate of HCRIs.28 In a more recent study that used the Delphi technique to assess staffing requirements for infection control programs in health care facilities in the United States, researchers recommended a ratio of 0.8 to 1.0 IC nurses per 100 occupied acute care beds as an appropriate level of staffing.29 CONCLUSION This study demonstrated the need for legislation to ensure the availability of an IC nurse in each hospital in Jordan to advance safe IC practices. Proper guidelines for the qualifications and training of IC nurses should be clearly delineated within the proposed legislation,
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and the role and authority of IC nurses must be established. The IC nurse needs to be a major part of an audit system that ensures high compliance with IC standards. Results from this study convey a clear and explicit message to all health care sectors in Jordan and similar countries about the necessity of establishing need-based IC training programs, especially for newly employed nurses. The availability of an IC procedure manual in all care units that embraces IC standards pertinent to RN practice is essential to ensure correct utilization of IC practices. Resources facilitating the safe practice of infection control (eg, handwashing facilities, protective equipment) should be readily available to enhance compliance with IC standards by RNs. To counteract the issue of limited resources, a multifaceted, collaborative approach that is based on improved health care structures, increased knowledge, effective guidelines, behavioral change, attitude adjustment, and efficient exploitation of existing resources to the maximum potential is indispensable. References 1. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51:1-29. 2. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35:S65-164. 3. Knoll M, Lautenschlaeger C, Borneff-Lipp M. The impact of workload on hygiene compliance in nursing. Br J Nurs 2010;19:S18-22. 4. Akyol AD. Hand hygiene among nurses in Turkey: opinions and practices. J Clin Nurs 2007;16:431-7. 5. Adinma ED, Ezeama C, Adinma JI, Asuzu MC. Knowledge and practice of universal precautions against blood borne pathogens amongst house officers and nurses in tertiary health institutions in Southeast Nigeria. Niger J Clin Pract 2009;12:398-402. 6. Korniewicz DM, El-Masri M. Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Appl Nurs Res 2010;23:86-90. 7. Creedon SA. Hand hygiene compliance: exploring variations in practice between hospitals. Nurs Times 2008;104:32-5. 8. Chau JP, Thompson DR, Lee DT, Twinn S. Infection control practices among hospital health and support workers in Hong Kong. J Hosp Infect 2010;75:299-303. 9. Luo Y, He GP, Zhou JW, Luo Y. Factors impacting compliance with standard precautions in nursing, China. Int J Infect Dis 2010;14:e1106-14. 10. Naing L, Nordin R, Musa R. The prevalence of, and factors related to, compliance with glove utilization among nurses in Hospital Universiti Sains Malaysia. Southeast Asian J Trop Med Public Health 2001;32:636-42.
11. Jeong I, Cho J, Park S. Compliance with standard precautions among operating room nurses in South Korea. Am J Infect Control 2008;36:739-42. 12. Jordanian National Department of Statistics. Selected Indicators. 2010. Available from: http://www.dos.gov.jo/dos_home_a/main/jorfig/2010/1.pdf. Accessed May 20, 2010. 13. Al-Dwairi ZN. Infection control procedures in commercial dental laboratories in Jordan. J Dent Educ 2007;71:1223-7. 14. Qudeimat MA, Farrah RY, Owais AI. Infection control knowledge and practices among dentists and dental nurses at a Jordanian University Teaching Center. Am J Infect Control 2006;34:218-22. 15. Ministry of Health. Annual statistical book. Amman: Ministry of Health; 2008. 16. Askarian M, Mirzaei K, Mundy LM, McLaws ML. Assessment of knowledge, attitudes, and practices regarding isolation precautions among Iranian healthcare workers. Infect Control Hosp Epidemiol 2005;26:105-8. 17. Paudyaly P, Simkhada P, Bruce J. Infection control knowledge, attitude, and parctice among Nepalese health care workers. Am J Infect Control 2008;36: 595-7. 18. Askarian M, Memish ZA, Khan AA. Knowledge, practice, and attitude among Iranian nurses, midwives, and students regarding standard isolation precautions. Infect Control Hosp Epidemiol 2007;28:241-4. 19. Kim HS, Schwartz-Barcott D, Holter IM, Lorensen M. Developing a translation of the McGill pain questionnaire for cross-cultural comparison: an example from Norway. J Adv Nurs 1995;21:421-6. 20. Al-Wazzan B, Salmeen Y, Al-Amiri E, Abul A, Bouhaimed M, Al-Taiar A. Hand hygiene practices among nursing staff in public secondary care hospitals in Kuwait: self-report and direct observation. Med Princ Pract 2011;20: 326-31. 21. Jenner EA, Fletcher BC, Watson P, Jones FA, Miller L, Scott GM. Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. J Hosp Infect 2006;63:418-22. 22. Daud-Gallotti RM, Costa SF, Guimaraes T, Padilha KG, Inoue EN, Vasconcelos TN, et al. Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PLoS One 2012;7. e52342. 23. Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford SM. Compliance with Universal/Standard Precautions among health care workers in rural north India. Am J Infect Control 2005;33:27-33. 24. Sadoh WE, Fawole AO, Sadoh AE, Oladimeji AO, Sotiloye OS. Practice of universal precautions among healthcare workers. J Natl Med Assoc 2006;98:722-6. 25. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2002;30:476-89. 26. Hosoglu S, Akalin S, Sunbul M, Otkun M, Ozturk R. Occupational Infections Study G. Healthcare workers’ compliance with universal precautions in Turkey. Med Hypotheses 2011;77:1079-82. 27. Yassi A, Lockhart K, Copes R, Kerr M, Corbiere M, Bryce E, et al. Determinants of healthcare workers’ compliance with infection control procedures. Healthc Q 2007;10:44-52. 28. Hughes JM. Study on the efficacy of nosocomial infection control (SENIC Project): results and implications for the future. Chemotherapy 1988;34: 553-61. 29. O’Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control 2002; 30:321-33.