1. Background
Infection containment in hospitals is a global challenge to prevent morbidity and mortality in patients and healthcare workers (HCWs) (1). Over recent decades, hospitals have faced challenges regarding the prevention of the spread of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) amongst HCWs and patients (2, 3). In 2020, the coronavirus disease (COVID-19) pandemic further highlighted these challenges, especially in the prevention of novel and reemerging infections (4). A systematic review reported that until May 8, 2020, nearly 152,888 COVID-19 infections and 1413 deaths occurred among HCWs (5).
The World Health Organization (WHO) developed a wide range of infection prevention and control guidelines to control the transmission of infectious diseases in hospitals, including environmental and administrative control measures, such as using personal protective equipment (PPE) and observing hand hygiene, to prevent infection transmission (6).
A systematic review indicated that in most studies, nurses had acceptable knowledge and attitude towards infection control, but their practice was poor, and they did not obey infection control guidelines perfectly (7). The compliance of HCWs with these guidelines may be influenced by their knowledge, attitudes, and practice (KAP) towards isolation precautions, as well as time, resources, and experience (8, 9). The understanding of the factors influencing HCWs’ compliance with infection prevention and control measures can help improve their adherence; for example, to wear PPE to reduce environmentally acquired deadly infections. We here surveyed nurses’ knowledge, attitudes, and practice towards infection control isolation precautions (IPs) in Shiraz, Iran.
2. Methods
This cross-sectional study was conducted on 676 nurses and auxiliary nurses working at the Nemazee hospital of Shiraz (the biggest teaching hospital in Southern Iran) between May 22 and July 23, 2019 (ie, nearly six months prior to the COVID-19 outbreak). The respective ethical approval codes were obtained from the ethical committee of Shiraz University of Medical Sciences (IR.sums.med.rec.1399.252, IR.sums.med.rec.1398.315, and IR.sums.med.rec.1399.277). All the nurses and auxiliary nurses who gave oral informed consent were included in the study. The investigators referred to the Nemazee Hospital during different work shifts and described the importance and aims of the survey for nurses and auxiliary nurses. A self-administered questionnaire was distributed among nurses and auxiliary nurses. The investigators responded to participants’ all questions and gathered completed questionnaires immediately. It took about 15 minutes to complete each questionnaire.
A five-part self-administered questionnaire was designed: (1) part 1 examined demographics, including age, gender, occupation (nurse/auxiliary nurse), and prior participation in infection prevention training; and (2) parts 2, 3, 4, and 5 included nine, five, six, and eight items regarding knowledge, attitude, and practice (KAP) towards standard, droplet, airborne, and contact precautions, respectively. Responses to the items of the knowledge dimension were categorized as correct (score = 1) or incorrect/don’t know (score = 0), delivering the maximum knowledge scores of nine, five, six, and eight for the standard, droplet, airborne, and contact precaution domains, respectively.
Attitude items were scored on a Likert scale (1-5) ranging from unimportant, low importance, important, moderately important, and extremely important. So, the maximum score was 45 for standard precautions (i.e., nine items), 25 for droplet precautions (i.e., five items), 30 for airborne precautions (i.e., six items), and 40 for contact precautions (i.e., eight items).
The options of practice items ranged from never, seldom, sometimes, often, and always, which were scored as always = 1 and all other answers = 0. The maximum practice score was, therefore, nine for nine-item standard precautions, five for five-item droplet precautions, six for six-item airborne precautions, and eight for eight-item contact precautions. The validity and reliability of this questionnaire were assessed in previous studies (9-11). In this study, Cronbach’s alpha for the knowledge, attitude, and practice dimensions and the whole questionnaire were 0.84, 0.81, 0.80, and 0.84, respectively
All scores were rounded up at the 0.5 level. The independent sample t‑test was used to compare differences in the mean scores of KAP between the study groups. Analyses were performed in SPSS IBM statistics software for Windows version 20.0 (IBM Corp., New York, USA) at the significance level of 0.05.
3. Results
Among 734 nurses and auxiliary nurses working in Namazee hospital, 676 completed the questionnaire (i.e., the response rate: 92%). The majority of the participants were females (87%, 589/679) and nursing staff (92%, 624/679). The mean ± SD of the participants’ age was 29.72 ± 6.2 years. Nearly 73.2% (495/676) of the participants had already passed training programs on standard precautions. The mean scores of knowledge, attitude, and practice were high for all the four precaution domains (Table 1).
Table 1.Participants’ Scores of KAP Regarding Infection Prevention and Control Precautions
| Precautions | Knowledge | Attitude | Practice | |||
|---|---|---|---|---|---|---|
| Mean ± SD | Range a | Mean ± SD | Range a | Mean ± SD | Range a | |
| Standard | 8.11 ± 1.34 | 0 - 9 | 37.56 ± 4.81 | 9 - 45 | 5.55 ± 2.56 | 0 - 9 |
| Droplet | 3.72 ± 0.81 | 0 - 5 | 19.92 ± 2.29 | 5 - 25 | 2.99 ± 1.42 | 0 - 5 |
| Airborne | 4.77 ± 1.03 | 0 - 6 | 24.74 ± 3.14 | 6 - 30 | 3.69 ± 1.80 | 0 - 6 |
| Contact | 6.88 ± 1.42 | 0 - 8 | 34.21 ± 4.69 | 8 - 40 | 5.34 ± 2.59 | 0 - 8 |
a Possible range: Minimum and maximum possible scores.
Regarding the standard precaution domain, less than three-quarter of the participants failed to observe the following practices before and after patient care: hand hygiene, glove use, wearing goggles, wearing a gown, and not bending needles after use (Table 2). Less than three-quarter of the participants correctly responded to the items of the droplet precaution dimension, including the need for an isolation room, the 1.5-meter distancing rule, and the need for patients to wear a face mask during transportation. The items needing attention in the airborne precaution domains were the requirement for negative air pressure rooms, wearing a face mask prior to entering the patient’s room, staff vaccination, and patients’ need for wearing face masks during transportation. Regarding the contact precaution domains, the items needing improvement included single room, hand hygiene, gown use, notifying wards about the patients requiring contact precautions, dedicated equipment and cleaning them, and gloving safety issues.
Table 2.Proportion of Participants with Correct Knowledge, Attitudes, and Practice a
| Questions | Correct Knowledge | Correct Attitude | Correct Practice |
|---|---|---|---|
| Standard precautions | |||
| Washing hands before and after patient care | 617 (91.3) | 654 (96.7) | 433 (64.1) |
| Washing hands before and after using gloves | 541 (80.0) | 633 (93.6) | 358 (53.0) |
| Washing hands after unwanted contact with blood, body fluids, excretions, and contaminated items | 663 (98.1) | 663 (98.1) | 552 (81.7) |
| Wearing gloves before touching mucous membranes and non-intact skin | 658 (97.3) | 664 (98.2) | 506 (74.9) |
| Wearing goggles to protect mucous membranes of the eyes during procedures that are likely to generate splashes or sprays of blood and body fluids | 617 (91.3) | 648 (95.9) | 362 (53.6) |
| Washing hands with betadine after contact with patients during the procedures and activities that are likely to generate splashes or sprays of blood and body fluids | 559 (82.7) | 323 (47.8) | 356 (52.7) |
| Wearing a surgical mask to protect nose and mouth during the procedures and activities that are likely to generate splashes or sprays of blood and body fluids | 623 (92.2) | 625 (92.5) | 419 (62.0) |
| Bending needles before disposal | 569 (84.2) | 287 (42.5) | 357 (52.8) |
| Wearing a gown during the procedures that are likely to generate splashes or sprays of blood and body fluids | 636 (94.1) | 644 (95.3) | 409 (60.5) |
| Droplet precautions | |||
| Patients with a droplet spreading disease should be isolated in a private room. | 625 (92.5) | 660 (97.6) | 496 (73.4) |
| Patients with a droplet spreading disease should be kept apart at a distance of at least 150 cm. | 81 (12.0) | 66 (9.8) | 74 (10.9) |
| Patients with a droplet spreading disease should wear a face mask during transport | 607 (89.8) | 656 (97.0) | 475 (70.3) |
| Masks should be worn when a subject is within a 90-cm distance from a patient under droplet precaution care. | 575 (85.1) | 637 (94.2) | 454 (67.2) |
| Hospital wards should be notified prior to the admission of a patient needing droplet precaution. | 630 (93.2) | 639 (94.5) | 524 (77.5) |
| Airborne precautions | |||
| Patients with an airborne transmissible disease should be isolated in a private room with a negative pressure. | 604 (89.3) | 646 (95.6) | 433 (64.1) |
| The door of the room of a patient with an airborne transmissible disease should always be closed. | 626 (92.6) | 654 (96.7) | 477 (70.6) |
| Wearing a mask is necessary when entering the room of patients with chickenpox or measles. | 599 (88.6) | 645 (95.4) | 472 (69.8) |
| All healthcare workers should be vaccinated with the B.C.G vaccine. | 182 (26.9) | 123 (18.2) | 114 (16.9) |
| Wards should be notified prior to the admission of a patient requiring airborne precautions. | 603 (89.2) | 637 (94.2) | 503 (74.4) |
| The patients requiring airborne precautions should wear a surgical mask during transportation. | 613 (90.7) | 648 (95.9) | 501 (74.1) |
| Contact precautions | |||
| The patients needing contact precautions should be kept in a private room. | 573 (84.8) | 644 (95.3) | 478 (70.7) |
| Wearing gloves on entry and removing them before leaving the room is necessary for the patients needing contact precautions. | 643 (95.1) | 660 (97.6) | 509 (75.3) |
| It is necessary to disinfect hands on the removal of gloves when caring for the patients needing contact precautions. | 603 (89.2) | 640 (94.7) | 490 (72.5) |
| It is necessary to wear a gown on entry to the room of the patients needing contact precautions. | 634 (93.8) | 644 (95.3) | 487 (72.0) |
| Wards should be notified upon the admission of the patient needing contact precautions. | 602 (89.1) | 642 (95.0) | 489 (72.3) |
| It is necessary to dedicate noncritical patient care equipment to the patients needing contact precautions. | 606 (89.6) | 642 (95.0) | 502 (74.3) |
| It is necessary to clean and disinfect all common equipment shared with the patients needing contact precautions. | 591 (87.4) | 621 (91.9) | 446 (66) |
| Double gloving with plastic kitchen gloves used at the hospital will give the same protection as latex gloves. | 399 (59.0) | 421 (62.3) | 214 (31.7) |
a Values are expressed as No. (%).
There were significant positive correlations between knowledge, attitude, and practice in all IP domains in nurses (P < 0.001) and auxiliary nurses, except for the correlation between knowledge and practice in standard precautions (P = 0.099). Among nurses, age significantly correlated with knowledge in airborne precautions (P < 0.001) and with attitude in droplet precautions (P = 0.003) (Table 3).
Table 3.The Correlation of Knowledge, Attitude, and Practice with the Age of Nurses and Auxiliary Nurses
| Isolation Precautions | Nurse | Auxiliary Nurse | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Knowledge | Attitude | Practice | Knowledge | Attitude | Practice | |||||||
| r | P-Value | r | P-Value | r | P-Value | r | P-Value | r | P-Value | r | P-Value | |
| Standard | ||||||||||||
| Knowledge | - | - | 0.488 | < 0.001 | 0.318 | < 0.001 | - | - | 0.578 | < 0.001 | 0.232 | 0.099 |
| Attitude | 0.488 | < 0.001 | - | - | 0.487 | < 0.001 | 0.578 | < 0.001 | - | - | 0.397 | 0.004 |
| Practice | 0.318 | < 0.001 | 0.487 | < 0.001 | - | - | 0.232 | 0.099 | 0.397 | 0.004 | - | - |
| Age | 0.031 | 0.436 | 0.012 | 0.763 | 0.071 | 0.076 | 0.008 | 0.956 | 0.189 | 0.179 | 0.015 | 0.917 |
| Droplet | ||||||||||||
| Knowledge | - | - | 0.461 | < 0.001 | 0.377 | < 0.001 | - | - | 0.425 | 0.002 | 0.329 | 0.017 |
| Attitude | 0.461 | < 0.001 | - | - | 0.595 | < 0.001 | 0.425 | 0.002 | - | - | 0.296 | 0.033 |
| Practice | 0.377 | < 0.001 | 0.595 | < 0.001 | - | - | 0.329 | 0.017 | 0.296 | 0.033 | - | - |
| Age | 0.062 | 0.123 | 0.117 | 0.003 | 0.046 | 0.256 | 0.079 | 0.579 | 0.054 | 0.704 | 0.020 | 0.891 |
| Airborne | ||||||||||||
| Knowledge | - | - | 0.529 | < 0.001 | 0.430 | < 0.001 | - | - | 0.313 | 0.024 | 0.345 | 0.012 |
| Attitude | 0.529 | < 0.001 | - | - | 0.612 | < 0.001 | 0.313 | 0.024 | - | - | 0.555 | < 0.001 |
| Practice | 0.430 | < 0.001 | 0.612 | < 0.001 | - | - | 0.345 | 0.012 | 0.555 | < 0.001 | - | - |
| Age | 0.147 | < 0.001 | 0.064 | 0.108 | 0.057 | 0.158 | 0.102 | 0.470 | 0.082 | 0.566 | 0.008 | 0.954 |
| Contact | ||||||||||||
| Knowledge | - | - | 0.582 | < 0.001 | 0.494 | < 0.001 | - | - | 0.679 | < 0.001 | 0.546 | < 0.001 |
| Attitude | 0.582 | < 0.001 | - | - | 0.609 | < 0.001 | 0.679 | < 0.001 | - | - | 0.575 | < 0.001 |
| Practice | 0.494 | < 0.001 | 0.609 | < 0.001 | - | - | 0.546 | < 0.001 | 0.575 | < 0.001 | - | - |
| Age | 0.033 | 0.410 | 0.000 | 0.996 | 0.047 | 0.240 | 0.080 | 0.573 | 0.127 | 0.369 | 0.122 | 0.390 |
Regarding KAP scores, nurses had significantly better knowledge (P = 0.037) and attitude (P = 0.009) scores in standard precautions compared to auxiliary nurses. Women had significantly better attitude and practice scores in all IP domains (P < 0.05) and better knowledge scores in all IP domains but droplet (P = 0.320) and contact (P = 0.138) precautions compared to men. The participants taking part in previous training sessions delivered higher knowledge scores in standard (P = 0.003), droplet (P = 0.002), airborne (P < 0.001), and contact (P < 0.001) precautions, higher attitude scores in standard (P < 0.001), and contact (P < 0.001) precautions, and higher practice scores in droplet (P = 0.001), airborne (P = 0.011), and contact (P = 0.004) precautions (Table 4).
Table 4.Comparing KAP Scores Between Participants According to Their Occupation, Gender, and Previous Training
| Variables | Isolation Precautions | |||
|---|---|---|---|---|
| Standard | Droplet | Airborne | Contact | |
| Knowledge Score (Mean ± SD) | ||||
| Occupation | ||||
| Nurse | 8.14 ± 1.32 | 3.72 ± 0.84 | 4.77 ± 1.03 | 6.89 ± 1.45 |
| Practical | 7.65 ± 1.6 | 3.75 ± 0.7 | 4.80 ± 0.9 | 6.71 ± 0.4 |
| P-value | 0.037 | 0.817 | 0.806 | 0.376 |
| Gender | ||||
| Man | 7.56 ± 1.71 | 3.64 ± 0.68 | 4.51 ± 1.27 | 6.59 ± 1.94 |
| Woman | 8.19 ± 1.2 | 3.73 ± 0.8 | 4.81 ± 0.9 | 6.92 ± 1.3 |
| P-value | 0.002 | 0.320 | 0.039 | 0.138 |
| Previous training | ||||
| Yes | 8.23 ± 1.02 | 3.78 ± 0.75 | 4.87 ± 0.98 | 7.07 ± 1.15 |
| No | 7.78 ± 1.9 | 3.54 ± 0.9 | 4.49 ± 1.2 | 6.33 ± 1.9 |
| P-value | 0.003 | 0.002 | < 0.001 | < 0.001 |
| Attitude Score (Mean ± SD) | ||||
| Occupation | ||||
| Nurse | 37.70 ± 4.71 | 19.90 ± 2.23 | 24.79 ± 3.17 | 34.20 ± 4.72 |
| Practical | 35.90 ± 5.04 | 20.1 ± 2.27 | 24.17 ± 0.3.23 | 34.42 ± 3.97 |
| P-value | 0.009 | 0.519 | 0.174 | 0.744 |
| Gender | ||||
| Man | 35.27 ± 5.13 | 19.31 ± 2.54 | 23.73 ± 3.35 | 32.87 ± 6.16 |
| Woman | 37.90 ± 4.68 | 20.01 ± 2.29 | 24.89 ± 3.14 | 34.41 ± 4.43 |
| P-value | < 0.001 | 0.007 | 0.001 | 0.025 |
| Previous training | ||||
| Yes | 38.10 ± 4.42 | 20.02 ± 2.15 | 24.88 ± 2.93 | 34.67 ± 4.16 |
| No | 36.09 ± 5.42 | 19.65 ± 2.66 | 24.35 ± 3.57 | 32.96 ± 5.72 |
| P-value | < 0.001 | 0.092 | 0.079 | < 0.001 |
| Practice Score (Mean ± SD) | ||||
| Occupation | ||||
| Nurse | 5.60 ± 2.51 | 2.99 ± 1.45 | 3.70 ± 1.76 | 5.3 ± 2.64 |
| Practical | 4.94 ± 2.65 | 3.00 ± 1.34 | 3.61 ± 1.87 | 5.44 ± 2. 38 |
| P-value | 0.075 | 0.969 | 0.730 | 0.785 |
| Gender | ||||
| Man | 4.91 ± 2.73 | 2.68 ± 1.36 | 3.22 ± 1.92 | 4.63 ± 2.76 |
| Woman | 5.64 ± 2.51 | 3.0 ± 1.43 | 3.76 ± 1.72 | 5.45 ± 2.55 |
| P-value | 0.014 | 0.033 | 0.009 | 0.006 |
| Previous training | ||||
| Yes | 5.59 ± 2.58 | 3.10 ± 1.34 | 3.81 ± 1.73 | 5.52 ± 2.52 |
| No | 5.41 ± 2.63 | 2.68 ± 1.54 | 3.38 ± 1.98 | 4.85 ± 2.76 |
| P-value | 0.425 | 0.001 | 0.011 | 0.004 |
4. Discussion
Healthcare workers, individually and collectively, must have a high level of understanding and compliance with the guidelines developed to protect themselves, their team, and patients from acquiring a communicable disease (12). The understanding and practice of precautions by all HCWs in non-pandemic conditions are pivotal to develop an enduring safety habit that will transfer safely to the pandemic time, such as COVID-19 (13).
Our current knowledge suggests that COVID-19 is transmitted directly via droplets or indirectly by contact with opportunistic airborne spread in poorly ventilated spaces (13). To protect both HCWs and patients, the WHO (13) recommended contact precautions, while the Center for Disease Control (14) recommended airborne precautions. The majority (75% or more) of our participants were equipped with adequate knowledge to protect themselves. Comparing the scores of different precaution domains showed that the participants scored lower in the practice dimension compared to the knowledge or attitude across all the four precaution domains. The exception was the low proportion of participants with sound knowledge, attitudes, and practice around physical distancing, BCG vaccine, and inappropriate double-gloving with kitchen gloves for protection. Previously, Shirazi healthcare workers were found to score sub-optimally for compliance with contact, standard, and isolation precautions (9-11). Over years, training programs (lectures, workshops, etc.) have been provided for all new staff; however, these classes seem to have had a non-significant impact. In a study in 2012, hand hygiene performance and mask use were poor among HCWs in an Iranian ICU, with low practice scores for these two precautions (15). Earlier in 2010, 1500 nurses in China were found to have poor compliance with standard precautions (16). In 2015, HCWs’ compliance with standard precautions was low in Brazil (69%) and Hong Kong (57%) (17). We noticed that the majority of our HCWs had good knowledge and attitudes but poor practice, which was similar to the results of a study on nurses in the USA (18) where 94% of American nurses had appropriate knowledge about standard precautions, yet only 62% actually adhered to these precautions (18). Similarly, 90% of HCWs in Jordan scored good at knowledge about isolation precautions, while only 65% of them complied with the precautions, which was also the case in Pakistan. In another study, only 56% of 2000 nurses and physicians, working at a teaching hospital in Switzerland who had adequate knowledge about correct precautions also had acceptable practice about it. (19-21). Nurses and midwives in Yazd, Iran, were reported to have a moderate level of knowledge and attitude, yet their level of practice was low (22). Also, 70% of Vietnamese HCWs demonstrated adequate knowledge and attitude, while only 46% of them applied that knowledge in practice (23).
There was a positive linear correlation between our participants’ knowledge and practice in the most domains of IPs, which was similar to the findings of other studies (9-11, 23, 24). As a whole, better knowledge and attitude could positively affect practice; however, these parameters are not the only predictors (25). Hospital managers should identify various factors affecting nurses’ compliance with isolation precautions and implement effective intervention programs to improve their performance.
Evaluating the association between demographic characteristics and KAP scores showed that in some IP domains, nurses had better knowledge than auxiliary nurses, but there were no significant differences between nurses and auxiliary nurses regarding attitude and practice. Women had better KAP scores than men in almost all IP domains, and taking part in training sessions predicted a higher level of knowledge in all and better attitudes and practice in most IP domains.
Similar to the results of this study, participation in training sessions (21, 26, 27), gender (22, 25), and job (24, 28) were reported to be significantly associated with KAP scores. The results of some studies, however, did not show significant differences in KAP scores considering participation in training sessions (19) and gender (15, 16). Holding effective training courses and using new training methods can improve nurses’ KAP scores. Men and practical nurses should be given priority to participate in such training programs.
Nurses are at the front line of COVID-19 management, and their health is very important. This study tried to describe the status of infection control practices in one of the biggest hospitals in Iran. The results of this study were based on self-reporting. Therefore, the participants may have reported their practice better than their actual compliance. Observing nurses’ compliance in future studies can help estimate nurses’ practice more accurately.
4.1. Conclusions
Compliance with IPs is not adequate among nurses and auxiliary nurses in Nemazee hospital. Our study highlighted a gap between knowledge, attitude, and practice of nurses in one of the biggest hospitals in Iran. Those responsible for infection prevention and control programs in our hospital must address the poor practice of nurses and auxiliary nurses to warrant the safety of individuals, health care teams and workers, and patients.
