CHAPTER TWO: LITERATURE REVIEW
2.0 Introduction
This chapter presents a review of literature related to the study, and its objectives. In essence, the chapter is presented in three sections; level of compliance to infection control precautions among health workers, institutional factors associated with compliance to infection control precautions among health workers and individual factors associated with compliance to infection control precautions among health workers. The literature was sourced from journals including, the Journal of Global Infectious Diseases, Journal of Obstetrics and Gynecology, International Journal of Infection Control Brazilian Journal of Infectious Diseases, Journal of Health and Pharmacology, Journal of Health Science, Journal of Public Health, International Journal of Cosmetic Science, The Journal of International Society of Preventive Community Dentistry, Indian Journal Medical, Journal of Nursing Studies, American Journal of Critical Care, Journal of Environmental And Public Health, International Journal of Infection Control, American Journal of Infection Control, Journal of Infection Control, Eastern Mediterranean Health Journal, Journal of Infection in Developing Countries, Journal of Infection and Public Health, and Journal of Environmental And Public Health.
2.1 Level of compliance to infection control precautions among health workers
It has been proved by numerous studies that adherence to Standard Precautions among health workers, is lower than the recommended levels (Porto and Marziale, 2016; Haile et al., 2017). Powers, et al. (2016) say that despite published guidelines on infection control and negative health consequences of SP noncompliance, significant issues remain around SP adherence to protect nurses from blood borne infectious diseases, including hepatitis B virus, hepatitis C virus (HCV) and HIV. Some literature has suggested that the adherence rate amongst healthcare workers (HCWs) is less than 50% (Hessels et al., 2016; Pyrek, 2017). In countries like Hong Kong and Brazil, it has been reported that compliance to infection control guidelines is 57.4 and 69.4% respectively among nurses (Lam, 2014; Pereira, Lam, Chan, Malaguti‐Toffano, & Gir, 2015).
Hand hygiene is a major and most effective component of standard precautions because hands are considered the most common vehicle that can transmit pathogenic organisms (FGPS Challenge, 2009; CDC, 2014). Contrary to this fact, CDC (2017) reports that on average, healthcare workers, worldwide, practice hand washing less than half the recommended standards. Moreover, in 2009, the World Health Organization (WHO) designed the recommendations for hand hygiene in healthcare settings which involves the “My five moments for hand hygiene” approach aimed at improving the practice. The approach prompts healthcare workers to clean their hands at five different stages of patient care,“(1) before touching the patient or the patient’s surroundings, (2) before an aseptic procedure, (3) after a body fluid exposure risk, (4) after touching the patient, (5) after touching the patient’s surroundings”(FGPS Challenge, 2009).
Healthcare workers are also encouraged to adhere to the respiratory hygiene and cough etiquette to reduce the spread of infection via respiratory secretions (e.g. mucus and saliva), measures which include covering the mouth or nose when sneezing, use and safe disposal of tissues (CDC, 2016). In addition, hand hygiene should be practiced after contact with respiratory secretions or possibly infectious objects/materials; health providers should avail the materials for adhering to this strategy in patients/visitors’ waiting areas. Furthermore, CDC (2016) recommends that people with signs of respiratory infections should be given a space to sit far away from other patients or visitors. The healthcare facilities should also provide hand hygiene resources, such as dispensers of hand rub (alcohol-based), soap, disposable towels, in or near waiting areas.
However compliance to hand hygiene has been disappointingly low in many health settings (Mathur 2011). According to Aziz (2013), on average health care workers follow recommended hand hygiene procedures less than half of the time. Previous systematic reviews of studies on compliance to hand hygiene conducted in various settings such as hospitals and nursing homes revealed low compliance rates of between 20% and 50% among nurses in developed and developing countries (Ahlström 2014; Abdella et al 2014; Darawad et al 2012:1; Sakihama et al 2014; Muharjan & Mathew 2013; Erasmus et al 2013; Wen-I et al 2013 & Krediet et al 2011). The lowest adherence rate to hand hygiene of 36% was found in intensive care units, where indications for hand hygiene were typically more frequent. The highest adherence rate of 59% was observed in pediatrics wards, where the average intensity of patient care was lower than in other hospital areas.
Similar to other studies, Hessels, et al. (2016) observed that, “Similar to other studies, we found hand hygiene was performed around half of the time when indicated and was more often missed prior to patient contact than after patient contact. Notably, one-quarter of the time when hand hygiene was missed, the HCW was wearing gloves, even when gloves were not indicated. We also found on the other hand that donning gloves or gowns when indicated did not occur during 13 percent and 43 percent of observed encounters, respectively.” They added that, “Appropriate donning of masks and sharps and linen handling were also suboptimal. These findings are concerning given the high burden of HCW sharps injury and blood borne pathogen exposures, transmission risks of epidemic concern, such as influenza, and in the context of accruing evidence of the importance of environmental cleanliness to prevent the spread of healthcare-associated infection.” The researchers emphasize that measuring SP adherence and associated factors using reliable and valid observation and survey tools will allow healthcare administrators and infection preventionists to both target local interventions and measure and benchmark progress internally and externally to improve SP adherence.
In a review of 96 studies by Erasmus et al. (2010) on adherence to hand hygiene guidelines, an overall median adherence rate of 40% was found. Adherence was further studied in a review covering only qualitative studies where it was concluded that low hand hygiene guideline adherence was eminent (Smiddy, O’Connell, & Creedon, 2015). Studies on nursing students’ adherence to hand hygiene guidelines have also been performed, for example by Cruz, Cruz, and Al-Otaibi (2015) who revealed gender differences regarding hand hygiene guideline adherence where women demonstrated higher levels than men. Moreover, Shinde and Mohite (2014) found nursing students to report significantly higher levels of adherence to hand hygiene guidelines compared to the nurses in their study.
According to Jahangiri et al. (2016), a high prevalence of unsafe injection practices and needle stick injuries (NSIs) among healthcare staff has also been reported in developing countries. Approximately 50% of needle stick injuries (NSIs) are among nurses. A South African study was conducted amongst 202 nurses at a regional hospital to depict the incidence and factors associated with needle stick injuries. Thirty eight (18.8%) nurses reported having such injuries in the previous 12 months (Kruger et al., 2012), with 78.3% associated with syringe needles and 28.9% during recapping of needles; only 50% of the injuries were reported to the relevant authorities.
Colet, et al. (2016) surveyed 250 nursing students in a cross-sectional, self-reported study. The majority were females (61 per-cent), single (79.7 percent), enrolled in the regular BSN program (65.3 percent), registered in the final year of the program (53.4 percent), and had attended training or seminars regarding infection control in the last 12 months (88.1 percent). According to the researchers, the students reported highest compliance in disposing of used sharp articles and instruments into sharps-only boxes, with a compliance rate of 84.3 percent, followed by decontaminating hands immediately after removal of gloves (compliance rate, 78 percent), washing hands between patient contacts (compliance rate, 75.8 percent), changing gloves between each patient contact (compliance rate, 74.2 percent), and wearing a surgical mask alone or in combination with goggles, face shield, and apron whenever there was a possibility of a splash or splatter (compliance rate, 72.9 percent). On the other hand, three of the items in the scale received a compliance rate of below 50 percent. The lowest compliance rate was reported in the item on using water only for hand washing (compliance rate, 26.7 percent), followed by placing waste contaminated with blood, body fluids, secretion and excretion in red plastic bags, irrespective of the patient’s infective status (compliance rate, 48.3 percent), and not recapping used needles after administering an injection (compliance rate, 49.2 percent).
Haile (2017) conducted an institution-based cross-sectional study and found that among the healthcare workers who participated in the study, 80.6%, 18.4%, and 39.6% reported that they always wash hands after removal of gloves, before touching patient, and before clean or aseptic techniques, respectively. Only 32.4% of the respondents reported that they always protect themselves against body fluid exposure regardless of the diagnosis of patients while 88.7% of HCWs reported that they always wear gloves whenever there is a possibility of exposure to any body fluids. The compliance of the HCWs with wearing a waterproof apron and eye goggles whenever there is a possibility of body fluid splashing and the compliance of HCWs in segregation of infections and noninfectious wastes into appropriate dust bins were found to be below 50%
Lastly, Maharaj et al. (2012) made a study among 33 doctors randomly selected from two hospitals in New Zealand. The objective was to determine awareness of compliance with SPs by medical staff in Obstetrics and Gynecologic Units. Among the respondents, 30% gave a significant compliance to SP affected by health threats by using goggles (63.6%), wearing gloves (97.0%) and using aprons (75.8%). An anonymous self-administered questionnaire was given to these doctors and its retained result data were analyzed using Microsoft office excel garnering a 95% confidence interval result (p<0.05) as reported. Among the 33 doctors in the gynecology department, those who use full precautions were categorised as consultants (35.7%), registrars (33.3%), senior medical officers (33.3%) and house surgeons (0.0%). This means that <70% of the 33 doctors perceived themselves as non-compliance to the practice of SPs. Just like the previous studies.
In another study by McGaw (2012), the vast majority of respondents, 86%, agreed with the Universal Precautions (UP) guideline that needles should never be recapped. However, in actual practice, only 16, 12%, of respondents stuck rigidly to the guideline (i.e., never recap) while 42% occasionally recapped needles. On the other hand, 39% usually and 7% always recap their used needles. Despite the fact that only 68% of respondents agreed with the policy that ‘facemasks should always be worn by non-scrubbed staff’, the declared rate of compliance with the policy was high (86%). All respondents agreed that the use of eye protection, gloves and gowns was necessary when attending to patients where splashes of body fluids were likely. However, only 56% declared compliance with use of eye protection, 52% amongst physicians and 65% amongst nurses. Ninety-eight percent (98%) of physicians and nurses stated that they wore gloves and 83% that they wore gowns, when touching non-intact skin.
In the study by Sahiledengle (2018) two-thirds (66.1%) of HCWs had good infection prevention practices. Studies conducted in Northwest of Ethiopia (54.2%) (Gulilat, 2014), North Ethiopia (42.9%) (Hu, 2012) and West Arsi Zone,Ethiopia (36.3%) (Morka, 2015) have reported lower compliance. Studies in Edo State, Nigeria (46.8%) (Alice, 2013) and Iran (42%) (Sarani, 2014) have reported lower levels of compliance.
2.2 Institutional factors associated with compliance to standard infection control precautions
External factors may also confer several influences on compliance to infection control guidelines. Among the barriers related to external factors, organizational/institutional constraints are of major importance. Therefore, improvements in the organization of care are necessary, which may be promoted by the standardization of processes and procedures (Lugtenberg, 2009) and the development of protocols (Luitjes, 2010). Environmental factors were the most prominent barrier related to behaviour of doctors and nurses in practicing according to guidelines in a study by Radwan (2017). Particularly, lack of reimbursement, lack of resources, time constraints and lack of clinical audit and feedback (A&F) were often reported as barriers to guideline adherence in that study.
A study in a Kenyan hospital documented motivating factors and barriers to compliance to standard precautions amongst nurses (Moyo, 2013). That study found feeling at risk of contracting infections, continuous supply of IPC materials, regular education and training and offering incentives for positive work performance to be motivating factors for compliance to standard precautions among nurses. Problems with a supply of infection prevention and control equipment and supplies were found to be barriers to adherence (Moyo, 2013).
A related study conducted in Nigerian public secondary health facilities found that the compliance to standard precautions among healthcare workers was below the recommended levels, with the main reason being an inadequate supply of Infection prevention and control (IPC) equipment and materials (Okechukwu and Motshedisi, 2012).
Piai-Morais (2015) found strong magnitude of correlation between the adhesion to SP scale and the availability of PPE, that is, the lower the perception of obstacles to following standard precautions and the higher the climate of security and the availability of PPE, the better the adhesion to SP. There was also a strong correlation between safety climate scale and training for prevention of HIV exposure scales and availability of PPE. According to the author, that indicated that the higher the security climate in the institution, the more one recognizes the need for training and the availability of personal protective equipment.
A study in Nigeria by Unekea et al (2014) outlined a summary of factors associated with noncompliance with hand hygiene identified by nurses and doctors as inadequate supply of water soap and paper towel, inadequate manpower, absence of guidelines on hand hygiene and disinfection practices, unreported consequences of noncompliance the need for regular re-orientation and training of health care workers, the importance of improvement of health facilities. In Australia White et al (2015) cited major themes of barriers to hand hygiene as being too busy (due to heavy work load at the facility), being distracted or forgetful, dealing with emergency situations.
De Wandel et al (2010) on the other hand identified that social pressure, although present, did not have a significant effect on an individual’s hand hygiene conformity, with participants reporting that their noncompliance did not result in negative feedback or criticism from their colleagues. Jackson et al (2013) found that nurses were critical of noncompliant behaviours in their colleagues, but tended to rationalise that same behaviour in their own practice. That study by Jackson et al (2013) identified role modelling, or peer example, as a means of improving practice through display of correct behaviours among colleagues. It was thought that if a right behaviour was repeated and witnessed many times, it would then become the norm of routine hand hygiene practice (Jackson et al, 2014).
2.2 Individual factors associated with compliance to infection control precautions among health care workers
Hospital-acquired infections often occur because of lapses in accepted standards of practice on the part of health care personnel themselves. Thus, compliance may also be influenced by individual beliefs about guideline effectiveness, uncertainty about when and how to use it, perceived interruption of workflow and redundancy with other checklists or processes, resistance to change) and team-related factors (professional hierarchy in the operating room where individual physicians rather than multidisciplinary teams make decisions (Treadwell, 2014; Tang, 2014; Lubbeke, 2013; Russ, 2013; Waehle, 2012; Fourcade, 2012; O’Connor, 2013; Pickering, 2013).
In a study by Naik et al (2014), self-reported reasons for frequent lack of compliance to hand hygiene included individual perceptions like (1) hand washing agents cause skin irritation and dryness, (2) lack of soap or too busy/hand washing takes too long, (3) wearing of gloves; hands do not look dirty; and 4) a perceived low risk of acquiring infection from patients.
In South Africa, Nieuwoudt (2014) carried out a study (discussed in chapter 1) with the aim of establishing personal and contextual factors which effect adherence to standard precautions at public healthcare facilities in the Cape Winelands and Overberg District. Nurses’ attitude, staff shortages and a lack of training were identified as the main factors that impeded adherence (Nieuwoudt, 2014).
Another study was conducted in Northern KwaZulu-Natal (Massinga et al., 2016), South Africa, to describe perceptions of registered nurses regarding factors influencing adherence to standard precautions in operating theatres. Findings showed that compliance to standard precautions was suboptimal and insufficient knowledge was associated with inadequate compliance. In a study conducted by Jain et al (2012) on infection control practices among doctors and nurses in a tertiary hospital in India, it was found that there was a lack of knowledge and practice regarding basic infection control.
In a similar study by Sharma and George (2014) involving 130 nurses, it was found that the staff nurses had good knowledge of standard precautions but low practices of the same; in that study, knowledge was found to be associated with practices. van der Berg and Daniels (2013), in their study among undergraduate nursing students in South Africa, found that there was a lack of knowledge regarding standard precautions and self-practice of standard precautions was poor
Aung (2017) also conducted a study on factors affecting the compliance of Myanmar nurses in performing standard precautions. The study revealed that almost respondents had a good knowledge of prevention standards and 73.5% of respondents had good adherence in taking standard precautions. There was a significant influence between adherence to standard precautions and the incidence of injury due to needle puncture.
Haile (2017) established that being a female healthcare worker, higher infection risk perception, training on standard precautions, accessibility of personal protective equipment, and management support were found to be statistically significant. In this study, female healthcare workers were 2.18 times more likely to be always compliant with standard precautions as compared to male HCWs. The findings of that study also showed that healthcare workers who had taken infection prevention training were 2.9 times more likely to be always compliant with standard precautions as compared to none trained HCWs. In addition to this, HCWs who had more frequent management support towards safety environment at the institution were 2.23 times more likely to be always compliant than those who had less frequent management support.
Further still, according to the literature, major reported factors that affect compliance with standard precautions include but not limited to lack of understanding and knowledge among healthcare workers on SPs (Sreedharan, 2011; Fayaz, 2014), shortage of time to implement the precautions (work overload), limited resources, lack of proper training, uncomfortable equipment, skin irritation, forgetfulness, distance from the necessary facilities, and insufficient support from management in creating a facilitating work environment (Efstathiou, 2011). Moreover, certain socio demographic variables such as age, sex, job category, marital status, working site in the hospital and work experience have also been reported to be associated with compliance with standard precautions (Felix, 2013).
The type of cadre has also been found to be important in determining compliance to SP. A study conducted by Ledibane (2015) described the epidemiology and management of needle-stick injuries between 2008 and 2011 among healthcare workers in Mangaung sub district, Bloemfontein (South Africa). That study reviewed records of staff members who reported needle-stick injuries and 34 cases were reported in this four-year period. The largest number of injuries was amongst nurses – professional (38.2%) and auxiliary nurses (14.7%). Most injuries were linked to administering injections (38.5%) (Ledibane, 2015).
A Brazilian study, by Pereira et al. (2013),among Intensive Care nurses evaluated individual factors related to adherence to standard precautions and found ‘risk-taking personality’ as an example of individual factors associated with low adherence to SPs. The study revealed that nurses were engaged in potentially harmful situations just for the amusement or “preferring unpredictable experiences.”
