Improving Nurses' Compliance with Standard Precautions of Infection Control in Pediatric Critical Care Units

Transcription

1 World Journal of Nursing Sciences 3S: 01-09, 014 ISSN -135 IDOSI Publications, 014 DOI: /idosi.wjns.014.3S Improving Nurses' Compliance with Standard Precautions of Infection Control in Pediatric Critical Care Units 1 Randa M. Adly, Fatma M. Amin and Magda Ahamed Abd El Aziz 1 Pediatric Nursing Department, Faculty of Nursing, Ain Shams University,Cairo, Egypt Pediatric Nursing Department, Faculty of Nursing, Mansoura University, Mansoura, Egypt Abstract: Severely ill pediatric patients have a greater risk of acquiring nosocomial infections, however, this problem is greatest in critical care units. Therefore, healthcare professionals have an obligation to follow scientifically accepted standards for infection control to prevent disease transmission amongst pediatric patients or among patients and healthcare professionals. This study aimed to improve the nurses compliance with standard precautions of infection control in pediatric critical care units. Research design was a quasiexperimental design. Settings: four pediatric critical care units (medicine, surgery, cardiac and neonatal intensive care unit) at El Mansoura University Children's Hospital. Purposive samples of 60 nurses working in the previously mentioned settings were used. Tools of data collection included 1- Structured interview questionnaire to assess nurses' knowledge and barriers regarding standard precautions of infection control - Nurses Observational checklists to assess nurses practices regarding standard precautions of infection control. 3- Nurses' self-reported compliance with SPIC to assess the nurses' compliance with standard precautions of infection control 4-Educational and training intervention for nurses. Results revealed that there was a significant improvement in nurses' compliance as well as their knowledge and practices toward standard precautions of infection control after the intervention. In conclusion:, the intervention of the study improved the nurses' compliance with standard precautions of infection control by increasing their knowledge and practices. For recommendation, availability of all facilities and equipment required for applying SPIC as well as, the accessibility of written guidelines and emphasize on the importance of continuing in service education for nurses using the evidence-based practices for application of standard precautions of infection control. Key words: Infection control Standard precautions Nurses' compliance Pediatric critical care INTRODUCTION setting. It is intended to protect health care workers from percutaneous injuries and prevent transmission of Pediatric nurses are at risk of occupational nosocomial infection that to be applied to the care of all exposure to infection associated with clinical, di- patients in all health care setting regardless of the agnostic and therapeutic procedures [1]. Therefore, suspected or confirmed presence of an infectious agent nurses' compliance with standard precautions of infection [6, 7]. Hence, nurses' strict adherences constitute an control guidelines and preventive measures is crucial to important factor in determining the rate of hospital prevent the transmission of infectious pathogens []. associated infections [8]. The pediatric patients are faced with increased risks of The Compliance of pediatric nurses with the standard nosocomial infections and so life-threatening conditions precautions of infection control has been recognized as because of the lack immunity to many pathogens, use of being an efficient means to prevent and control invasive procedures and devices and frequent exposure healthcare-associated infections. Such measures not only to broad spectrum antibiotic agents [3-5]. protect the pediatric patients, but also the nurses and the Standard precautions are a set of guidelines designed environment [6,8]. However, several studies indicated that to reduce the risk of acquiring occupational infection from better knowledge of standard precautions among health both known and unexpected sources in the healthcare care workers was one of the predictors of better Corresponding Author: Fatma M. Amin, Pediatric Nursing Department, Faculty of Nursing, Mansoura University, Mansoura, Egypt. f.amin@mu.edu.sa. 1

2 compliance [9, 10]. Other reported factors that contribute to non-compliance with the standard precautions include lack of understanding and knowledge among health care workers on how to properly use protective barriers, lack of time, lack of resources and lack of proper training [5, 11, 1]. The cornerstone of efforts to reduce infection in the critical pediatric departments is an effective infection prevention and control program to improve the nurses' compliance with standard precautions of infection control [13]. Therefore, education has been identified both nationally and internationally that as a part of any overall strategy for infection prevention and control in health care settings. Interventional measures have been proposed as a key strategy to minimize exposure of pediatric nurses and pediatric patients to infection with the implementation of standard precautions as one of the strategies [11]. Pediatric nurses have a critical role in the prevention efforts while, they are an important population to study their level of knowledge, performance and compliance regarding infection control measures [14]. By obtaining their compliance with the standard precautions, the incidence of infectious disease outbreaks and the risk of occupational exposures could be minimized [15]. MATERIALS AND METHODS Aim of the Study: The aim of this study was to improve the nurses compliance with standard precautions of infection control in pediatric critical care units. Research Hypothesis: The study hypothesized that, the compliance of pediatric nurses with standard precautions of infection control in pediatric critical care units might be improve after the implementation of the study through improving their knowledge and practices. Research Design: To carry out this study, a quasiexperimental design (Pre and post intervention study design) was used. Setting: The study was conducted at 4 pediatric critical care units (medicine intensive care unit, surgery intensive care unit, cardiac intensive care unit and, neonatal intensive care unit) at El Mansoura University Children's Hospital. While, the admission of pediatric critical conditions necessitates the compliance with standard precautions of infection control. Subjects: The subjects of this study included a purposive sample of 60 nurses working in the above mentioned settings (18 nurses in medicine intensive care unit, 6 nurses in surgery intensive care unit, 6 nurses in cardiac intensive care unit and, 30 nurses in the neonatal intensive care unit). The inclusion criteria were included, willingness to participate in the study and having at least 3 months' work experience in the study settings; while this a period that the nurses are supposed to be acquired the policy of infection control. The exclusion criteria were included the head nurses while, they were busy with the administrative issues in the study settings. Tools for Data Collection it Included Four Tools Tool I: Pre-designed questionnaire sheet for nurses (pre, post and follow-up). It was designed by the researchers in an Arabic language after reviewing of the related literature. This tool was comprised of the following parts:- Part 1: Characteristics of nurses such as age, education, setting, years of experience and the attendance of previous training concerning the standard precautions for infection control. Part : Nurses knowledge about standard precautions of infection control (Definition, aim, indications, hand washing, use of personal barriers, handling the sharp objects and waste disposal. Scoring System: Total questions were 5 questions, the correct answer was given a score of one and the incorrect a score of zero. The total score of knowledge ranged between 0-5. Nurses scored less than 75%, their knowledge considered unsatisfactory, however, scores 75 % and more considered satisfactory. Part 3: This part was concerned with the assessment of nurses barriers for application of the standard precautions of infection control in the pediatric critical care units and assessed before the intervention only. Tool II: Observational checklists to assess nurses practices regarding the standard precautions of infection control, that were adopted from Craven[16] and Hirnle and Perry et al. [17] (pre, post and follow-up). It covered 4 main items with 36 steps related to hand washing was (16 steps), gloving was (3 steps), gowning was (8 steps) and masking (9 steps). The nurses' actual practices were assessed by the researchers using the checklists by direct and indirect observation.

3 The scoring system: one score was given for done anonymity and the confidentiality of their replies. Written correctly and zero for not done or done incorrectly. consent was obtained from nurses who accepted to take The total score of practice ranged from 0-36.However, part in the study. scores less than 75% are considered unsatisfactory practices & scores from 75 % and more are considered Methods: Once permission was granted to proceed in the satisfactory. current study, the researchers initiated the data collection phase. Data were collected from May 013 to January Tool III: Nurses' self-reported compliance with standard 014.The purpose and nature of the study were explained precautions of infection control (pre, post and follow-up). by the researchers for the nurses included in the study. This Likert type scale was adopted from Siegel et al.[6]., The assessment phase in the first time was done for all Chan et al. [18]and Berman et al. [19] to assess the nurses at the beginning of the study as a baseline nurses' self-reported compliance with standard measure before implementing the intervention (pretest) precautions of infection control. The area addressed and to assess the nurses' needs. The second time was 16 within this scale included 6 main items related to hand weeks (4 weeks for each unit) after the intervention washing (10 sub-items), gowning (15 sub-items), waste (posttest) to assess the effect of intervention on disposal (5 sub-items), handling sharp disposal (3 sub- improving nurses' compliance, knowledge and practice items), gloving (3 sub-items) and masking (3 sub-items). with standard precautions of infection control. The nurses were asked to pick out among the three Meanwhile, the third time was 3 months after the responses ("never", "sometimes" or "always"). intervention (Follow-up), two weeks the time required in each phase. The Scoring System for Compliance: This scale contains Researchers were available three days weekly in the 39 sub-items, the scores ranged from 0 "never" to study settings, while the actual work started by meeting "always". the nurses and giving them a brief idea about the study and its aim. All nurses were assessed for their knowledge, Tool IV: Educational and training contents were designed practices and their compliance by using the study tools. in an Arabic Language by the researchers based upon the While, the questionnaire sheet and self-reported actual needs assessment of nurses. It was also compliance tools were administered to be fulfilled by the supplemented with information based on a review of nurses at the end of their work, both took about 45 relevant literature (textbooks, journals and internet minutes to be fulfilled. As regards the observational resources).the contents were reviewed by a panel of checklist it was assessed by the researchers throughout experts before its implementation. their daily work, time consumed about 45 minutes for fulfilling this tool. According to the deficit needs of the Tools Validity: The content validity of study tools was nurses, the contents of a guideline booklet concerning the approved by experts in the pediatric nursing and standard precautions of infection control was prepared infection control field. According to their comments some and given to the nurses. The intervention was achieved items were eliminated, added and some were modified. through training sessions (1 sessions )which conducted The reliability was confirmed by Cronbach's alpha by the researchers, 4 sessions for theory which include coefficient (0.81). (Definition, aim and the indications of standard precautions of infection control, hand washing, use of Pilot Study: A pilot study was carried out on 10 nurses to personal barriers, handling sharp objects and nurses' test the clarity, completeness, the objectivity of the study response toward barriers of applying standard tools and also, to determine the time required to be precautions of infection control) and 8 sessions for fulfilled. According to the results of the pilot study, the practice which include (hand washing, gowning, gloving, necessary modification, omissions and/or additions were masking, eye shield goggle and apron, sharp disposal and performed. waste disposal). Nurses were divided into subgroups not more than 10 nurses. Three sessions were conducted Ethical Consideration: Permission to conduct the study weekly throughout their working time, the sessions were was obtained from the study administrative authorities repeated for different groups in the same day. The and confidentiality was assured. It was emphasized to all duration of time in each session was about 50 minutes, the nurses included in the study that, their participation will basic content was the same for all groups. Methods of be voluntary also; they were assured about the teaching included modified lecture, demonstration and re- 3

4 demonstration and group discussion in addition to while, more than two third of them (68.3%) had an audiovisual materials and handouts as suitable teaching experience less than five years. The majority of nurses aids. The effect of intervention was evaluated by (85%) mentioned that, there is no available guideline comparing the results of pre and post test and three concerning standard precautions for infection control. months after (follow-up). Although, 75% of them had attained previous training program. Statistical Analysis: The collected data were organized, Figure 1 illustrates nurses' distribution regarding tabulated and statistically analyzed using SPSS version 19 barriers for applying standard precautions of infection (Statistical Package for Social Studies) created by IBM, control. It reveals that, the most frequently reported Illinois, Chicago, USA. For numerical values, the range barriers to apply these precautions were inadequate mean and standard deviations were calculated. The equipment, limited number of nurses in the unit, differences between mean values at different periods of ineffectiveness of the precautions and insufficient time measurements were analyzed using repeated measurement (86.7%, 86.7%, 43.3% and 36.7%) respectively. analysis of variance. (F). When analysis of variance was Table reveals nurses' knowledge about standard found significant, least significant difference test was precautions of infection control, this table reveals that used to compare between each two groups. For there was a statistical significant difference before, categorical variable the number and percentage were immediately after the intervention and at follow up. calculated. Pearson s, correlation coefficient, tested the Where, 91.7 and 63.3% of nurses had a satisfactory relations between two variables. For comparison of knowledge about the aim and the indications of standard observation of variables presented in number and precautions immediately after the intervention compared percentage at different series of measurements, Friedman to 83.3% and 38.3 % of them at follow-up respectively. As X test was used. The level of significant was adopted at regards the nurses' knowledge about the hand washing, p<0.05. use of personal barriers and handling sharp objects a statistical significant difference was found (X 7.511, RESULTS 6.& respectively) after the intervention. Nevertheless, there is no statistical significant difference Table 1 shows the characteristics of studied nurses, it is obvious from this table that, more than one third of them (35%) aged from 0 to less than 5 years and, the minority of them (6.7%) was less than 0 years. Concerning their educational level it was found that, 71.7% of nurses had a bachelor degree in nursing. Only, 10% of them had more than 10 years' experience concerning nurses' knowledge about the waste disposal in the unit. Table 3 shows the mean values for nurses' practices related to standard precautions of infection control, this table reveals that, there was a highly statistical significant difference before, immediately after the intervention and, at follow-up. Fig. 1: Nurses' distribution regarding barriers for applying standard precautions of infection control (no. =60) 4

5 Table 1: Characteristics of the studied nurses Variables Number (n=60) % Age in years: <0 ys ys ys ± ys Educational level: Diploma in nursing Bachelor in nursing Years of experience: 3 mo. - < 5ys ys. < ys. < Setting Medicine intensive care unit Surgery intensive care unit 6 10 Cardiac intensive care unit 6 10 Neonatal intensive care unit Previous training program Yes No Availability of hospital guidelines related to standard precaution for infection control Yes No Table : Nurses' knowledge about the Standard precautions of infection control before, immediately after the intervention and at follow up (no.=60) Before Immediately after At follow up Nurses' Knowledge N % N % N % X p. value -Definition of standard precautions Aim of standard precautions * -Indications of standard precautions ** -Hand washing ** -Use of personal barriers * - Handling sharp objects ** - Waste disposal *: Statistically significant at p < 0.05 **: Highly statistically significant at p < Table 3: Mean values of nurses' practices concerning the standard precautions of infection control before, immediately after the intervention and at follow up (no. =60) Nurses' practices Before mean±sd Immediately after mean±sd At follow up mean±sd F. P. Value Hand washing 7.03± ± ± ** Gloving 1.75± ± ± ** Gowning 4.83± ± ± ** Masking.87± ± ± ** **high Significant difference (P<0.001). Table 4: Nurses self-reported compliance with standard precautions of infection control before, after the intervention and at follow-up (no. = 60) Item Before ± SD Immediately after ± SD At follow up ± SD F. P. Value -Hand washing 4.0± ± ± ** -Gowning 6.15± ± ± ** -Waste disposal 6.57± ± ± # - Handling Sharp objects 6.00± ± ± # - Gloving.03± ± ± ** - Masking 9.35± ± ± ** *Significant difference (P<0.05) **High Significant difference (P<0.001) # Significant difference only between before and immediately after the intervention 5

6 Table 5: Mean values of total nurses' knowledge, practices and compliance before the intervention, immediately after and at follow-up (no. = 60) Item Before Mean±SD Immediately after Mean±SD At follow up Mean±SD F. P. Value Knowledge 8.88± ± ± * Practice 16.48± ± ± ** Compliance 74.30± ± ± ** *Significant difference (P<0.05) **High Significant difference (P<0.001) Table 4 indicates the nurses self-reported compliance Researchers in this study believe that easy access of with standard precautions of infection control, this table guidelines will help the nurses in the continuity of the illustrates that there was an improvement professional nursing role. In our study, unavailability of immediately after the intervention and, at follow-up. guidelines was reported by the majority of nurses. In this While, high significant statistical differences were found context, it was mentioned in a study conducted by Qalawa in relation to hand washing, gowning, gloving and et al. [] about the factors that influence nurses' masking (F. =13.675, F. =3.56, F. =10.38 and F. = compliance with standard precaution while, it was respectively). reported by the majority of nurses that the guidelines Table 5. indicates the mean values of total nurses' located in the head nurse's office. Also, they knowledge, practices and compliance before the recommended in their study with paying adequate intervention, immediately after and at follow- up. As attention and efforts towards education in terms of evident that, the nurses had a higher score of knowledge training and retraining about standard infection control. (31.8±.91), practices (34.78±3.73) and, compliance with This was supported in this study while, three quarters of standard precautions of infection control (99.45±17.14) nurses attained previous training program related to our immediately after the intervention while, this improvement study topic. These results emphasized by Sopirala et al. reflected a highly statistically significant difference. [3] who stated that, without clear orientation and enough training for nurses, no clear outcomes could be achieved. DISCUSSION In an attempt to identify factors that affect on the compliance with standard precautions of infection control Pediatric patients in critical care units are considered among nurses in the current study, nurses attributed their very susceptible to nosocomial infections due to the lack of compliance due to inadequate equipment, increase hospital environment and their exposure for multiple the number of sick children with the limited number of invasive procedures [18]. Nurses' compliance with nurses in the unit and their believe that, ineffectiveness of standard precautions of infection control play an standard precautions to protect them from infection. This important role in preventing infection for all healthcare finding is in agreement with Ibrahim et al. [4], who professionals, not only for their health, but also to reduce assessed infection control practices in a neonatal nosocomial infections and thus improve the patient' intensive care unit and attributed the lack of compliance safety [0]. Therefore, this study aimed to improve the with the standard precautions of infection control to lack nurses compliance with standard precautions of infection of knowledge; poor design of the intensive care unit; high control in critical pediatric units. work load; lack of sustainable resources and As regards nurses' characteristics, findings of this arrangements and lack of training and constructive study revealed that more than two thirds of studied supervision. The same authors emphasized the nurses had less than five years of experience. According importance of compliance with infection control standards to Abolwafa et al. [1] who conduct a study to assess the in-hospital to reduce neonatal morbidity and mortality. effect of educational and training program for nurses' Additionally, Amoran and Onwube [0] found in their about infection control of invasive procedure in neonatal study about infection control and practice of standard units it was mentioned that, nurses working in the precautions among healthcare workers in northern Nigeria emergency departments should be experienced to know that, the majority (98.6%) of the respondents reported that how to be complied with standard precautions of infection the major reason for noncompliance to standard control. From the researchers' point of view, years of precautions is the non availability of the equipments. experience in the emergency departments have a However, Eskander et al.[5] mentioned in their study significant effect on the nurses' knowledge and practices about assessment of nurses' knowledge and evaluation of which result in improving nurses compliance with the their practice regarding standard precautions of infection optimum performance in all nursing aspects of their field. control in selected Egyptian cancer hospital that, lack of 6

7 nurses' adherence to standard precautions of infection The results of this study indicated that, self-reported control when carrying out certain tasks could reflect the compliance with standard precautions of infection control gap between knowledge and practice. among nurses in our study was significantly improved The present study revealed that nurses' knowledge immediately after the intervention while this improvement about standard precautions of infection control were decreased at follow-up. This drop of compliance might be improved immediately after the intervention, in relation to due to inadequate equipment, facilities, lack of continuous (definition, aim, indication of standard precaution, hand education/ trainings and feedback. In addition, various washing, use of personal barriers, handling sharp objects factors ranging from personal to organizational were and waste disposal). This finding is in congruence with responsible for non-compliance with the basic principles the results of the study conducted by Galal et al. [6] who of standard precaution. This improvement in our study is found in their study about the impact of an infection- similar to study conducted by Ching [] who found the control program on nurses' knowledge and attitude in effectiveness of educational programs to improve the pediatric intensive care units (PICUs) at Cairo University knowledge and compliance of health care workers towards hospitals that, there was an improvement in nurses' standard precautions. As, recommended by Eskander knowledge regarding infection-control measures in PICUs et al. [5] that, nurses attending continuing education after implementation of educational program. They also, courses about hospital infection had a positive effect on recommended with the intervention of educational infection control procedures and compliance with barrier training programs which may help healthcare workers to techniques. realize the importance of basic infection-control measures According to the present study findings, in reducing pediatric morbidity and mortality and improvement in the nurses' compliance with standard improving the quality of care. Also, this finding is similar precautions of infection control was correlated with their to Abolwafa et al. [1] who reported that, there was a knowledge and practice. While, this finding reflects that remarkable improvement of nurses' knowledge after the nurses who improved in their knowledge and practice intervention of the training program about standard immediately after the intervention, they improve in their precautions of infection control. compliance with standard precautions of infection control Concerning the nurses' practices in this study as well. The researchers found this finding could be due regarding the standard precautions of infection control, to the effectiveness of the study intervention. This is in the present study showed that, significant improvement agreement with Luo et al. [10], who investigated factors immediately after the intervention and at follow-up related impacting compliance with standard precaution in nursing to hand washing, gloving, gowning and masking. The and indicated that, better knowledge and practice of researchers attributed this that, although, these practices standard precautions among health care workers was one done routinely in their units but, there are some factors of the predictors of better compliance. In this respect, may hinder its' competency such as, work overload, Huang et al. [8] demonstrated that educational unawareness with the correct steps, or inadequate time to interventions positively increased compliance with make the procedure correctly such as hand washing. So, standard precautions by increasing the healthcare these results could reflect the nurses' need to refresh and workers knowledge base and modifying their attitude and update their skills. Moreover, the clinical practices are behavior. At the same point of view, Suchitra and Devi continually growing and changing and, specific clinical [9] who found in their study about the impact of practices may evolve as a result of new evidence. This education on knowledge, attitudes and practices among result is congruent with Abd-alla [7] who study the various categories of health care workers on nosocomial impact of health education on infection control measures infections that, education has a positive impact on in the operating theater, it was found that, inadequate retention of knowledge and practices in all the categories practices related to standard precautions of infection of staff. They recommended that there is a need to control could be due to lack of nurses' awareness with the develop a system of continuous education for all the importance of infection control and safe health practice. categories of staff in order to reduce the incidence of Similarly, Abolwafa et al. [1] stated that, an improvement nosocomial infections while, compliance with among the majority of nurses' knowledge and practice was interventions are mandatory. In addition, Vaz et al [1] found after implementation of the training program about and Livshiz-Riven et al.[30] concluded that, compliance infection control. with infection control procedures is tied to environmental 7

8 factors and organizational characteristics, they. Ching, Y.S., 007. The effectiveness of educational recommended that efforts to improve availability of equipment and promote a safety culture are key and should be offered to high-risk health care workers. programs to improve the knowledge and compliance of health care workers towards standard precautions. M.S. Thesis, University of Hong Kong. 3. Garland, J.S., 010. Strategies to prevent ventilator CONCLUSION associated pneumonia in neonates. Clinics in Perinatology, 37: Based on the results of the present study it can be 4. Al-Tonbary, Y., O. Soliman and M. Sarhan, 011. concluded that, the research hypothesis is accepted while Nosocomial infections and fever of unknown origin it was found that, the intervention of the study significantly improves the nurses' compliance with standard precautions of infection control by increasing their knowledge and practices. Recommendations: Availability of all facilities and equipments required for applying standard precautions of infection control. Availability and accessibility of written guidelines in the hospital and unit polices related to standard precautions for infection control. Emphasizing on the importance of continuing in service education for nurses by using the evidencebased practices for application of standard precautions of infection control. Maintaining patient staff, ratio to avoid shortage of staff and work overload which mentioned as a barrier for compliance. Follow up the nurses compliance/ performance/ utilization of standard precautions of infection control by the infection control team. Providing orientation programs for newly employed nurses about standard precautions infection control. Availability of posters for reminding nurses to comply with standard precautions. ACKNOWLEDGMENT Researchers would like to express their sincere gratitude to the hospital administrating team who helped in facilitating conduction of this study. Great appreciation as well as to the nursing staff who participated in this study. REFERENCES 1. Vandijck, D., I. Cleemput, J. Hellings and D. Vogelaers, 013. Infection prevention and control strategies in the era of limited resources and quality improvement: A perspective paper. Australian Critical Care, 6: in pediatric hematology/oncology unit: a retrospective annual study. World Journal of Pediatrics, 7: Richard A. M.D. Polin, D. Susan, M.D. Michael and T. Brady, 01. Strategies for prevention of health care-associated infections in the NICU, Pediatrics, 19: e1085-e Siegel, J.D., E. Rhinehart, M. Jackson and L. Chiarello, 007. Health care Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Available from 7. Tavolacci, M., J. Ladner, L. Bailly, V. Merle and I. Pitrou, 008. Prevention of nosocomial infection and standard precautions: knowledge and source of information among healthcare students. Infection Control & Hospital Epidemiology, 9: Zimmerman, P., H. Yeatman and M. Jones, 01. Frameworks to assist adoption of infection prevention and control programs. Does the literature exist? Healthcare Infection, 16: Chan, M.F., A. Ho and M.C. Day, 008. Investigating the knowledge, attitudes and practice patterns of operating room staff towards standard and transmission-based precautions: results of a cluster analysis. Journal of Clinical Nursing, 17: Luo, Y., G.P. He, J.W. Zhou and Y. Luo, 010. Factors impacting compliance with standard precaution in nursing, china. International Journal of Infectious Diseases, 14: e1106-e Vaz, K., D. McGrowder, R. Alexander-Lindo, L. Gordon, P. Brown and R. Irving, 010. Knowledge, awareness and compliance with universal precautions among health care workers at the University hospital of the West Indies, Jamaica. International Journal of Occupational and Environmental Medicine, 1:

9 1. Efstathiou, G., E. Papastavrou, V. Raftopoulos and.. Qalawa, S.A., S.M. Mahran and E. Alnagshabandi, A. Merkouris, 011. Factors influencing nurses 014. Investigation of factors influencing nurses compliance with standard precautions in order to compliance with standard precaution in critical avoid Occupational exposure to microorganisms: A care areas. Journal of Social Science & Humanities, focus group study. BMC Nursing, 10: : Ward, D., 011. The role of education in the 3. Sopirala, M.M., L. Yahle-Dunbar, J. Smyer, prevention and control of infection: a review of the L. Wellington and J. Dickman, 014. Infection control literature. Nurse Education Today, 31: link nurse program: An interdisciplinary approach in 14. Labrague, L.J., R.A. Rosales and M.M. Tizon, 01. targeting health care-acquired infection. American Knowledge of and compliance with standard Journal of Infection Control, 4: precautions among student nurses. International 4. Ibrahim, Y.S., A.M. Said and G.K. Hamdy, 011. Journal of Advanced Nursing Studies, 1: Assessment of infection control practices in neonatal 15. Aboumatar, H., P. Ristaino, R.O. Davis, L. Maragakis intensive care unit. Egyptian Journal of Community and C.B. Thompson, 01. Infection prevention, Medicine, 9: promotion program based on the precede Model: 5. Eskander, H.G., W.Y. Morsy and H.A. Elfeky, 013. improving hand hygiene behaviors among healthcare Intensive care nurses knowledge & practices personnel. Infection control and Hospital regarding infection control standard precautions at a Epidemiology, 33: selected Egyptian cancer hospital. Journal of 16. Craven, R.F. and C..J. Hirnle, 007. Fundamentals of Education and Practice, 4: nursing human health and education. Philadelphia, 6. Galal, Y.S., J.R. Labib and W.A. Abouelhamd, 014. th. Lippincott Williams &Wilkins, 5., pp: Impact of an infection-control program on nurses' 17. Perry, A.G., A.P. Potter, M.K. Elkin and knowledge and attitude in pediatric intensive care W. Ostendorf, 01. Nursing Intervention and units at Cairo University hospitals. Journal of the Clinical Skills. St. Louis, Mosby, pp: Egyptian Public Health Association, 89: Chan, R., A. Molassiotis, C. Eunice, C. Virene and 7. Abd-alla, A., 008. Impact of Health Education on H. Becky, 00. Nurses knowledge of and infection control measures in an operating theater. compliance with universal precautions in an acute Doctoral Thesis, Tanta University. care hospital. International Journal of Nursing 8. Huang J, D. Jiang, X. Wang, Y. Liu, K. Fennie and Studies, 39: J. Burgess, 01. Changing knowledge, behavior and 19. Berman, A. and S.J. Snyder, 01. Fundamentals of practice related to universal precautions among Nursing Concepts, Process and Practice. Person, New hospital Nurses in China. The Journal of Continuing th. York, London, 9 ed., pp: Education in Nursing, 33: Amoran, O.E. and O.O. Onwube, 013. Infection 9. Suchitra, J.B. and N.L. Devi, 007. Impact of control and practice of standard precautions among education on knowledge, attitudes and practices healthcare workers in Northern Nigeria. Journal of among various categories of health care workers on Global Infectious Diseases, 5: nosocomial infections. Indian Journal of Medical 1. Abolwafa, N.F., W.E. Ouda, F.Z. Mohammed and Microbiology, 5: E.S. Masoed, 013. Developing educational program 30. Livshiz-Riven, I., R. Nativ, A. Borer, Y. Kanatfor nurses' related to infection control of invasive Maymon and O. Anson, 014. Nursing students procedures in neonatal units at EL-Minia university intentions to comply with standard precautions: An and general hospitals. Journal of American Science, exploratory prospective cohort study. American 9: Journal of infection control, 4: