Knowledge, Attitude and Practice Regarding Universal Precautions among Nursing Students

Transcription

1 Knowledge, Attitude and Practice Regarding Universal Precautions among Nursing Students Rajinder Kaur, Baljit Kaur, Indarjit Walia Abstract : The study was conducted in the months of September and October 2007 at Government Multi Specialty Hospital, Chandigarh. The study aimed at evaluating the knowledge, attitude and practice of nursing students regarding universal precautions. Students of parent institute and of institutes which make their students visit the GMSH for clinical experience were taken as subjects. These respondents were 144 in number. The study revealed that mean age of the students was 20.3 Years, almost all the students were females and about 80% of the students had senior secondary certificate while remaining were graduates. About 72% of the students were in the third year of their professional training. The mean knowledge score regarding universal precautions was calculated to be and that of practice score was These scores were almost directly proportionate to year of the training of students. Key words : Universal Precautions, Knowledge, Practice, Students. Correspondence at : Rajinder Kaur Nursing Tutor, School of Nursing, Government Multispecialty Hospital, Sector 16, Chandigarh. Introduction Universal precautions are the infection control techniques that were recommended following the AIDS outbreak in the 1980s. Essentially it means that every patient is treated as if they are infected and therefore precautions are taken to minimize risk. No doubt, universal precautions are good hygiene habits, such as hand washing and the use of gloves and other barriers, correct sharps handling, and aseptic techniques. 115

2 Additional precautions are used in addition to universal precautions for patients who are known or suspected to have an infectious condition, and var y depending on the infection control needs of that patient. Additional precautions are not needed for blood-borne infections, unless there are complicating factors. Universal precautions are recommended not only for doctors, nurses and patients, but for health care support workers. Some suppor t workers, most notably laundry and housekeeping staff, may be required to come into contact with patients or body fluids. 1 All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure during contact with any patient's blood or body fluids that require universal precautions. Gloves should be worn: for touching blood and body fluids requiring universal precautions, mucous membranes, or non intact skin of all patients, and for handling items or surfaces soiled with blood or body fluids to which universal precautions apply Gloves should be changed after contact with each patient. Hands and other skin sur faces should be washed immediately or as soon as patient safety permits if contaminated with blood or body fluids requiring universal precautions. Hands should be washed immediately after gloves are removed. Gloves reduce the incidence of blood contamination of hands during phlebotomy, but they cannot prevent penetrating injuries caused by needles or other sharp instruments. In addition, the following general guidelines apply: Use gloves for performing phlebotomy when the health care worker has cuts, scratches, or other breaks in his/her skin. Use gloves in situations where the health care worker judges that hand contamination with blood may occur. Use gloves for performing finger and/ or heel sticks on infants and children. Use gloves when persons are receiving training in phlebotomy. 2 All sharps should be handled with extreme care. They should never be passed directly from one person to another, and their use should be kept to a minimum. Do not recap used needles by hand; do not remove used needles from disposable syringes by hand; and do not bend, break, or other wise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades and other sharp items in punctureresistant containers for disposal. Punctureresistant containers must be readily available, close at hand, and out of reach of children. Sharp objects should never be thrown into ordinary waste bins or bags, or to rubbish heaps or into waste pits or latrines. 3 Cover any existing cuts or lesions with a waterproof dressing, paying par ticular attention to hands and forearms. Any staff with chronic skin lesions to hands or forearms or persistent skin problems should avoid invasive procedures and seek advice from the Occupational Health Depar tment. 4 Hand washing is one of the most impor tant defenses against the spread of infectious 116

3 disease. Hands should always be washed with soap and running water following contact with blood or other potentially infectious body secretions, even if gloves have been used for the task. Do remember that hand washing is the most effective way to reduce the spread of disease. Here is a brief review of the method of hand washing: Use of liquid soap is best with warm running water. Rub hands together vigorously for at least 30 seconds. Remember all sur faces including thumbs, wrists, back of hands, between fingers and around and under nails. Rinse hands well, letting water drain from wrists to fingers - don't turn off faucet. Dry hands with paper towel, then use same towel to turn off faucet. Discard towel. 5 Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated. Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated (e.g., autopsies, or thopaedic surgery). 6 One study done by Snowden L in Canterbury Christ Church College, England was aimed to examine whether a 3-year programme of nursing studies enabled nursing students to graduate from the course with greater knowledge and more positive attitudes towards HIV infection and AIDS than when they began the course. Students on a maths and information technology course were used as controls. The study involved the use of a questionnaire which gathered information about students' experience, knowledge, attitudes and moral judgment regarding HIV infection and AIDS. The experimental hypothesis stated that nursing students would show a greater increase in knowledge and positive attitude change towards HIV infection and AIDS than maths students. The results showed significant differences between third year nursing students' knowledge about HIV and AIDS when compared with other groups but it was noted that knowledge levels for all groups was quite low. There was no difference between first and third year nursing students' attitudes and moral judgment about HIV and AIDS but there was a significant difference between nursing students and students of mathematics. It was suggested that there is a need to modify nurse education programmes in order to have greater impact on this topic area

4 Another research on needle stick injuries (NSI) done in Taiwan by Judith Shu- Chu Shiao, et al concluded that the majority (70.1%) of NSI occurred in the patient's room. Hollow-bored needles contributed to half (219/438) of the NSIs of which 86.8% were syringe needles. Just over half (53.2%) of those items involved in NSIs had been used on patients. Of the hollow-bored needles involved in NSIs, 21.5% had been used on a patient with an infectious disease. 8 One study done on the student nurses at the University of Ibadan, Nigeria, examined the impact of systematized education's impact on their knowledge, attitudes and compliance with universal precautions. This paper reports the findings of a study which examines changes in a group of B.Sc. Nursing students' perceptions, knowledge of and attitudes towards human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/ AIDS), occurring from attempts at a systematized education for the cohort. Based upon a 3-month study of 141 registered nurses enrolled in the programme, it investigates alterations in knowledge and attitudes resulting from intense instruction on HIV/AIDS, AIDS patient care, and compliance with universal precautions. With regard to knowledge enhancement and attitudinal transformation, the research reveals that a number of positive changes occurred over the period of the study. Not only were the nurses better informed about AIDS than previously, but their attitudes towards the disease and patient care had become considerably more liberal, as well as their disposition to comply with universal precautions. The conclusion emphasizes that it is very important for education about HIV/AIDS to be incorporated within current undergraduate and in-service training programmes for nurses. 9 A study, on the universal precautions' training of preclinical students showed that Universal precautions' knowledge scores increased significantly af ter training (P < ). Personal assessments of the risk of developing HIV due to patient care significantly decreased (P < ) and willingness to provide care for AIDS patients increased (P = 0.004). Importantly, students reported that high expected rates of contact with HIV-positive and other patient groups would not significantly affect their specialty choice. Observed compliance with universal precautions procedures during practical training ranged from 95-99% for glove use, 76-77% for direct sharps disposal without needle recapping, and 56-78% for hand washing af ter glove removal during phlebotomy and intravenous catheter inser tion. The study concluded that such programs were effective in increasing students' knowledge of universal precautions. Training favorably affects students' willingness to care for HIV-positive patients and their assessed risk of developing occupational blood borne infection. 10 Another study titled, "Compliance with universal precautions: knowledge and behavior of residents and students in a depar tment of obstetrics and gynecology" done at USA showed that thirty residents (100%) knew the appropriate barrier 118

5 equipment required for each type of procedure performed. One student (< 1%) did not know that booties were appropriate for the surgical procedures. Rationale for lack of compliance with universal precautions elicited by the questionnaire included time constraints (64%), inconvenience (52%), and presumption that patient was not infected (34%). The observed rate of compliance with universal precautions by par ticipants indicates that individual compliance was inversely related to the years of experience (overall compliance rate of students was 96%; for first-year residents, 92%, second-year residents, 89%, third-year residents, 84%, four th-year residents, 78%; r = , P = ). The study concluded that the knowledge regarding universal precautions was nearly 100%, while overall observed compliance was only 89%. Compliance with universal precautions was better among students (96%) than among residents (88%). Compliance with universal precautions was inversely related to years of experience. 11 An impor tant study conducted on senior medical students' knowledge of universal precautions by Koenig S, Chu J, at University of Washington School of Medicine, Seattle US, studied that the questionnaires were completed by 137 (91%) of the students. The mean percentage of correct answers by the responding students was 67%. For five of the ten procedures, from 104 to 123 (76-90%) of the students reported the proper levels of protection. For the remaining five procedures, from 58 to 75 (42-55%) of the students knew the proper levels of protection. The study concluded that the results of the sur vey were worrisome, because many students--immediately before they graduated--lacked adequate knowledge of universal precautions regarding the ten common clinical procedures. This study advocated more emphasis on universal precautions during undergraduate medical education. 12 Though many studies could be quoted from developed nations but there is paucity of data related to nursing students' knowledge, attitude and practices regarding Universal Precautions especially in Indian scenario. Thus the present study was undertaken with the main objective to assess the knowledge and practice of nursing students regarding universal precautions and thereby planning to develop required interventional strategies. Materials and Methods The study was conducted in the Government Multi-Specialty Hospital, Sector 16, Chandigarh which has the strength of 500 beds. It has an emergency unit which is combined with Critical Care Unit, AIDS Cell, 20 indoor wards/ departments and 10 outpatient depar tments. The hospital has one dialysis unit and four major operation theaters and there are three minor operation theaters. The students from various nursing schools and colleges including the school of nursing of parent institute come for clinical practice in the hospital especially in the obstetrics, gynecology and neonatology wards. The purposive sampling technique was followed 119

6 and all the Nursing students were taken for the purpose. The tools used for data collection were Interview schedule for data identification which included 9 questions, Structured Questionnaire for assessing the knowledge regarding universal precautions which included 15 questions and Structured Questionnaire for assessing the practice and attitude regarding universal precautions that contained 25 questions. The tools were validated by the experts. Data was collected during the months of September and October Results Table 1 shows the socio demographic characteristics of the students who participated in the research study. As the table shows, a total of 144 students were the respondents for this study. Age of the students varied from years. The standard deviation of the students was calculated to be ± It is evident that about more than 60% were in the age group of years. The mean calculated for the age is years. The next most accounted category for age group was which had 30% respondents. All the respondents were females with the exception of one male. The reason being that male students are just star ting getting attracted towards this international job oriented course. The academic qualification of students is such that 79.20% of them had senior secondary cer tificate while 20.80% of them were graduates. The graduates included those who after completing their general graduation started the job oriented courses of nursing. Table 1: Socio demographic characteristics of the respondents N = 144 Characteristics f (%) Age of Respondent (in Years) ( 29.9) (62.5) ( 7.6) Mean = S.D. ± Range = Sex Females 143 (99.3) Males 1 ( 0.6) Academic Qualification Senior Secondary 114 (79.2) Graduation 30 (20.8) 120

7 Table 2 shows the distribution of students according to their professional qualification. It shows the course and the course year in which students are presently enrolled in. The students taken for the present study were B.Sc. (total 85) and GNM (total 59) courses. While only third year students were taken from B.Sc. whereas for GNM all three years students participated. The reason for this is that the students of the parent institute gain clinical experience right from the first year itself, whereas the students from other nursing institutes come only for midwifery experience in the third year. Table 2: Distribution of the respondents according to professional qualification N=144 Year of Training f (%) First Year 18 ( 12.5) Second Year 23 ( 16.0) Third Year 103 ( 71.5) Type of Professional Course B. Sc. 85 ( 59.0) G. N. M. 59 ( 40.9) Figure 1 shows the classification of students according to their scores of the knowledge of universal precautions. Neither of the students was below 20 marks nor above 80 marks. The mean marks were calculated 60 to be Those who scored in the category of marks were 52.10% of the total students, while 40.30% of the students scored in the category of marks Students (in percentage) < >80 Marks Obtained Mean Score = Figure 1: Classification according to knowledge score N =

8 Figure 2 describes the scores of the students for their practice of universal precautions. Only 1 student was below the score of 60%, while 60-70% score was obtained by 4.16% of them. Thus, 96% of the students scored more than 70%. Here these figures may be misleading if not seen from the perspective of the seriousness of conforming to guidelines of universal precautions. Each and every student must reach near perfect 100 score because if students are not trained of this grade they will malpractice in their profession which deals with lives of people. Figure 2: Classification according to practice score N = 144 < Marks Obtained < Students (in Percentage) Mean Score = Figure 3 shows the occurrence of frequency of injury among the respondents during last six months. When surveyed, the respondents were asked about any needle prick injury caused to them during last six months during practical hours. It was surprising to know that 54% subjects out of the total of 144 reported injury due to needle prick. Out of the total injured respondents, those got injured once were 25.6% and those who got injured twice were 32%. Students 122

9 with needle prick injury frequency of three and four times were 15.4 and 14.1% respectively. The needle prick caused injury to 6.4% students 5 times. There were 2 students who injured themselves 6 times with needle prick and another 2 students who got this injury 10 times during last six months of their practical classes. One students reported to have been injured 15 times with needle prick. The frequency of injury was higher in the students who in the first year of their training. It is further surprising to know that 61.2% of the B.Sc. 3rd year students got needle prick injury whereas 11% of the GNM students were injured with needle prick Non Injured = 66 Injured = 78 Respondents ( in Percentage) Once Twice Thrice 4 Time 5 Time 6 Time 10 Time 15 Time Frequency of Needle Prick injury Figure 3: Distribution of the Respondents According to Frequency of Needle Prick Injury N =

10 Table 3 shows the comparison of knowledge and practice scores of students of different institutes. The students who get more practice hours do better in practice score. This is irrespective of the course of what they are enrolled in. The mean of GMSH students was for knowledge and for practice. GN College of Nursing students Table 3: Comparison of knowledge and practice scores of different institutions N = 144 Institution Knowledge Score Practice Score (Mean) (Mean) GMSH (GNM) GN CON (B.Sc.) Silver Oaks CON (B.Sc.) GMSH GN CON (GNM) = Government Multi Specialty Hospital, Sector 16, Chandigarh. (B. Sc.) = Guru Nanak College of Nursing, Dhahan Kaleran, Jalandhar. Silver Oaks CON (B. Sc.) = Silver Oaks College of Nursing, Mohali, Table 4 shows change in knowledge and practice quotient of GNM students of different years in the GMSH School of Nursing. When compared, the mean score of knowledge of first and second year students got mean knowledge score and as mean practice score. Mean values for knowledge and practice scores of Silver Oaks College of Nursing were and respectively. This table shows the outperformance of GNM students in practice when compared to their B.Sc. counterparts in the study in terms of years of training. were almost the same (52) but it increased in third year students to Where as the practice score variation in different years was more conspicuous as the practice score increased with an average of about 5%. Table 4: Comparison of knowledge and practice scores of GNM students of different years of training N = 59 Year of Training Knowledge Score Practice Score (Mean) (Mean) First Year Second Year Third Year

11 Discussion Universal precautions are infection control guidelines designed to protect people from diseases spread by blood and certain body fluids. Always assume that all "blood and body fluids" are infectious for blood-borne diseases such as HBV (Hepatitis B Virus), HCV (Hepatitis C Virus) and HIV (Human Immunodeficiency Virus). 13 A total of 144 students were the respondents for this study. Age of the students varied from years. The standard deviation of the students was calculated to be ± It is evident that about more than 60% were in the age group of years. The mean calculated for the age is years. The next most accounted category for age group was which had 30% respondents. The academic qualification of 79.20% students was senior secondary cer tificate while 20.80% of them were graduates. The students taken for the present study were of B.Sc. (total 85) and GNM (total 59) courses. While only third year students were taken from B.Sc. whereas for GNM all three years students participated. Therefore a total of 71.5% students were in the third year of their professional training. Only 16% and 12.5% were in second year and first year of the professional GNM training respectively. Neither of the students was below 20 marks nor above 80 marks in the knowledge score. The mean marks were calculated to be Half of the Students 52.10% scored in the category of marks while 40.30% of the students scored in the category of marks. The results were directly proportionate to the year of training of the students. Still, the performance of students in knowledge score was quite low as no student could get marks more than 80. A study conducted among senior medical students' knowledge of universal precautions concluded that most of the students lacked adequate knowledge of universal precautions. This study advocated more emphasis on universal precautions during undergraduate medical education. Practice of universal precautions shows that only 1 student obtained below 60% marks. Only 4.17% students obtained 60-70% marks, about 96% of the students obtained more than 70% marks. Here these figures may be misleading if not seen from the perspective of the seriousness of conforming to guidelines of universal precautions. Each and every student must reach near perfect 100 score because if students are not trained of this grade they will malpractice in their profession which deals with lives of people. A research conducted on needle stick injuries (NSI) done in Taiwan revealed the worrisome results as about 22% of the respondents were injured with needles which had been used on patient with an infectious disease. Comparison of knowledge and practice scores of students of different institutions shows that students who get more practice hours do better in practice score. This is irrespective of the course they are enrolled in. The mean of GMSH students was for knowledge and for practice. GNCON 125

12 students got mean knowledge score and as mean practice score. Mean values for knowledge and practice scores of Silver Oaks CON were and respectively. This shows the outperformance of GNM students in practice when compared to their B.Sc. Nursing Students counterparts in the study in terms of years of training. One study done by Snowden l in Canterbury Christ Church College, England aimed to examine whether a 3-year programme of nursing studies enabled nursing students to graduate from the course with greater knowledge and more positive attitude revealed that the knowledge level for all groups was quit low. The study suggested a need to modify nurse education programmes in order to increase the understanding of universal precautions amongst students. Present study shows change in knowledge and practice quotient of GNM students of different years in the GMSH School of Nursing over 3 years of course. When compared, the mean score of knowledge of first and second year students was almost the same (52) but it increased in third year students to Where as the practice score variation in different years was more conspicuous as the practice score increased with an average of about 5% and the third year students got 91 as mean marks in practice of universal precautions. The knowledge score creates concerns over the understanding of universal precautions amongst students and therefore there is a need to organize different educational programmes with greater student involvement and at the same time curriculum should also be more student engaging. Recommendations: 1. Administration should initiate in increasing the knowledge and understanding of students regarding universal precautions. 2. Educational programmes regarding universal precautions should be organized for students at the time of commencement of their training and before they graduate the course. 3. The involvement of students in different activities regarding universal precautions should be encouraged and events such as exhibitions, poster making, quizzes, debates and other competitions regarding universal precautions should be organized consistently. 4. There should be qualifying exams for students before sending them to practise in clinical duties. References 1. h t t p : / / e n. w i k i p e d i a. o r g / w i k i / Universal_precautions 2. Division of Healthcare Quality Promotion (DHQP), Atlanta, USA, Universal Precautions. Available from URL : ncidod/dhqp/bp_universal_precautions.html 3. Guidelines for HIV/AIDS intervention in emergency settings. Available from URL: / /intranet/eha/iascguidelines/ action-sheet7-8.html 4. Universal Infection Control Precautions Pages 16, revised March Available from 126

13 URL : univprecautions.pdf 5. Jane Cotler, Universal Precautions. Available from URL: w w w. c d p h e. s t a t e. c o. u s / p s / h c c / univprecautions.pdf 6. Occupational Safety and Health Standards, U.S. Department of Labor. Available from URL : owa d is p.show_d ocu me nt?p_ta ble= STANDARDS &p_id= Snowden L. An investigation into whether nursing students alter their attitudes and knowledge levels regarding HIV infection and AIDS following a 3-year programme leading to registration as a qualified nurse. Journal of Advanced Nursing Jun 1997; 25 (6): Available from URL: - abs/ /j x 8. Judith Shu-Chu Shiao, Mary-Louise Mclaws, Kun-Yen Huang, Yueliang Leon Guo. Student Nurses in Taiwan at High Risk for Needlestick Injuries The official journal of the American college of epidemiology. April 2002; 12(3): Pages Available from URL: - / /ar ticle/ PIIS /abstract 9. Uwakwe CB. Systematized Education University of Ibadan, Nigeria: impact on knowledge, attitudes and compliance with universal precautions. Journal of Advanced Nursing. August 2000; 32(2): Available from URL : - pubmed/ ? ordinalpos = 3 & itool = EntrezSystem 2. PEntrez. Pubmed. Pubmed_Results Panel.Pubmed_ RVDocSum 10. Diekema DJ, Schuldt SS, Albanese MA, Doebbeling BN. Universal precautions training of preclinical students: impact on knowledge, attitudes, and compliance. Journal of Preventive medicine 1995 Nov;24(6): Available from URL : ? ordinalpos=4 & itool = Entrez System 2. PEntrez. Pubmed. Pubmed_Results Panel. Pubmed_RVDocSum 11. Helfgott AW, Taylor-Burton J, Garcini FJ, Eriksen NL, Grimes R. Compliance with universal precautions: knowledge and behavior of residents and students in a department of obstetrics and gynecology. Available from URL: - nlm.nih.gov/pubmed/ ? ordinalpos = 10 & itool = Entrez System2. PEntrez.Pubmed.Pubmed_Results Panel.Pubmed_RVDocSum 12. Koenig S, Chu J. Senior medical students' knowledge of universal precautions. Journal of the Association of American Colleges. May 1993;68(5): Available from URL: ordinalpos = 3 &i tool= Entrez System2. PEntrez. Pubmed.Pubmed_Results Panel. Pubmed _ RVDocSum 13. Universal Precautions Guidelines. University of Waterloo. Available from URL:- / w ww. h e al th s er vic es. u water loo. c a/ occupationalhealth/universalprecautions.html 127