Nurses’ Knowledge Regarding Infection Control Standard Precautions at Shar Teaching Hospital in Sulaimani City

Background: Healthcare-associated infections (HAIs) are a major public health problem that can affect a patient's health and quality of life. All healthcare providers should be concerned about patient safety and use standard precautions to minimize infection. Aim: The present study aims to evaluate nurses’ Knowledge regarding infection control standard precautions at Shar Teaching Hospital in Sulaimani City. Methods: A descriptive observational design used in this study includes 212 nurses in all departments of Shar Teaching Hospital in Sulaimani city. A probability, the stratified random sampling method is used and the data were collected from 15 th March 2022 to 20 th September 2022 using a related questionnaire; the questionnaire was composed of three parts, including sociodemographic data, information about the setting of the study, and information related to Knowledge of standard precautions. The data were analyzed by SPSS, version 24. Results: The result of this study indicates that 12.3% of the nurses had poor Knowledge, 30.2% had fair Knowledge, and 57.5% had good Knowledge regarding infection control standard precautions. Conclusion: The present study concludes that the majority of the nurses had good Knowledge regarding infection control standard precautions, and there was a significant association between the level of Knowledge of the nurses and their level of education. Therefore, it is recommended to provide training programs on standard precautions for newly employed nurses at regular intervals, and guideline posters are available for nurses to follow.


INTRODUCTION
Nurses are at the core of patient care, and they're the ones most likely to identify faults and protect patients from damage.The concept of safety is crucial in nursing, both for the care of clients and for the safety of care professionals.Meanwhile, patient safety procedures are "those that lower the risk of adverse outcomes connected to medical care exposure across a spectrum of diseases or disorders.Health-associated infection (HAI) prevention has become a main concern in patient safety.Standard precautions, policies, protocols, and procedures aimed at preventing and managing infections and transmission of illnesses in healthcare settings are referred to as infection control.Any delay in the implementation of infection control practices might have serious negative consequences (Ibrahim Ezz Eldeen, 2016).
Healthcare-associated infections (HAIs) continue to be the most common adverse event in any healthcare system, affecting millions of individuals each year and causing significant morbidity and mortality (Haile T., 2017).
All healthcare providers are concerned about patient safety.It is, therefore, critical for nurses.They give healthcare services to their consumers in hospitals and other healthcare settings 24 hours a day, seven days a week.Every hospital's "heart and soul" is considered to be its nurses.Nurses' Knowledge and behaviours play an important role in infection control, which improves patient care quality.Nurses, on the other hand, have a unique opportunity to reduce the risk of hospital-acquired infections.They can aid patients in their rehabilitation and decrease infectionrelated problems by utilizing appropriate Knowledge and techniques (Sadia H., 2017).
A collection of preventive measures aimed at avoiding the spread of infectious diseases is known as standard precautions.Standard precautions include wearing gloves, aprons, and goggles, as well as handling contaminated instruments (needles and sharps), housekeeping with adequate cleaning protocols, and strictly adhering to standard practices.This necessitates the availability of protective equipment, proper healthcare professional training, and adherence to sterilization and disinfection practices (Asmr et al., 2019).
Nursing monitoring is critical for patient safety because nurses can avoid iatrogenic injury and protect patients in hospitals from medical mistakes made by others.The demands of the profession, which include continuous, careful monitoring of the patient, dynamic data analysis, anticipating difficulties, complex decision-making, continual review of interventions, and emotional support for the patient and family, impact nurses' role in patient safety (Adly et al., 2020).

Aim of the study:
To evaluate Nurses' Knowledge Regarding Infection Control Standard Precautions at Shar Teaching Hospital in Sulaimani City.

METHOD
Research design: A descriptive observational design.

Research setting:
The study was conducted at Shar Teaching Hospital in Sulaimani City, which consists of 400 beds.It is a multi-department hospital that consists of an emergency, Medical Ward, Surgical Ward, ICU, CCU, Urology, Nephrology, Dialysis, Neurology, Neurosurgery, Orthopedic, Operation Room, and Outpatient) departments, Shar Teaching Hospital, receives all kinds of patients regardless of whether they have an infection.

Sample size:
The sample size was 212 nurses from each department of Shar Teaching Hospital; they were chosen according to the inclusion and exclusion criteria of the research.

Sample type:
A probability, stratified random sampling.

The Study Instruments and Tools:-
A questionnaire used in this study, which is consisted of three parts.

Part I: (Sociodemographic Data)
This part includes demographic data of nurses, and it consisted of (14) items, including age, gender, level of education, marital status, working department, employment, working shifts, and items about training and years of experience.

Part II: (Information Related to the Setting of the Study)
This part includes (7) items that consist of an educational program availability of guidelines, Personal Protective Equipment (PPE) and Hand Washing, items related to the availability of suitable waste bins according to the type of waste, and central sterilization supply department (CSSD).

Part III: (information related to Knowledge of standard precautions)
This part was designed to include (30) questions related to the Knowledge of infection control standard precautions, which were based on the extensive review of the literature and related previous studies.

Validity of the questionnaire
The content validity of the study instrument (questionnaire) was determined by the panel of (10) experts who have experience in their fields to investigate the content of the questionnaire.The questionnaire was reviewed by the experts for face and content clarity, relevance, and adequacy to achieve the study objectives.The outcome indicated that the experts agreed on the tool items.Except for a few changes, the investigator considered their responses and suggestions, and some changes were made to the tools.

Pilot study
A pilot study was carried out on (20) nurses at Shar Teaching Hospital.The pilot study aimed to achieve the following aims: 1. To determine the reliability of the questionnaire.2. To evaluate the time required for data collection.
3. To know whether items of the questionnaire are clear, understood, and applicable.4. To identify the barriers and difficulties facing the researcher during data collection.
The nurses filled out the questionnaire.The results of the pilot study revealed that the items of the questionnaire were clear and understandable to the nurses.The time required to fill out the questionnaire by the nurses is approximately around (15) minutes.The sample of the pilot study was excluded from the original sample of the present study.
Cronbach's alpha was used to obtain the final result of reliability, the information of the question was obtained from the participation twice to make the hones of the respondents, and the result of the reliability was 0.904.As a result, the respondents to the questionnaire were reliable.

Statistical Methods
The statistical analysis in this study was conducted using SPSS version 24, which significantly enhanced the computation of various statistical methods.The data underwent coding, tabulation, and presentation in a descriptive format.The inferential data analysis involved two key statistical procedures: the Chi-Square Test and Spearman Rank correlation.To determine the significance of these tests, specific criteria were applied based on the p-value, with results categorized as follows: High significance (P< 0.001), Significant (P< 0.05), Non-significant (P> 0.05), and Very highly significant (P< 0.000).These statistical methods and significance levels were employed to draw meaningful conclusions from the study's data.

Limitations of the study
During the course of the study, the researcher encountered several challenges and barriers.Firstly, nurses' limited availability to complete questionnaires, particularly in high-pressure environments like emergency units and operating rooms, posed a significant hurdle.Secondly, the study's small sample size hindered the ability to generalize the findings to a broader population.Additionally, some nurses declined to participate due to concerns about divulging personal information and worries about having their names included in hospital directories.Another obstacle was the scarcity of recent study references directly relevant to the research topic.Lastly, logistical issues related to transportation also presented difficulties for the researcher throughout the study.These challenges collectively influenced the research process and outcomes.

RESULTS
Table (1) shows the nurse's socio-demographic characteristics.The age of the majority of the participants was between 30 -40 years old, representing (60.4%) and only 26.4% were less than 30 years old.Regarding education, the majority of the nurses graduated from an institute (65.6%).Most participants in the study (67.0%) were females.(20.8%) of the nurses worked in the operation department, (10.4%) of the participants worked in the neurology department, and (0.9%) of the nurses worked in the OGD department.(72.2%) of the participants are married.Most participants (86.3%) of the nurses were employed by the government.Table (2) represents the distribution of characteristics related to the nurse profession and years of experience.Most participants (67.5%) of the nurses were working the afternoon shift.Only (31.1%) of nurses work in a private clinic.In addition, the majority of the total years of service was between (5 and 10) years, which equalled (63.7%).Most participants (37.2%) of nurses had more than 6 years of service (experience) at Shar Teaching Hospital.On the other hand, (30.2%) of nurses had infection control training, 26.56%) of the nurses had more than 10 days of the infection control course, and (57.8%) of nurses had between 3 and 6 years since the last training.However, (89.6%) of nurses had prior infection control information, (55.4%) of the nurses had studied to receive information about infection control, and (98.1%) of nurses were exposed to infection while working in the hospital.Table (3) illustrates the distribution of characteristics related to information about the setting of the study.All of the participants (100.0%) of the nurses said that they did not have a regular departmental training program on infection control, and (58%) of nurses did not have an infection control policy in the unit.On the other hand, The majority of personal protective equipment was a surgical mask (13.28%) and (13.22%) were clean gloves available as personal protective equipment, (25.5%) of participants had hand rubs with alcohol to wash equipment, and (25.37%) of participants had sinks with running water to wash equipment and only (24.5%) of participants had soap to wash equipment disposal.Additionally, the majority of the waste bins were medical waste yellow represented (49.53%), and (49.06%) was general waste black.Most of the participants (100%) of the departments have a sharp disposal box.Then (100.0%) of the participants have the central sterilization supply department available.Table (4) demonstrates the result of the Knowledge of the nurses regarding infection control standard precautions, which indicates that 12.3% of the nurses had poor Knowledge, 30.2% had fair Knowledge, and 57.5% had good Knowledge regarding infection control standard precautions.Table (5) shows the association between the Knowledge of nurses and socio-demographic characteristics.A result shows that there was a statistically significant association between nurses' Knowledge and their level of education (p-value=0.000) because the result of the p-value was less than the common alpha of 0.05.While, there was no statistically significant association between nurse's Knowledge related to age (p-value=0.063),gender (p-value=0.743),marital status (p-value=0.434), and employment (p-value=0.49)because the result of p-value was more than the common alpha 0.05.

DISCUSSION
In the present study, the knowledge of 212 nurses regarding infection control standard precautions was evaluated through a questionnaire; regarding the result of the sociodemographic data of this study, the majority of the participants (60.4%) were between (30-40) years old, most them (65.6%) had diploma degree, gender-wise the females were more than males with the percentage of (67.0%), majority of the nurses (72.2%) were married, similar to this study is a study done in Egypt the results demonstrate that 46.4% of the research nurses were between the ages of 30 and 39, 71.3% were female, 76.2% were married, and 52.5% had a nursing diploma (Azab et al., 2021).
While a study was done in Saudi Arabia with opposite results to this study, results show that more than half of nurses (59.9%) were aged less than 30 years, and (55.7%) were males.Most of the participants (45.3%) had Bachelor's degrees (Al-Ahmeri, 2017).
Regarding the working shifts of the nurses, most of the nurses (67.5%) were on night shifts, but in a study done in Egypt, most of the nurses were on morning shifts (El-Enein & El Mahdy, 2011).
As for working experience, the result of this study shows that (63.7%) of the nurses have worked between (5-10) years total, and the majority of the nurses (69.8%) have not participated in an infection control training course, although there was no periodic educational program in any of the departments of Shar Teaching Hospital regarding infection control, which is opposite to the result of a study done by Yohanis Asmr in Ethiopia, while the majority (74.0%) had less than five years of experience and most of them (62.6%) have participated in training regarding infection control (Asmr et al., 2019).
However, in a study done in Egypt, the result is quite similar to this study as (40.0%) of the nurses have less than 10 years and more than five years of experience.Also, most of them (80.0%) have not participated in the training course regarding infection control (Mohammed Ali Hassan et al., 2022).
About exposure of the nurses to blood and body fluids while working in a hospital, the majority of them (98.1%)answered yes, which is opposite to the result of the study held in Nigeria, in which the result comes out to be (94.8%)not exposed (Amoran & Onwube, 2013).
Information related to the setting of the study was collected through seven questions regarding periodic educational programs.All the nurses answered with (No), which means there is no educational program regarding infection control in any of the departments of Shar Teaching Hospital.(58.0%) of the nurses mentioned that there is no guideline in their department, while in research in Egypt, all the nurses mentioned that there are guidelines in their departments (Adly et al., 2020).
Regarding the availability of personal protective equipment, surgical masks, clean gloves, sterile gloves, gowns, and clinical waste bags were available in almost all the departments, but there was a lack of other personal protective equipment.A study proved that a lack of personal protective types of equipment was significantly associated with compliance (Haile T., 2017).
However, hand-washing equipment was available in all departments, which is a good indicator that there is no barrier for the nurses to perform hand washing.It is proven by research that a lack of hand-washing equipment is agreed to be a strong barrier to performing hand washing (Azab et al., 2021).
All the departments had medical (yellow) and general (black) waste bins, while there was a lack of glass (blue) and infectious (red) waste bins in almost all the departments.However, poor medical waste management is related to the absence of waste management and disposal systems.Also the topic is a low priority in many countries (Babanyara et al., 2013).
On the other hand, the sharp box was available in all departments, similar to the result of a study done in Palestine (97.4%) of the nurses answered the availability of sharp box in their departments (Fashafsheh Ahmad Ayed & Eqtait Lubna Harazneh 2015).
Central sterilization supply department was available at Shar Teaching Hospital.The central sterile supply department (CSSD) has a critical role in sterilizing and delivering expensive medical equipment to various users throughout the hospital (Krageschmidt et al., 2014).Knowledge of the nurses was assessed through 30 questions about the aspects of standard precautions.the result of this study indicates that 12.3% of the nurses had poor Knowledge, 30.2% had fair Knowledge, and 57.5% had good Knowledge regarding infection control standard precautions, in a study held in a university in Qassim, Saudi Arabia, the result of the Knowledge regarding standard precautions was close to the result of this study, 6.1% had poor Knowledge, 26.3 had fair Knowledge and 67.6% had good Knowledge (Abalkhail et al., 2021).
While in another study done in India, the majority 61.67%, had fair Knowledge regarding aspects of infection control standard precautions (Sherwani et al., 2018).
The results of a study done at Sulaimani Teaching Hospital confirmed that nurses have an important role in patient safety while they are in the hospital (Atiya, 2016).
According to the result of this study, there was a significant association between the level of Knowledge of the nurses and their level of education (p-value= 0.000), while there was no significant association between nursing knowledge in related to age (p-value=0.063), gender (p-value=0.743), marital status (p-value=0.434) and employment (p-value=0.49),supported by a study done in Nigeria that the results show that There was a statistically significant relationship between education level and Knowledge of standard precautions (p= 0.019) (Osagiede et al., 2020).
In a study done in Iran, their result shows that Knowledge and gender have a significant relationship (p = 0.02).Furthermore, no significant relationship was found between the level of Knowledge and age, marital status, employment, work experience, education, and place of employment (Sarani et al., 2015).
Although, in another study done in Egypt the result demonstrates that, there was a highly statistically significant relationship (P 0.01) between the total Knowledge of the nurses studied, years of experience, and job title.There was also a statistically significant relationship between their age and marital status (P 0.05).However, there was no significant relationship with their gender (P >0.05) (Adly et al., 2020).
However, in another study held in India, The level of Knowledge increased significantly with increasing age and duration of work experience (p-value < 0.05) (Sherwani et al., 2018).

Table ( 5): Association between the Knowledge of nurses and demographic characteristics
the level of significant 0.05, If (P-value <0.05) is significant The significant Test is the Chi-Square Test.