In the present study, the Arabic version of the Compliance with Standard Precautions Scale (CSPS-A) was used to assess compliance of NICU nurses with standard precautions of infection control.
The study results showed a suboptimal overall compliance rate among the study participants (66.7%). When compared to similar studies using the same tool, the compliance rate was found to be higher than that reported among nursing students in Saudi Arabia (61%) and among nursing students (53.5%) and nursing staffs (57.4%) in Hong Kong. Conversely, the compliance rate was lower than that reported among nursing staffs in Brazil (69.4%) [18, 27, 31].
This study revealed variability in the compliance rates of the participants in different CSPS items. Regarding the Disposal of Sharps, a high compliance rate was reported for the disposal of used sharp articles into sharps-only boxes (86.2%), whereas a low compliance rate was reported for not recapping used needles (48.3%) and for disposal of sharps box not only when full (27.6%).
Similarly, this erroneous practice by nursing students and staffs has been reported in previous studies [32,33,34]. A study among nursing students in Saudi Arabia showed a high compliance rate for the disposal of used sharp articles into sharps-only boxes (84.3%) and a low compliance rate for not recapping used needles (49.2%) . A comparable study in Hong Kong revealed a high compliance rate for the disposal of used needles in a sharps-only box (95.3%) and a low compliance rate for not recapping used needles (49.3%) . A Turkish study among Turkish nursing and midwifery students revealed a high compliance rate for both the disposal of used sharp articles into sharps-only boxes (86.5%) and not recapping used needles (89.4%).
Recapping used needles is considered a prime risk for needlestick injury; accordingly it is highly important to dispose used needles immediately in sharps-only boxes . Used needles should be recapped only if this is required in a certain procedure or if sharps-only boxes are not available, and even in such circumstances recapping should be done either by the one-handed technique or by using a mechanical device .
Regarding the CSPS items of cross-infection prevention, a high compliance rate was reported for washing hands between patients’ contacts (82.8%), immediately decontaminating hands after removing gloves (81%) and for changing gloves after contact with each patient (79.3%). These results are comparable to those reported in previous studies in Hong Kong, Jordan, Turkey, and Saudi Arabia [18, 34, 35, 38].
An earlier study denoted attending training infection control programs or workshops as a predictor of hand hygiene practice among nursing students . This could justify the findings of this study where a high percentage of participants reported attending infection control courses and workshops (77.6%).
Conversely, the compliance rate for the item of wearing a surgical mask alone or along with goggles and face shield was low (48.3%) and this may be attributed to the availability of these protective equipment in the NICU. This goes in line with the results of a former Turkish study, where a low compliance rate was reported for wearing personal protective equipment, such as masks, goggles or gowns whenever there was a possibility of blood or other body fluids splashing on clothes, due to the lack of such equipment in clinical settings . According to Colet et al. one plausible explanation for the high compliance rate in wearing a surgical mask alone or along with goggles and face shield (72.9%) is the accessibility of these equipment in clinical settings .
Regarding wastes disposal, the participants reported a high compliance rate. Optimally, healthcare waste disposal should never be mixed; wastes contaminated with blood or any body fluids should be placed in red plastic bags. These findings were different from those revealed by similar previous studies where low compliance rates were reported for placing contaminated wastes in red plastic bags [18, 40]. One qualitative study attributed improper waste disposal to lack of awareness and inadequate training on healthcare waste disposal .
On studying other potential factors affecting the nurses’ compliance with SPs, it was found that participants holding Bachelor’s degree in nursing as well as those who had three or more years of clinical experience reported higher compliance rates. This agrees with the findings of previous studies among nursing students, where senior students exhibited higher compliance rates with SPs of infection control [18, 38]. This could be related to the fact that nursing students in the latter years of the nursing programs have greater exposure to clinical settings and thus more clinical experience, which might enhance their implementation of SPs.
Findings of the present study suggest that clinical experience duration is a substantial factor affecting the nurses’ compliance with SPs. Nurses with longer durations of clinical experience become more acquainted with the infection control guidelines and protocols. The findings are also consonant with Patricia Benner’s theory “From Novice to Expert.” According to this theory, expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences.
The theory described five different levels of nursing experience; novice, advanced beginner, competent, proficient, and expert . Direct experience has been described as an indispensable tool in the elaboration and enhancement of psychomotor and decision making skills .
Addressing infection prevention and control can be challenging especially in complex healthcare settings as NICUs. One of the challenges is the increased number of diverse interprofessional practices within these settings and subsequently higher risk of infection. In order for HCWs to practice safely, their knowledge and skills should be up-to-date and evidence-based. Thus, healthcare organizations should provide periodic effective educational and training programs that link theory to clinical practice .
Infection prevention and control is also considered one of the primary goals of antimicrobial stewardship programs. Antimicrobial stewardship involves more than antibiotic prescribing alone; effective adherence of HCWs and patients to SPs will prevent infection transmission and thus remove the need for antibiotics. The role of antimicrobial stewardship is thus to prevent infection in the first place, and one challenge for healthcare organizations is to provide appropriate training, education and support for HCWs so that antimicrobial stewardship is embedded within their role .
Given the current global crisis of COVID-19 pandemic, healthcare systems should also ponder innovative ways to support and enrich their infection control programs. Antimicrobial stewardship efforts may also be redirected to help with COVID-19 combat efforts. These efforts should include investing in information technology and personnel. Beyond the current pandemic, substantial resources should be invested to enhance and sustain infection control infrastructure at the local, regional and national levels. Besides, new investment in training and expanding the infection control workforce will be crucial .
Infectious disease clinical pharmacist is one of the core members of antimicrobial stewardship team as well as the infection control committee at healthcare facilities with a prominent educational and vocational role aimed at patients and HCWs at the point of care .
This includes providing robust up-to-date evidence-based educational and training programs that link theory to clinical practice and elucidate the importance of accurate implementation of proper infection prevention and control practices while focusing on the points of weakness revealed by the results of the periodic assessment of compliance with SPs.
Our study addresses a timely and important problem regarding infection control in clinical settings. Considerable findings are revealed regarding the compliance of NICU nurses with standard precautions of infection control; however, there are some limitations. Using a self-report tool may have allowed some response bias such as social desirability and acquiescence. Also, the fact that the study was conducted in a single NICU, the use of a convenience sampling technique and the small sample size hinder the generalizability of the results. Hence, wider settings and larger sample sizes are recommended for future studies.
It also is worth noting that the current study design initially included further assessment of the impact of clinical pharmacist-led education and training programs on enhancing the adherence of NICU nurses to infection control measures; however, the mitigation strategies adopted in NICU to combat the COVID-19 pandemic and the restricted access to the unit hindered the implementation of the program. Nevertheless, the program is currently in the preparation phase with the aid of technologies and online tools that may help to overcome the barrier of limited access and thus allow prompt implementation.