Knowledge, Attitude and Practice of Staff nurses on Hospital Acquired Infections in tertiary care Hospital of Dhaka city

Introduction : Hospital acquired Infections (HAIs) are called those infections that were not present at the time of patient’ hospitalization in a hospital and have been acquired after hospitalization. Nurses are an important part of the any healthcare team who play a unique role in the control of Hospital acquired infections. Objective : The aim of this study was to investigate the level of knowledge, attitudes, and practices of staff nurses about preventing the spread of hospital acquired infections (HAIs) at tertiary care Hospital of Dhaka city. Methods and Materials : This descriptive cross-sectional study was done among nurses having two years experience from two tertiary level hospitals in Dhaka city during January to June 2017. Self administered questionnaire containing different set of questions regarding knowledge, attitude and practice on HAI were used as a tool for data collection. Questionnaire was supplied to all staff nurses available at different in-patient wards of these two hospitals. Only 234 staff nurses who completed and returned the questionnaire were included in this study. Data were analyzed using Microsoft excel 2013 software. Result : Staff nurses were found to have good knowledge, moderately positive attitude but poor practice in prevention of hospital acquired infections. About 95% of the participants considered that prevention of HAIs were a valuable part of their role. About 65% of the staff nurses had received formal training regarding hand hygiene. The 100 % of participants felt that they would be less likely to transmit infection to the patients if they performed hand-hygiene. About 64% of them argued that hand hygiene agents were not readily available in current settings. Regarding practice, only 6% performed hand hygiene before patients contact and 27% of the staff nurses reported that they often forgot to perform hand hygiene. Conclusion : The finding of this study revealed a good knowledge of infection prevention among the majority of participants with relatively minimal level of practice. For strengthening the knowledge, attitude and practice towards HAIs, there is in need of developing regular training program and monitoring on performance feedback regarding hand hygiene is recommended.

develop HAIs and subsequently results in adverse healthcare outcomes as increased hospital stay, economic burden, significant morbidity, and mortality. 1 The high burden of HAIs is due to lack of standardized infection prevention program which was neglected due to limited resources, poor sanitary conditions and hygiene practices. 2 In 2010, a data report for HAIs cases among 2,473 hospitals showed an increased number of infections associated with the use of medical equipment, most of which were displayed in surgical units. Also, other researchers reported

Introduction
Hospital Acquired Infections (HAIs) are not present at the time of patient' hospitalization but acquired after admission in to hospital. It is also referred to as Nosocomial infections. The time frame definition of HAIs is at least 48-72 hours after hospitalization, 3 days after leaving the hospital, 30 days after surgery or 1 year after the implant. Hospital acquired infections (HAIs) are a common global challenge mainly in low and middle-income countries. 1 An estimated 10% of hospitalized patients in developed countries and 25% in developing countries

Original Article
Knowledge, Attitude and Practice of Staff nurses on Hospital Acquired Infections in tertiary care Hospital of Dhaka city A S M A Kabir et al.

Inclusion criteria:
Only staff nurses who completed at least diploma in nursing or having higher degree, 2 years experience in nursing service and agreed to participate in this study.
Exclusion criteria: Staff nurses having less than 2 years working experience and were not to agree to participate and staff nurses who did not complete and returned data sheet were excluded from this study sample. Data was analyzed using Microsoft excel 2013 software. Permission from Ethical review board of these two hospitals was obtained and written consent was taken from all participants in this study.
Instruments and Techniques: Structured, self administered questionnaire prepared following the guide line of "WHO hand hygiene knowledge questionnaire for health care workers". It was consisting of questions on knowledge, attitude and practices on HAIs. Knowledge was assessed using 10 questions with options either "yes" or "no". Attitude and practice were assessed using a set of 14 and 8 questions respectively. The participants were given "yes" or "no" options to select based on their attitude and practice regarding HAIs. All the questions were subjected to a pre-testing prior to the study and obtained suggestions were taken into consideration. A scoring system was used where 1 point was awarded for each correct response to knowledge, positive attitudes, and good practices. Incorrect knowledge, negative attitudes, and poor practices were given 0 points. A score greater than 75% was considered as good, 50% -74% moderate and less than 50% poor.

Attitude-is s personal view on infection prevention activities when caring patients.
Practice-is a skill on infection prevention activities when caring patients.

Results
Highest proportion of the participants( 95%) were aware of the fact that washing hands with soap or an alcohol based antiseptic decreases the risk of transmission of hospital acquired pathogens. Similarly, (91%) of them disagreed to the fact that hand washing is not necessary if the hand are not visibly dirty. A larger proportion (79%) of the participants still considered that gloves provided complete protection against acquiring/ transmitting infections. Only (88%) of them realized that same pair of gloves cannot be worn for multiple patients as long as there is no visible contamination on the gloves and it should be changed after each patient contact. The percentage of participants who considered that healthcare-associated pathogens can be found on normal, intact patient skin was (78%) whereas the rest (12%) believed that intact skin does not harbor pathogens. The knowledge that when using alcohol that patients who underwent surgical procedures had a greater chance of developing HAIs, compared to other patients. 3 HAIs associated morbidity and mortality are preventable through infection prevention strategy like, proper hand hygiene. 4 A prevalence survey conducted under the auspices of WHO in 55 hospitals of 14 countries representing 4 WHO Regions (Europe, Eastern Mediterranean, South-East Asia and Western Pacific) showed an average of 8.7% of hospital patients had HAIs. At any time, over 1.4 million people worldwide suffer from infectious complications acquired in hospital. 5 HAIs are mostly transmitted by healthcare workers (HCW) who fail to practice infection prevention measures. Hence, Healthcare workers including nurses, doctors are front line of protecting themselves and patients from infection. 3 Identifying existing infection control knowledge attitudes, and practices (KAP) among health care workers (HCWs) is a key first step in developing a successful infection control program. In an effort to raise awareness and provide guidance in combating HAIs in resource limited settings (RLS), the World Health Organization (WHO) launched the Global Patient Safety Challenge: Clean Care is Safer Care campaign. A cornerstone of the program is to decrease HAIs through improving hand hygiene among healthcare workers. 6,7 Most HAIs are transmitted by health care personnel who fail to practice proper hand washing procedures or change gloves between patient contacts. Health care workers such as nurses, doctors can be a major source of pathogens. 8 As members of the health care team, nurses play a very important role in HAI control. Nurses must have sufficient information and necessary skills in this field. The results of a study conducted by Darawad et al. on nursing students in Yemen showed that most nursing students have low levels of knowledge, a positive attitude, and a moderate practice about infection control. The education, training, motivation regarding HAIs has a positive impact on retention of KAP in all categories of health workers including nurses to prevent infections that was evidenced in previous researches. 9 Therefore, this study aimed to investigate the knowledge, attitude and practice on hospital acquired infection prevention among health care workers (staff nurses) at tertiary care hospital.

Materials And Methods
This descriptive-cross-sectional study was done among staff nurses in two tertiary care Hospitals, Dhaka Medical College Hospital and Holy Family Red Crescent medical College hospital of Dhaka city during January-June, 2017.
Following inclusion and exclusion criteria a questionnaire was supplied to all staff nurses available at different in-patient wards of these two hospitals. Among 234 nurses who responded, filled completely and returned the questionnaire were included in this study. With respect to hand hygiene practices, 79 % of the participants had performed hand hygiene after going to toilet. Only 43% of the participants performed hand hygiene before caring for wound and 61% after caring for the wound. Only 6% performed hand hygiene before patient contact and 29 % performed hand hygiene act after patient contact. If the hands felt or looked dirty, 71% of the participants performed hand hygiene. Practice of hand hygiene after removal of gloves was performed by 37 % of the participants. Practice was poor only 36% practiced on HAI prevention.

Discussion
In order to reduce HAIs in any hospital, knowledge of HAIs and compliance to methods in preventing them like proper practice of aseptic and antiseptic precautions by health care workers are very much essential. This study was done to assess the level of knowledge, attitudes, and practices of staff nurses working in tertiary hospitals.
In our study among the staff nurses, we found good knowledge based antiseptics, hands should be rubbed until dry prevailed among 70% of the participants. The fact that hand hygiene act should be performed before and after direct patient contact was agreed upon by 91% of the study population. About 77.3% of the participants had good knowledge regarding HAIs. However, 22.7% still lacked good knowledge regarding HAIs More than half (64%)of the participants reported that hand hygiene agents like-alcohol based hand sanitizer, soap and water were not easily available. Similarly, (84%) reported, clean towels to dry the hands after washing were also not always available. The sinks for washing purposes were inconveniently located and inadequate at the hospital-settings. These findings are in accordance to a similar study conducted in Srilanka 13 . Thus increasing the supplies necessary for hand washing and institutional support is essential in combating the substandard practices in hand hygiene. 9,11,12 Limited accessibility of hand hygiene facilities has been shown to be an important risk factor for poor adherence to recommendations. 13 Our study showed that although there were a number of limitations in currenthealth care settings, staff nurses had moderately positive attitude towards limiting hospital acquired infections control.
More than half (57%) of the participants reported that the importance of hand hygiene was emphasized by their clinical supervisors. An important finding from this study was that 94% of the participants do not adopt any measure of hand hygiene for prevention of HAIs prior to patient contact despite 91% have the knowledge that hand hygiene should be performed before and after direct patient contact. The result of the present study showed that nurses had a good knowledge but poor practice in prevention of HAIs. A study in India reported less than desirable level of practice but a study in Nepal reported more among the health care personnel. 11

Conclusion
The finding of this study revealed a good knowledge of infection prevention among the majority of participants with relatively minimal level of practice. However there is the need of regular