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Knowledge, Attitude and Practices on Universal Precautions of Staff Nurses and Midwives in the Delivery Room.

ABSTRACT

This study is aimed to identify the knowledge, attitude and practices on universal precautions of the staff nurses and midwives in the delivery room and at the NICU. This study was based on the Philosophy and Science of Caring of which it has four major concepts: human being, health, environment/society, and nursing. This study utilized the descriptive-correlational research design was used with 30 staff nurses and midwives. The data were presented and organized through the 4-point likert scale, frequency counts, percentages and weighted mean while the null hypothesis was tested through the Chi-square and Pearson-r. As an important set of guidelines designed to protect people from diseases spread by blood and certain body fluids, it is important that staff nurses practice universal precautions carefully and proficiently. High levels of knowledge, attitude, and practices or skills on universal precautions is important based on the findings of this study, these three factors are inter-related and can influence each other towards achieving an effective implementation of the said guidelines. It is still important for staff nurses' and midwives to continuously stay updated on current trends on infection control and to continue practicing their profession in the clinical setting since a longer duration of clinical experience can increase the nurses' levels of knowledge and skills on universal precautions as documented in this study.

Keywords: Knowledge, attitude, practices, universal precautions, delivery room, NICU, staff nurses and midwives

INTRODUCTION

The most common hazard faced by health care providers is the threat of communicable disease. It poses a serious risk to health care workers. Healthcare-associated infections are infections caused by a wide variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care. These infections related to medical care can be devastating and even deadly (http://www.cdc.gov/hai/).

Transmission of at least 20 different pathogens by needle stick and sharps injuries has been reported. Despite improved methods of preventing exposure, occupational exposures continue to occur. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of health care workers have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of hepatitis B virus transmission is 6 to 30%, and the risk of hepatitis C virus transmission is approximately 1.8%. Occupational exposures that may result in Human Immunodeficiency Virus, Hepatitis B, or Hepatitis C transmission include needle stick and other sharps injuries; direct inoculation of virus into cutaneous scratches, skin lesions, abrasions, or burns; and inoculation of virus onto mucosal surfaces of the eyes, nose, or mouth through accidental splashes. These viruses do not spontaneously penetrate intact skin, and airborne transmission of these viruses does not occur (http://cmr.asm.Org/content/13/3/385.full)

In 1996, the Centers for Disease Control and Prevention (CDC) issued the Standard Precautions, a set of guidelines to prevent exposure. Health care professionals should follow standard practices and use personal protective equipment when providing medical care to patients. These practices are commonly referred to as universal precautions or body substance isolation.

Universal precautions are infection control guidelines designed to protect people from diseases spread by blood and certain body fluids. This principle advises health care workers to always assume that all "blood and body fluids" are infectious for blood-borne diseases.

Unfortunately, despite the simplicity and clarity of these guidelines, compliance among nurses is reported low. Although high incidence of occupational exposure to microorganisms is observed among all health care professionals, nurses are among those who are more highly exposed. Therefore it is ethical to explore the factors that affect nurses' knowledge, attitude and practices on Universal Precautions, which may affect their compliance with the said guidelines (Vaz, McGrowder, Alexander-Lindo, Gordon, Brown, Irving, 2010).

The researcher is currently working as a clinical instructor at Mindanao State University--Iligan Institute of Technology--College of Nursing. And is assigned in various clinical areas, specifically in the Delivery room, NICU and OR. A clinical area in the hospital where health care providers are exposed to blood and other potentially infectious materials putting them at risk of infection from blood borne pathogens. Because of this, the researcher realized the need to create an atmosphere in the workplace environment that makes infection-control procedures easy to implement. By initiating this research, the researcher believes that this is the first step in determining other necessary steps to implement to achieve that work environment be free from nosocomial infections.

CONCEPTUAL FRAMEWORK

This study was based on the Philosophy and Science of Caring of which it has four major concepts: human being, health, environment/society, and nursing. Jean Watson refers to the human being as "a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. Human is viewed as greater than and different from the sum of his or her parts." Dr. Jean Watson. Dr. Watson is an American nursing scholar born in West Virginia and now living in Boulder, Colorado since 1962. From the University of Colorado, she earned her undergraduate degree in nursing and psychology, her master's degree in psychiatric-mental health nursing, and continued to earn her Ph.D. in educational psychology and counseling. The changes in the health care delivery systems around the world have intensified nurses' responsibilities and workloads. Nurses must now deal with patients' increased acuity and complexity in regard to their health care situation. Despite such hardships, nurses must find ways to preserve their caring practice and Jean Watson's caring theory can be seen as indispensable to this goal.

Being informed by Watson's caring theory allows us to return to our deep professional roots and values; it represents the archetype of an ideal nurse. Caring endorses our professional identity within a context where humanistic values are constantly questioned and challenged (Duquette & Cara, 2000). Upholding these caring values in our daily practice helps transcend the nurse from a state where nursing is perceived as "just a job," to that of a gratifying profession. Upholding Watson's caring theory not only allows the nurse to practice the art of caring, to provide compassion to ease patients' and families' suffering, and to promote their healing and dignity but it can also contribute to expand the nurse's own actualization. In fact, Watson is one of the few nursing theorists who consider not only the cared-for but also the caregiver. Promoting and applying these caring values in our practice is not only essential to our own health, as nurses, but its significance is also fundamentally tributary to finding meaning in our work.

As a support for this model, the Health Promotion Model by Nola J. Pender was also used. According to this model, each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral specific knowledge and affect (knowledge, attitude and practices on universal precautions) have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior (compliance to universal precaution guidelines) is the desired behavioral outcome and is the end point in the Health Promotion Model. Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development (avoidance of health care associated infections). The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail an intended health promoting actions (www.nursingplanet.com).

The hospital setting is a good setting for communication about personal hygiene, such as informing visitors and the general public about hygiene rules such as washing hands.

Personal protective equipment reduces but does not completely eliminate the risk of acquiring an infection. It is important that it is used effectively, correctly, and at all times where contact with blood and body fluids of patients may occur. Continuous availability of personal protective equipment and adequate training for its proper use are essential. Staff must also be aware that use of personal protective equipment does not replace the need to follow basic infection control measures such as hand hygiene.

Studies have shown that compliance with precautions among nurses in order to avoid exposure to microorganisms is low. More specifically, compliance was found inadequate concerning hand hygiene guidelines, use of gloves when exposure to body fluids was anticipated, eye protection, mouth and nose protection (mask use), wearing a gown when required, avoid recapping the needle after it was used for a patient, and provision of care considering all patients as potentially infectious (Efstathiou, Papastavrou, Raftopoulos, Merkouris, 2011).

Training and education have been found to be of paramount importance to developing awareness among health care workers, as well as improving adherence to good clinical practice. The greater awareness of universal precautions among health care workers employed may reflect their participation in a greater number of training and educational sessions on universal precautions which not only encouraged safer work practices but also improved concordance with policy and procedures. There are studies that have reported significant improvement in compliance with the standard precautions from 48% to 74% after an educational symposium, and after a 30-minute educational program. Regular training should include the universal precautions, initial biohazard handling, safety policies, safety activities, safety equipment and materials, on-going monitoring and potential exposure of staff. The increasing availability of personal protective equipment and compliance with standard precautions in hospitals most countries should reduce health care workers' risk of blood-borne pathogen exposure (Vaz et al., 2010).

According to Thorndike's Laws of Learning, The Law of Readiness is the First primary law of learning, according to him, is the 'Law of Readiness' or the 'Law of Action Tendency', which means that learning takes place when an action tendency is aroused through preparatory adjustment, set or attitude. Readiness means a preparation of action. If one is not prepared to learn, learning cannot be automatically instilled in him, for example, unless the typist, in order to learn typing prepares himself to start, he would not make much progress in a lethargic & unprepared manner. The second law of learning is the 'Law of Exercise', which means that drill or practice helps in increasing efficiency and durability of learning and according to Throndike's S-R Bond Theory, the connections are strengthened with trail or practice and the connections are weakened when trial or practice is discontinued. The 'law of exercise', therefore, is also understood as the Taw of use and disuse' in which case connections or bonds made in the brain cortex are weakened or loosened. Many examples of this case are found in case of human learning. Learning to drive a motorcar, typewriting, singing or memorizing a poem or a mathematical table, and music etc. need exercise and repetition of various movements and actions many times. The third law is the 'Law of Effect', according to which the trial or steps leading to satisfaction stamps in the bond or connection. Satisfying states lead to consolidation and strengthening of the connection, whereas dis-satisfaction, annoyance or pain lead to the weakening or stamping out of the connection. In fact, the 'law of effect' signifies that if the response satisfy the subject, they are learnt and selected, while those which are not satisfying are eliminated. Teaching, therefore, must be pleasing. The educator must obey the tastes and interests of his pupils. In other words, greater the satisfaction stronger will be the motive to learn. Thus, intensity is an important condition of 'law of effect' (Ghandi, 2010).

OBJECTIVES OF THE STUDY

This study determined the knowledge, attitude and practices of (25) staff nurses and (5) midwives on universal precaution at Gregorio T. Lluch Memorial Hospital in Iligan City.

Specifically, this study sought to answer the following objectives: 1) to determine the demographic profile of the respondents in terms of age, gender, civil status, highest educational attainment, length of clinical experience, and related seminars and trainings attended; 2) to assess the level of knowledge and attitude on universal precautions of the respondents in terms of safe work practices, use of personal protective equipment and housekeeping and laundry management; 3) to describe the practices on universal precautions of the respondents in terms of safe work practices, use of personal protective equipment and housekeeping and laundry management; and 4) to relate the profile of the respondents to the level of knowledge, attitude and practices on universal precautions.

METHODOLOGY

These are the processes used to collect information and data about the research study. The methodology used includes journals, interviews, surveys, statistical analysis and other research techniques that is relevant to the purpose of this research study.

The descriptive-correlational design of research was used in this study. In this research, this design will be used to determine the level of knowledge, attitude, and practices on universal precautions of the respondents and how it is related to their profile. This design also determined whether a relationship exists between the level knowledge, attitude, and practices on universal precautions of the participants.

This research was conducted at Gregorio T. Lluch Memorial Hospital (GTLMH) famously known among Iliganon's as "The City Hospital". GTLMH is a 75 bed tertiary hospital, located at Pala-o, Iligan City. The hospital caters more than a hundred patients each day. GTLMH hospital not only cater the needs aong the residents in Iligan City but also in the nearby towns. GTLMH is manned by 70 - 80 staff nurses, trained to cater the needs of Iliganon's. Services offered includes, emergency services, outpatient department, hemodialysis unit, ICU, surgery, delivery room, OR procedures, adult and neonatal intensive care unit, laboratory procedures.

The participants of this research were thirty (25) staff nurses and (5) midwifes from Gregorio T. Lluch Memorial Hospital selected through universal sampling. This population was targeted because they are in contact with the majority of patients attended to at the labor and delivery room and in the neonatal intensive care unit and their practices can either minimize or perpetuate the transmission of nosocomial infections.

Part I of the questionnaire was a researcher-made questionnaire that gathered the demographic data of the respondents such as their age, gender, civil status, years of formal education, length of clinical experience and number of hours of seminars and trainings attended.

Part II of the questionnaire was a modified standardized tool from Judilla's (2006) study on Awareness and Compliance of Staff Nurses to Universal Precautions. This portion is divided into three parts. Each part is a 28-item questionnaire that measures the level of knowledge (Part 1), level of attitude (Part 2), and level of practices (Part 3) on universal precautions of the respondents. Each part is further subdivided into three, questions 1 to 10 refer to safe work practices, questions 11 to 17 refer to use of personal protective equipment and questions 18 to 28 refer to housekeeping and laundry management. A 4-point Likert Scale was used and respondents were asked to indicate their degree of agreement with each item (1 for strongly disagree, 2 for disagree, 3 for agree, and 4 for strongly agree). A higher score indicated a higher level of agreement to the variable in question. The questionnaires were distributed to the respondents during their most convenient time. The researcher then discussed to the respondents how to answer the questionnaire. They were then given 20 minutes to answer the questions after which, the questionnaires were collected and tallied. The data gathering procedures for this research were as follows: After the instrument was finalized, a letter of request to conduct the study was secured the Dean of Liceo de Cagayan--School of Graduate Studies. Once approved by the dean, a transmittal letter was then forwarded to the Head of Nursing Services Office at Gregorio T. Lluch Memorial Hospital and likewise, to the nurse supervisors, staff nurses, requesting permission to conduct the study in the aforementioned hospital to ensure cooperation throughout the study. Upon approval of the request to conduct the study by the institution, the researcher then administered the questionnaires to the staff nurses of the said hospital. The respondents were given 20 minutes to answer the tool. After which, the data was collected, tallied, and subjected to statistical analysis for further interpretation of data.

To determine the demographic profile of the staff nurses and midwives at the Gregorio T. Lluch Memorial Hospital assigned in the labor and delivery room and in the neonatal intensive care unit, the Frequency and Sample Percentage was used.

The Weighted Mean was utilized to determine the responses of the respondents as to the level of knowledge, attitude, and skills on universal precautions of the staff nurses.

The Chi-Square was utilized to determine the relationships between the profile and level of knowledge, the profile and level of attitude, and the profile and level of skills of the staff nurses.

Finally, the Pearson-r was used to determine the relationship between the following: level of knowledge, level of attitude and level of practices; level praactices and level of attitude on universal precautions.

RESULTS AND DISCUSSION

Profile of the Staff Nurses

Table 1 presents the profile of staff nurses. In terms of age, 27 or 90% of the staff nurses belonged to the age group of 19-40 years old, while 3 or 10% are from 41 -65 years of age. This indicates that majority of the respondents belong to the early adulthood stage of development. According to Robert Havighurst, this is the stage where individuals are getting started in an occupation, taking on civic responsibility and acquiring a set of values and an ethical system as a guide to behavior.

The predominance of young nurses in this study can be explained by the escalating demand of nurses from developed countries such as the U.K., Middle East and the U.S. It is reported that the Philippines supplies 25 percent of all overseas nurses worldwide. This is an integral part of its employment policy. Because of this, older nurses, or those who have had years of experience tend to be the one being employed abroad where salaries are higher, leaving behind the younger nurses until they too can gain years of experience and also be employed abroad.

In relation to universal precautions, a study conducted in Iran by Motamed showed that knowledge on universal precautions was highest in the 20-40 years old age group and lowest in the > 50 years group (Motamed et al, 2006)). In Thailand, a study by Honda showed that age group is not a risk factor associated with predisposing staff nurses to sharp injuries (Honda, Chompikul, Rattanapan, Wood, Klungboonkrong et al., 2011).

As to the gender of the staff nurses, 30 Or 100% are females. All are females and there are no males in the said clinical area of study.

According to statistics from the American Society of Registered Nurses (2008), in our current society, male nurses represent just a small fraction of the nursing workforce. The popular notion that nursing is not for men seem to be one of the major obstacles towards bringing more men to the profession. Although male nurses often face the challenges of gender discrimination, especially in specialties like obstetrics and gynecology, where, women often prefer to have female nurses, male nurses often end up in leadership roles and in specialties like intensive care, emergency and operating room nursing. Although studies indicate an overall positive acceptance of men in nursing, they do indicate a need for professional adaptations in core issues like care, for men to remain and flourish in the profession. A study by Hesselbart as quoted by American Society of Registered Nurses (2008), have also shown that men entering a predominantly female profession are perceived more deviant than women (Men in Nursing, http://www.asrn.org/journal-nursing/374-men-in-nursing.html).

In addition, psychology studies revealed that women are more willing to conform to authority while men are more aggressive and more likely to have expectations of success, but these are minor differences. With increasing female participation rates in the workforce which have taken place in the last 25 years, there is no significant difference in job productivity between men and women. There is no evidence that points to the face that employees gender affects job performance (Robbins, 2009).

In relation to universal precautions, a study by Vaz et al. (2010) showed that there was a significant statistical relationship between utilization of protective gear of the respondents. In terms of the civil status, most of the respondents are single (66.67%) while 33.33% are married. This is consistent with the study conducted by Lorenzo et al. (2007) which also showed that the nurses' profile in the country with regards to civil status is predominantly single because most nurses in the Philippines took up the course in order to work abroad to obtain a higher salary. With this scenario, most nurses who are left in the Philippines are single because most nurses who seek employment abroad do not return to the Philippines (particularly those who bring their families) and end up getting married there and becoming citizens of that particular country, others return en route to another job abroad, and only some return permanently (Lorenzo, Galvez-Tan, Icamina, Javier, 2007).

As to the highest educational attainment, majority (90%) of the staff nurses have only finished the BS Nursing degree while 10% have already taken some masteral units. Also considering the staff nurses' attendance to seminars or trainings related to infection control, 25 or 83.64% have attended at least one (1) seminar or training while 5 or 16.66% have not attended any seminar or training regarding infection control.

Training and education have been found to be of paramount importance to developing awareness among health care workers, as well as improving adherence to good clinical practice. The greater awareness of universal precautions among health care workers employed may reflect their participation in a greater number of training and educational sessions on universal precautions which not only encouraged safer work practices but also improved concordance with policy and procedures. There are studies that have reported significant improvement in compliance with the standard precautions from 48% to 74% after an educational symposium and after a 30-minute educational program (Vaz et al, 2010). In a study by Motamed et al, 2006 the group with a bachelor degree or more had the highest knowledge of and practice toward universal precautions. Also, a study by McGovern, Vesley, Kochevar, Gershon, Rhame, Anderson (2000) showed that having had some training in the use of personal protective equipment is associated with compliance to universal precaution practices (McGovern et al., 2000).

As to the length of clinical experience, 8 or 26.67% have less than one year clinical experience, 14 or 46.67% have 1 to 5 years of clinical experience, 5 or 13.33% have 6-10 years of clinical experience and the other 13.33% remaining staff nurses have more than 10 years of clinical experience.

As previously stated, the predominance of young, less experienced nurses in this study can be explained by the escalating demand of nurses from developed countries. With the Philippines being a major supplier of nurses worldwide, seasoned nurses, or those who have had years of experience tend to be the one being employed abroad where salaries are higher leaving behind the younger nurses until they too can gain years of experience and also be employed abroad.

The study by Motamed et al. (2006) showed that the group with the fewest years of experience (0-5 years) had the highest knowledge score. In addition, a study conducted in Thailand about needle stick injuries showed that the nurses who had been working from 1 to 20 years were about two times more likely to have needle stick injuries than those working from 21 to 40 years. Less experienced nurses were more likely to have needle stick injuries form improper practice of universal precautions compared to more experienced nurses. This was consistent with the findings in a study from Africa which showed that less experienced nurses were 1.67 times more likely to have needle stick injuries than those having more experience (Honda et al., 2011). This means that as a nurse gains more years of experience, he/she can perfect the practice of universal precautions such that he/she can avoid needle stick injuries.

In spite of that, some experienced nurses express that certain universal precaution guidelines may not be followed as they gain considerable clinical experience. They argue that; "... the more capable I feel, the less preventive measures I may take (Efstathiou et al., 2011)."

Level of Knowledge on Universal Precautions

Table 2 presents the staff nurses' level of knowledge on universal precautions in terms of safe work practices, use of personal protective equipment, and housekeeping and laundry management. As used in the study, the level of knowledge refers to the degree of the staff nurses' theoretical and practical understanding of universal precaution.

The data shows that the staff nurses are highly knowledgeable on safe work practices with a mean of 3.79. For this category, statement number 1, "I know that hand washing facilities, or antiseptic cleansers shall be available to employees who are exposed to blood and other potentially infectious materials," elicited the largest number of agreement from the respondents with a mean of 3.95, while statement number 6, "I know that eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses are prohibited in work areas where there is likelihood of occupational exposure," elicited the least agreement from the respondents with a mean of 3.55.

Considering the staff nurses' knowledge regarding housekeeping and laundry management, the respondents are considered highly knowledgeable with a mean of 3.76. For this category, statement number 1, "I know that work surfaces must be decontaminated with an approved disinfectant as soon as possible after contamination with blood or other potentially infectious materials," with a mean of 3.93, elicited the highest number of agreement from the respondents while statement number 5, "I know that contaminated linens should be washed with detergent in water at least for 25 minutes," elicited the least.

The data also shows that the staff nurses are also highly knowledgeable on use of personal protective equipment with a mean of 3.75. For this category, statement number 4, "I know that face and eye protection must be worn when splashes, sprays or droplets of blood or other potentially infectious materials pose as hazards to the eyes, nose and mouth," elicited the largest number of agreement from the respondents with a mean of 3.88 while statement number 3, "I know that utility gloves may be decontaminated for reuse if the integrity of the gloves is not compromised" elicited the least agreement from the respondents with a mean of 3.38.

The general mean for the level of knowledge of the staff nurses on universal precaution is 3.75, which means that the respondents are highly knowledgeable on universal precautions.

The high level of knowledge among the respondents may be related to the strict implementation of infection control practices and regular postemployment education on issues of universal precautions because of the new Phil Health bench book guidelines for all Philippine hospitals. The high level of knowledge may also be explained by the predominance of female respondents in the early adulthood stage and the fact that the respondents are all nurses with bachelor's degree, which according to the study by Motamed, et al (2006), are the factors that may contribute to a higher level of knowledge on universal precautions.

A study by Vaz et al. (2010) showed that insufficient knowledge on universal precautions and lack of understanding among health care workers of how to properly use protective barriers are associated with a high rate of non-compliance among health care. This study also showed that the longer a health care worker was employed to the health care sector, the more likely that his or her level of awareness of universal precautions increased. According to Vaz, et al, most employees in the health care sector for 16 years and over reported higher levels of awareness of universal precautions than those who served for a shorter period. Conversely, more employees who served for less than five years were not aware of universal precautions (Vaz et al., 2010). This finding contradicts with this study because even though this study is predominated by respondents who only have 1-5 years of clinical experience, they still achieved a high level of knowledge on universal precaution.

Level of Attitude on Universal Precautions

Table 3 presents the level of attitude of staff nurses on universal precaution in terms of safe work practices, use of personal protective equipment and housekeeping and laundry management. This refers to the degree of the respondent's tendency to respond positively to universal precaution guidelines.

The data shows that the staff nurses highly tend to respond positively to the universal precaution guidelines with a general mean of 3.62.

When broken down into the subcategories, the data suggest that the staff nurses tend to respond positively to the universal precaution guidelines on housekeeping and laundry management with a mean of 3.80. For this category, statement number 11, "I prefer to place warning labels on containers of regulated wastes and refrigerators containing blood or other infectious materials," elicited the most positive responses from the respondents with a mean of 3.92 while statement 5, "I prefer to wash contaminated linens with detergent in water at least for 25 minutes," elicited the least positive response with a mean of 3.47.

For safe work practices, the respondents are considered to have a highly positive attitude to universal precautions with an average mean of 3.79. Statements number 2 and 9, "I prefer to wash hands after removal of personal protective gloves and whenever there is a likelihood of contamination" and "I prefer to conduct all procedures in a manner that will minimize splashing, spraying, splattering and generation of droplets of blood or other potentially infectious materials," elicited the most positive responses from the respondents with a mean of 3.88 while statement number 3, "I prefer to use waterless antiseptic products to wash my hands or other parts of my body after contamination with blood or other potentially infectious materials when hand washing facilities are not available," elicited the least positive responses with a mean of 3.47.

Finally, the use personal protective equipment category elicited an average mean of 3.76 which is considered highly positive. Statement number 1, "I prefer to wear gloves where it is reasonably anticipated that I will have contact with blood, other potentially infectious materials, non-intact skin and mucous membranes," elicited the most positive responses with a mean of 3.88 while statement number 3, "I consider decontamination of utility gloves for them to be reused if the integrity of the gloves is not compromised," elicited the least, with a mean of 3.28.

A study in Thailand by Honda et al. (2011) found that the relationship between nurse attitudes towards needle-stick injury prevention which includes the practice of universal precaution guidelines and occurrence of needle-stick injuries was statistically significant. A study in Nepal quoted by Honda et al. (2011) also found that health care workers had negative attitudes towards reporting needle-stick injuries; still, another study from Nigeria, quoted from the same study showed that poor attitudes regarding the practice of universal precautions caused high prevalence of needle-stick injuries. Nurses' attitude towards prevention of needle-stick injuries was found to be the strongest predictor when adjusted for other factors. Nurses who had a negative attitude towards prevention of needle-stick injuries were nearly two times more likely to have needle-stick injuries than those with a positive attitude.

Non-compliance among health care workers could also be due to their belief that influences their attitude that their workload is increased by adhering to universal precautions and therefore, these procedures are difficult to accommodate due to day to day current clinical pressures.

Level of Practices on Universal Precautions

Table 4 presents the level of practices on universal precaution of the staff nurses. This refers to the degree of the respondents' ability to proficiently implement and comply with universal precaution guidelines.

The data shows that the staff nurses almost always practice universal precaution practices on safe work practices with a mean of 3.85. For this category, statements number 1, 7 and 8, "I use available hand washing facilities, or antiseptic cleansers when I'm exposed to blood and other potentially infectious materials," "I close sharps containers prior to removal or replacement to avoid spilling or protrusion of the contents during handling or storage," and "I do not place food and drinks in refrigerators, freezers, shelves and cabinets or on countertops or bench tops where blood or other potentially infectious materials are present," elicited the largest number of agreement from the respondents with a mean of 3.92, while statement 6, "I do not eat, drink, apply cosmetics or lip balm and handle contact lenses when I'm in a work area where there is likelihood of occupational exposure," elicited the least agreement from the respondents with a mean of 3.72.

The data also suggests that the staff nurses' also almost always practice universal precautions in housekeeping and laundry management with a mean of 3.80. For this category, statement number 1, "I decontaminate work surfaces with an approved disinfectant as soon as possible after contamination with blood or other potentially infectious materials," with a mean of 3.88, elicited the highest number of agreement from the respondents while statement number 5, "I wash contaminated linens with detergent in water for at least 25 minutes," elicited the least, with a mean of 3.58.

For the use of personal protective equipment, the respondents still almost always apply universal precaution practices with a mean of 3.31. For this category, statement number 7, "I remove immediately or as soon as possible, all garments that are penetrated with blood," elicited the largest number of agreement from the respondents with a mean of 3.87 while statement 3, "I decontaminate utility gloves for them to be reused if the integrity of the gloves is not compromised," elicited the least agreement from the respondents with a mean of 3.28.

The general mean for the level of practices of the staff nurses on universal precaution is 3.65, which means that the respondents almost always practice universal precautions. Possible factors associated with the high level of practices of universal precautions of the staff nurses as stated by McGovern et al. (2000) are at least one of the following: longer tenure in one's job, increased knowledge of human immunodeficiency virus (HIV) transmission, a conservative attitude toward risky behaviors, a perception of a strong organizational safety climate, and having had some training in the use of personal protective equipment.

Knowledge of factors associated with compliance helps to explain why health care workers sometimes exhibit poor compliance despite the real occupational hazard posed by exposure to blood borne pathogens (McGovern et al., 2000).

The results of this study contradicts with the one conducted by Efstathiou et al. (2011) which shows that compliance with universal precautions among nurses in order to avoid exposure to microorganisms is low. More specifically, their study states that compliance was found inadequate concerning hand hygiene guidelines, use of gloves when exposure to body fluids was anticipated, eye protection, mouth and nose protection (mask use), wearing a gown when required, avoid recapping the needle after it was used for a patient, and provision of care considering all patients as potentially infectious.

Many researchers focused on the factors that contribute to non-compliance with Standard Precautions. Reported factors as presented by Efstathiou et al. (2011) in their review of literature were lack of knowledge, lack of time, forgetfulness, lack of means, negative influence of the equipment on nursing skills, uncomfortable equipment, skin irritation, lack of training, conflict between the need to provide care and self-protection and distance to necessary equipment or facility.

Profile of Respondents and Level of Knowledge on Universal Precautions

Presented in table 5 is the relationship between the profile of the staff nurses and their level of knowledge on universal precautions. For age and level of knowledge on universal precaution, the chi value is 0.02 with p value of 3.84 denoting no significant relationship thus the null hypothesis is accepted. For gender and level of knowledge, the obtained chi value is 0.074 with p value of 3.84 which denotes no significant relationship and the acceptance of null hypothesis. Furthermore, for civil status and level of knowledge, the chi value is 2.29 with the p value of 3.84 which again denotes no significant relationship and the acceptance of the null hypothesis. For highest educational attainment and level of knowledge, the chi value is 0.62 with p value of 5.99 which denotes no significant relationship and the acceptance of null hypothesis. For related seminars/trainings attended and level of knowledge, the chi value is 0.18 with p value of 3.84 which denotes no significant relationship and the acceptance of null hypothesis.

Meanwhile, for length of clinical experience and level of knowledge, the chi value is 24.53 which is greater than the p value of 7.82 signifying a significant relationship and the rejection of null hypothesis. This means that the higher the clinical experience of a respondent, the higher his/her level of knowledge on universal precaution tend to be. This result contradicts with the study by Motamed et al. (2011) which stated that no significant relationship between knowledge and years of experience existed and instead, listed younger age group and increased level of education as factors for increased knowledge level on universal precaution of staff nurses.

On the other hand, this results coincided with the results of a study conducted by Vaz et al. (2010) which stated that the longer a health care worker was employed to the health care sector, the more likely that his or her level of awareness of universal precautions is increased. According to Vaz et al. (2010) most employees in the health care sector for 16 years and over reported higher levels of awareness of universal precautions than those who served for a shorter period. Conversely, more employees who served for less than five years were not aware of universal precautions (Vaz et al., 2010).

Profile of Respondents and Level of Attitude on Universal Precautions

Presented in table 6 is the relationship between the profile of the staff nurses and their level of attitude on universal precautions. For age and level of attitude on universal precaution, the chi value is 3.6 with p value of 3.84 denoting no significant relationship thus the null hypothesis is accepted. For gender and level of attitude, the obtained chi value is 0.5 with p value of 3.84 which denotes no significant relationship and the acceptance of null hypothesis. Furthermore, for highest educational attainment and level of attitude, the chi value is 0.217 with the p value of 5.99 which again denotes no significant relationship and the acceptance of the null hypothesis. For length of clinical experience and level of attitude, the chi value is 4.68 with p value of 5.99 which denotes no significant relationship and the acceptance of the null hypothesis. For related seminars/trainings attended and level of attitude, the chi value is 0.0114 with p value of 3.84 which denotes no significant relationship and the acceptance of the null hypothesis.

On the other hand, for civil status and level of attitude, the chi value is 4.47 which is greater than the p value of 3.84 which denotes a significant relationship and the rejection of the null hypothesis. This indicates that single respondents tend to have a greater level of attitude on universal precautions.

According to Vanagas et al. (2004) the magnitude of job strain varies according to socio-demographic characteristics. In his study, highest rates of job strain were found among married females (Vanagas et al., 2004). Another study by Sehlen (2009) also found that nurses and physicians have high levels of stress at work. Furthermore, job stresses are high among married individuals. Therefore it is evident that high levels of stress can affect work attitudes and consequently, the respondents' attitude on universal precautions (Sehlen et al., 2009).

Profile of Respondents and Level of Practices on Universal Precautions

Presented in table 7 is the relationship between the profile of the staff nurses and their level of practices on universal precautions. For age and level of practices on universal precaution, the chi value is 0.031 with p value of 3.84 denoting no significant relationship thus the null hypothesis is accepted. For gender and level of practices, the obtained chi value is 0.123 with p value of 3.84 which denotes no significant relationship and the acceptance of null hypothesis. Furthermore, for civil status and level of practices, the chi value is 2.71 with the p value of 3.84 which again denotes no significant relationship and the acceptance of the null hypothesis.

For highest educational attainment and level of practices, the chi value is 0.06 with p value of 5.99 which denotes no significant relationship and the acceptance of the null hypothesis. For related seminars/trainings attended and level of practices, the chi value is 0.86 with p value of 3.84 which denotes no significant relationship and the acceptance of null hypothesis.

Meanwhile, for length of clinical experience and level of practices, the chi value is 16.5 with p value of 7.82 which denotes a significant relationship and the rejection of null hypothesis. The means that the higher the length of clinical experience of the respondent, the greater is his/her tendency to practice universal precautions practices proficiently. According to an author, after much practice and experience, a skill becomes habitual or automatic. This is the autonomous stage. In this stage, improvements come slowly, but there is good consistency of performance. Most of the skill is performed without thinking because the person requires less attention to basics. Instead, he or she can give more selective attention to higher-order cognitive activities, such as strategies and external cues. This may explain the reason behind the significance of length of clinical experience to the respondent's level of practice (Vishton, 2012).

The relationship between the length of clinical experience and level of practices may also be explained by Thorndike's Law of Exercise and Law of Readiness in relation to learning.

The Law of Exercise stresses the idea that repetition is basic to the development of adequate responses; things most often repeated are easiest remembered. The mind can rarely recall new concepts or practices after a single exposure, but every time it is practiced, learning continues and is enforced. This may be the reason why the length clinical experience and the level practices on universal precautions are related, because opportunities for staff nurses to practice or repeat universal precaution practices are always available when staff nurses go on duty. Repetition consists of many types of activities, including recall, review, restatement, manual drill and physical application. Practice makes permanent, not perfect unless the task is taught correctly (Vishton, 2012).

Furthermore, the Law of Readiness states that a person can learn when physically and mentally adjusted (ready) to receive stimuli. Individuals learn best when they are ready to learn, and they will not learn much if they see no reason for learning. If the staff nurses have a strong purpose, a clear objective and a sound reason for learning universal precaution practices, they usually make more progress than staff nurses who lack motivation. When staff nurses are ready to learn, they are more willing to participate in the learning process, and this simplifies the infection control nurse's job. Meanwhile, on the other hand, if outside responsibilities or worries weigh heavily on staff nurses' minds or if their personal problems seem unsolvable, they may have little interest in learning universal precaution practices (Vishton, 2012).

Level of Knowledge and Attitude on Universal Precaution

Based on the findings the level of knowledge of the respondents has a direct relationship to the level of attitude of nurses. This means that the higher the level of knowledge of the staff nurses, the higher also is there level of attitude on universal precautions.

According to the Health Belief Model by Hochbaum et al. (2012) a persons knowledge is one of the factors that can influence his attitude and subsequently, the practice of universal precaution. When a person has been made aware of the presence of blood borne diseases and that those may be prevented when universal precaution is practiced, he/she will develop a positive attitude towards the practice of universal precaution to protect himself and to avoid those infectious diseases (Hochbaum et al., 2012).

Level of Knowledge and Practices on Universal Precaution

The level of knowledge of the respondents has a direct relationship to the level of attitude of nurses. This means that the higher the level of knowledge of the staff nurses, the higher also is there level of attitude on universal precautions. This coincided with the results of a study by Motamed et al. (2007) that also stated that a significant relationship between the respondents' knowledge of and practices toward universal precautions exists among health care workers.

The Health Promotion Model by Nola J. Pender explains this relationship by stating that each person has unique personal characteristics and experiences that affect a persons knowledge that subsequently his subsequent actions. The set of variables for behavioral specific knowledge and affect (knowledge, attitude and practices on universal precautions) have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior (compliance to universal precaution guidelines) is the desired behavioral outcome and is the end point in the Health Promotion Model.

Level of Practices and Attitude on Universal Precaution

The level of knowledge of the respondents has a direct relationship to the level of practices of the staff nurses with a computed r value of 6.4 and critical t-value of 2.0017. This means that the higher the level of knowledge of the staff nurses, the higher also is there level of practices on universal precautions. This can be explained by the health belief model which states that a person will take a health-related action (i.e., practice Universal Precautions) if that person has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition (i.e., practicing Universal Precautions will be effective in preventing nosocomial acquisition of nosocomial HIV); and finally when he/she believes that he/she can successfully take a recommended health action (i.e., he/she can practice universal precautions comfortably and with confidence).

CONCLUSIONS

As an important set of guidelines designed to protect people from diseases spread by blood and certain body fluids, it is important that staff nurses practice universal precautions carefully and proficiently. Having high levels of knowledge, attitude, and practices or skills on universal precautions are also important since based on the findings of this study, these three factors are inter-related and can influence each other towards achieving an effective or ineffective implementation of the said guidelines. Although this study demonstrated that levels of knowledge, attitude, and practices on universal precautions were high on the staff nurses surveyed, it is still important for staff nurses to continuously stay updated on current trends on infection control and to continue practicing their profession in the clinical setting since a longer duration of clinical experience can increase the nurses' levels of knowledge and skills on universal precautions as documented in this study.

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CARMELA D. ORTEGA

ORCID No. 0000-0003-3311-9000

tsokolate1@yahoo.com

Mindanao State University- Iligan Institute of Technology

Iligan City, Philippines
Table 1. Profile of the Respondents

PROFILE                              FREQUENCY  PERCENTAGE

AGE
 19-40 y.o.                              27         90
 41-65 y.o.                               3         10
GENDER
 Female                                  30        100
CIVIL STATUS
 Single                                  20         66.67
 Married                                 10         33.33
HGHEST EDUCATIONAL ATTAINMENT
 BS Nursing                              27         90
 with Masteral Units                      3         10
LENGTH OF CLINICAL EXPERIENCE
 Less than. 1 year                        8         26.67
 1-5 years                               14         46 67
 6-10 years                               4         13.33
 10 years or more                         4         13.33
RELATED SEMINARS/TRAININGS ATTENDED
 Attended Seminars                       25         83.34
 Not Attended Seminars                    5         16.66

Table 2. Level of Knowledge on Universal Precautions in terms of Safe
Work Practices, Use of Personal Protective Equipment and Housekeeping
and Laundry Management

         STATEMENTS           MEAN     INTERPRETATION

1. SAFE WORK PRACTICES        3.79  Highly Knowledgeable
I. USE OF PERSONAL
   PROTECTIVE EQUIPMENT       3.75  Highly Knowledgeable
3. HOUSE KEEPING AND LAUNDRY
   MANAGEMENT                 3.76  Highly Knowledgeable
   GRAND MEAN                 3.76         HIGHLY
                                       KNOWLEDGEABLE
Legend:
 3.26-4.00  Highly Knowledgeable
 2.51-3.25  Moderately Knowledgeable
 1.76-2.50  Knowledgeable
 1.00-1.75  Less Knowledgeable

Table 3. Level of Attitude on Universal Precautions in terms of Safe
Work Practices, Use of Personal Protective Equipment and Housekeeping
and Laundry Management

               VARIABLES                 MEAN  INTERPRETATION

1. SAFE WORK PRACTICES                   3.79  Highly Positive
2. USE OF PERSONAL PROTECTIVE EQUIPMENT  3.76  Highly Positive
3. HOUSE KEEPING AND LAUNDRY
   MANAGEMENT                            3.80  Highly Positive
   GRAND MEAN                            3.78  HIGHLY POSITIVE
Legend:
 3.26-4.00  Highly Positive
 2.51-3.25  Positive
 1.76-2.50  Negative
 1.00-1.75  Highly Negative

Table 4. Level of Practices on Universal Precautions in terms of Safe
Work Practices, Use of Personal Protective Equipment and Housekeeping
and Laundry Management

           VARIABLES             MEAN  INTERPRETATION

I.   SAFE WORK PRACTICES         3.85  Almost Always
II.  USE OF PERSONAL PROTECTIVE
     EQUIPMENT                   3.31  Almost Always
III. HOUSE KEEPING AND LAUNDRY
     MANAGEMENT                  3.80  Almost Always
     GRAND MEAN                  3.65  ALMOST ALWAYS
Legend:
 3.26-4.00  Almost Always
 2.51-3.25  Often
 1.76-2.50  Seldom
 1.00-1.75  Almost Never

Table 5. Relationship Between Profile of Respondents and Level of
Knowledge on Universal Precautions

      VARIABLES         COMPUTED   CRITICAL
      CORRELATED        CHI-VALUE  p-VALUE

Age and Level of          0.02       3.54
Knowledge
Gender and Level of       0.074      3.54
Knowledge
Civil Status and Level    2.29       3.54
of Knowledge
Highest Educational
Attainment and Level      0.62       5.99
of Knowledge
Length of Clinical
Experience and Level     24.53       7.32
of Knowledge
Related Seminars/
Trainings Attended and    0.18       3.54
Level of Practice

      VARIABLES         DECISION      INTERPRETATION
      CORRELATED         ON Ho

Age and Level of         Accept       No Correlation
Knowledge
Gender and Level of      Accept       No Correlation
Knowledge
Civil Status and Level   Accept       No Correlation
of Knowledge
Highest Educational
Attainment and Level     Accept       No Correlation
of Knowledge
Length of Clinical
Experience and Level     Reject   Significant Correlation
of Knowledge
Related Seminars/
Trainings Attended and   Accept       No Correlation
Level of Practice

Table 6. Relationship Between Profile of Respondents and Level of
Attitude on Universal Precautions

      VARIABLES          COMPUTED  CRITICAL
      CORRELATED        CHI-VALUE  p-VALUE

Age and Level of          3.6        3.84
Attitude
Gender and Level of       0.5        3.84
Attitude
Civil Status and Level    4.47       3.84
of Attitude
Highest Educational
Attainment and Level      0.217      5.99
of Attitude
Length of Clinical
Experience and Level      4.68       5.99
of Attitude
Related Seminars/
Trainings Attended and    0.0114     3.84
Level of Practice

      VARIABLES         DECISION      INTERPRETATION
      CORRELATED         ON Ho

Age and Level of         Accept       No Correlation
Attitude
Gender and Level of      Accept       No Correlation
Attitude
Civil Status and Level   Reject   Significant Correlation
of Attitude
Highest Educational
Attainment and Level     Accept       No Correlation
of Attitude
Length of Clinical
Experience and Level     Accept       No Correlation
of Attitude
Related Seminars/
Trainings Attended and   Accept       No Correlation
Level of Practice

Table 7. Relationship Between Profile of Respondents and Level of
Practice on Universal Precautions

VARIABLES               COMPUTED   CRITICAL
CORRELATED              CHI-VALUE  p-VALUE

Age and Level of         0.031      3.84
Practice
Gender and Level of      0.123      3.84
Practice
Civil Status and         2.71       3.84
Level of Practice
Highest Educational
Attainment and Level     0.06       5.99
of Practice
Length, of Clinical
Experience and Level    16.5        7.82
of Practice
Related Seminars/
Trainings Attended       0.86       3.84
and Level of Practice

VARIABLES              DECISION      INTERPRETATION
CORRELATED              ON Ho

Age and Level of        Accept       No Correlation
Practice
Gender and Level of     Accept       No Correlation
Practice
Civil Status and        Accept       No Correlation
Level of Practice
Highest Educational
Attainment and Level    Accept       No Correlation
of Practice
Length, of Clinical
Experience and Level    Reject   Significant Correlation
of Practice
Related Seminars/
Trainings Attended      Accept       No Correlation
and Level of Practice
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Author:Ortega, Carmela D.
Publication:Asian Journal of Health
Article Type:Report
Geographic Code:9PHIL
Date:Jan 1, 2015
Words:9356
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