Global Journal of Health Science; Vol. 8, No.

3; 2016
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education

Knowledge, Attitude and Practice of Nurses about Standard

Precautions for Hospital-Acquired Infection in Teaching Hospitals
Affiliated to Zabol University of Medical Sciences (2014)
Hamed Sarani1, Abbas Balouchi2, Nosratollah Masinaeinezhad3 & Ebrahim Ebrahimitabs1
1
Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, IR Iran
2
Research Committee Center, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol,
IR Iran
3
School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, IR Iran
Correspondence: Abbas Balouchi, Research Committee Center, School of Nursing and Midwifery, Zabol
University of Medical Sciences, Zabol, IR Iran. E-mail: abbasbalouche1990@gmail.com

Received: May 4, 2015 Accepted: June 23, 2015 Online Published: July 27, 2015
doi:10.5539/gjhs.v8n3p193 URL: http://dx.doi.org/10.5539/gjhs.v8n3p193

Abstract
Background and Objectives: Hospital-acquired infection (HAI) is one of the common problems and difficulties
faced by hospitals in all countries around the world. Since nurses are part of the healthcare team that plays a
unique role in the control of hospital infection, this study is conducted to analyze the knowledge and practice of
healthcare personnel about standard precautions for hospital infection.
Materials and Methods: This descriptive study was conducted on 170 nurses worked in medical surgical wards,
pediatric wards, dialysis units of two teaching hospitals in Zabol city, Iran, in 2014. The sample population was
selected through simple random sampling. The data collection instrument is composed of a researcher-made
questionnaire titled “Hospital-acquired infection Control” based on precautions posited by the World Health
Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC). Data were fed
into the SPSS software v.20 and were analyzed using descriptive and inferential statistics.
Results: The results show that 43% of the participants in this study had poor knowledge, 42% had average
practice, and 37% had a moderate attitude about hospital infection. There was a significant relationship between
knowledge and gender (r = 00.8 p = 0.02). However, the variables of age, marital status, employment, work
experience, education, and place of work did not establish a significant relationship with the independent
variables (p>0.05).
Conclusion: As the results indicate a low level of awareness among the personnel about hospital infection, it is
suggested to provide training sessions on the prevention and control of HAI to increase the awareness of
personnel and hold practical courses for practicing these principles.
Keywords: knowledge, attitude, practice, standard precautions, infection control
1. Introduction:
HAI is a major health problem in all societies. According to the WHO, 7.1 million cases of HAI occur every year.
One out of every 20 people suffers from hospital infection. This leads to 99,000 cases of death every year and
imposes an estimated cost of $ 32 million to society (Cardo et al., 2010). On arrival at the hospital, patients do
not have HAI but they may develop it during the 72 hours or more after hospitalization (Horan et al., 1992). The
WHO has provided a general definition of HAI and has renamed it as healthcare-associated infection. WHO
launched its activities in 2005 under the slogan, “clean care is safer care”. HAI is an infection that develops in a
limited or vast scope because of pathogenic reactions associated with the infectious agent or its toxins in the
hospital (but only if the infection is caused at least during the 48 to 72 hours after admission to the hospital or
during a specified period of 3 to 10 days after dismissal. So the patient must not show symptoms of infection at
the time of admission and the infection must not be in the incubation period (Boyce & Pittet, 2002; Safari &
Shojaei,2002). A study conducted by the WHO on 55 hospitals in 14 countries showed that 8.7% of the patients
hospitalized in these hospitals became infected with healthcare-associated infection. Studies conducted in Iran on

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the incidence of HAI and the subsequent increased length of stay and costs show that HAI is the most important
socioeconomic medical problem in the country. Simutaneousley, through hospital treatment for acute diseses,
people with long-term diseases will cure too and hospital treatment will become more sophisticated and therefore
hospital stay will be longer which this leads in to HAI (Arbabisarjou, 2012). The incidence HAI in Iran has been
reported to vary on a range from 1.9% to more than 25% (Angelillo et al., 1999).
Numerous factors are associated with high risk of HAI. The factors that can minimize the risk of HAI include the
systematic treatment of patients, avoiding prolonged hospitalization, the use of antibiotics, the use of suction
catheters, hand washing by health care personnel, and the use of sterilization techniques in therapeutic
procedures (Ayliffe et al., 2000). The high costs of treating large numbers of patients and increasing occurrences
of infection have posed a threat to standard precautions because these standards constitute the basic principles of
HAI control. HAI control means the reduction of infection risk by patients, hospital personnel, and patient care
attendants and the prevention of infection transmission by hospital personnel and patients’ families (Amerioun
et al., 2009). As members of the health care team, nurses play a very important role in HAI control (Saffari, et al.
2008). Nurses must have sufficient information and necessary skills in this field (Saleh Moghadam, 2005). 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 (Darawad &
Al-Hussami, 2013). A study by Hinkin et al. showed that most students have acceptable levels of knowledge
about infections, hand hygiene, the use of gloves and taking appropriate action after being injured by a sharp
object but had low levels of knowledge about the use of gel and other disinfecting procedures. The results also
showed that their level of knowledge depended on working pressure, time and access to facilities (Hinkin &
Cutter, 2014). Ghanbari et al. conducted a study on 130 nurses. The results showed that most nurses do not have
sufficient knowledge and practice about the prevention of hospital infection (Ghanbari et al., 2013).The
observation of health procedures is therefore the most fundamental health principle and the most basic health
behavior (Mac, 2002). The prevention of HAI requires attention to three concepts: knowledge, attitude, and
practice (Saffari & Shojaei, 2002). For the occurrence of a behavior, the presence of such factors as motivation
and emotion is necessary. This study was conducted to evaluate knowledge, attitude and practice of nurses
against HAI.
2. Materials and Methods
The present study was conducted using a descriptive cross-sectional on 170 nurses working at teaching hospitals
of Zabol, Iran, under the supervision of Zabol University of Medical Sciences in 2014. The sample population
was selected through simple random sampling. Inclusion criteria were having at least a bachelor’s degree and a
work experience of at least three months. The only exclusion criterion was reluctance to participate in the study.
The location of study covered internal medicine wards, Pediatrics wards, dialysis units, and surgical units of
Amir al-Momenin hospital and Imam Khmoeini hospital in Zabol city, Iran. For data collection, it used a
researcher-made questionnaire with confirmed validity and reliability by several preceding studies. The
questionnaire consists of two main parts: the first part collects demographic information including gender, age,
work experience, ward of activity, and a history of infection control training; the second part consists of three
subsections: the first subsection, Knowledge, including 5 items about the nature of infection, mode of
transmission, prevention of infection and the role of the nurse; the second subsection, practice, including 21
items measuring individual practice in relation to the adoption of preventive behaviors, hand washing, injection
and dressing skills, and the observation of precautions; the third subsection, attitude, including 10 items
measuring perceived threat by nurses about HAI of nurses and patients and perceived benefits by patients about
the observation of standard precautions. In the Knowledge subsection, each correct answer to the items was
scored 1 and each wrong answer was scored zero. In the end, the scores were calculated in percent - the number
of correct answers multiplied by 100 divided by the total number of items. The practice subsection was
comprised of 10 items rated on a 5-point Likert scale from 1 to 5 (Strongly Disagree=1, Disagree=2, Neutral=3,
Agree=4, Strongly Agree= 5). The total scores ranged between 1 and 20 and the individual scores for each
section were calculated in percent. Items in the practice checklist were rated on the Likert scale. Individual
practice scores were calculated based on the frequency of adopting preventive behaviors against HAI (according
to standard precautions) divided by the total number of listed behaviors multiplied by 100. Items in the attitude
subsection were similarly rated on a five-point Likert scale. In analyzing the data in both sections of knowledge
and practice of nurses in the context of standard precautions, the scores of nurses were categorized as low,
medium, and good. Scores below 50 were labeled as poor, scores between 50 and 75 were labeled as average,
and scores above 75 were considered as good. The study was conducted after obtaining informed consent from
nurses. Data were collected via questionnaires and were analyzed with the SPSS software product v.20 using

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descriptive statistics and correlation coefficient Pearson correlation test. Level of significance P value is ≤0.05
regarded as statistically significant.
3. Results
Of the 170 questionnaires distributed, 145 completed questionnaires were selected for analysis. The mean age of
participants was equal to 41±1.13, and the mean duration of employment was 8± 2.1 years. The mean score of
the participants on the knowledge of infection was poor (42.5±8). The highest levels of knowledge were related
to hand hygiene with a mean of 74.5±24 and precautions to avoid needle stick injuries with a mean of70±3. In
addition, the lowest level of knowledge was related to precautions such as wearing the gown, gloves, mask and
glasses during clinical procedures with a mean of64±2.8. Of the 145 nurse participants in this study, 43% (n=63)
had poor knowledge, 35% (n=51) had average knowledge, and 22% (n=31) of the nurses had good knowledge
about the prevention of HAIs. Based on the Pearson correlation coefficient, there is no statistically significant
relationship between knowledge and practice (r=00.8 p=0.3). However, there is a significant relationship
between knowledge and gender (p = 0.02). Besides, the variables of age, marital status, employment, work
experience, education, and place of work did not establish a significant relationship with the independent
variables (p>0.05). Out of 145 participants in this study, 24% (n=34) of the nurses had poor practice, 42% (n=61)
had average practice, and 34% (n=50) had good practice in the prevention of HAIs (Table 1). No statistically
significant association was observed between knowledge and practice (p<0.05).

Table 1. Knowledge, attitude and practice of nurses about infection control standards
Variable Level Frequency (no.) Percent (%) Mean ± SD
Poor 63 43
Knowledge Average 51 35 42±8.9
Good 31 22
Poor 34 24
Practice Average 61 42 48±7.5
Good 50 34
Poor 43 30
Attitude Average 54 37 40±6.2
Good 48 33

In relation to the attitude of nurses, the results showed that 30% (n=43) of nurses had a poor attitude, 37% (n=54)
had an average attitude, and 33% (n=33) had a good attitude about infection control. A statistically significant
relationship was found between the mean scores of nurses who had been trained and those who had not passed
training courses (p<0.01). The results also showed that those who had more knowledge about infection control
had a better practice. The results of the Pearson correlation coefficient test for the assessment of the relationship
between the knowledge, attitude and practice of nurses showed that the attitude of nurses was significantly
correlated with their practice (p<0.01 and r=46). The results also indicated that nurses who were less experienced
had average levels of knowledge.
4. Discussion
The findings of this study showed that most nurses had a poor knowledge (43%), an average practice (42%), and
a moderate attitude (37%) about HAI control. The results of this study are not consistent with the results of a
study conducted by Yang Luo et al. in China on 1,444 nurses, in which they assessed the knowledge of nurses
about standard precautions as average (Luo et al., 2010). In their study on the knowledge, attitude and practice
of nurses in the context of HAI control, Ghadamgahi et al. concluded that most nurses do not have a good
knowledge of HAI (Ghadmgahi et al., 2011). The results of this study are not consistent with the finding of the
study by Gould et al. on 173 nurses working in three wards (ICU, Medical-surgical wards), in which they
assessed the knowledge of nurses about standard precautions as low (Gould & Chamberlain, 1994). The results
of a study by D’Alessandro et al. showed that 90.8% of students had a poor knowledge about infection control
(D'Alessandro et al., 2014). The results of another study by Sodhi et al. showed that more than 90% of ICU
nurses had a very good knowledge of infection control (Sodhi et al., 2013). Chan’s study also showed that 56%

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of nurses had a good knowledge about infection control and 79% of them had a good practice in relation to
standard precautions for infection control (Chan et al., 2002). Allah-Bakhshian et al. assessed the knowledge,
attitude and practice of ICU nurses working at training centers in Tabriz, Iran, about hospital infection control
and concluded that the majority of nurses in this study had an average knowledge about HAI control
(Allah-Bakhshian et al., 2010). It is important to note that the knowledge of nurses about HAI depends on
many factors, including individual and educational characteristics, training courses, and managerial and
motivational factors. In their study on the knowledge, attitude and practice of different groups of healthcare
personnel about infection control, Suchitra et al. concluded that training has a positive impact on the
improvement of knowledge, attitude and practice in healthcare personnel. They also suggested that the
development of a continuous training program for all healthcare workers is necessary (Suchitra, 2007). Training
courses have been shown to be effective in promoting the knowledge and practice of health care personnel in the
UK (Elliott et al., 2005). Training and knowledge improvement are the most effective ways to fight HAI.
Obviously, continuous training and knowledge improvement besides the use of appropriate and effective
methods of disinfection and sterilization will reduce the frequency of developing HAI (Askarian et al., 2004).
The results of a study by Nasirudeen et al. on the knowledge and practice of students in Singapore showed that
66.3% of them had a have good practice and 48.9% of them had a good knowledge about hand hygiene
(Nasirudeen et al., 2012). It seems that since infection control topics are not included in academic nursing
courses and since they are not dealt with in the work environment either, nurses have a poor knowledge in this
area. Therefore, considering the guidelines on the treatment of hospital infection - that nurses should be trained
and retrained at least twice a year (Bischoff et al., 2000)- differences in the results can be interpreted. There was
a significant relationship between knowledge and gender which is consistent with the results of the study
(Ghadmgahi et al., 2011). The results of the present study showed that nurses have a poor practice in the
prevention of HAIs (Akyol, 2007). Bischoff et al. claimed that under normal conditions, the frequency of hand
washing by doctors and nurses was at an unacceptably low level. A study in India reported less than desirable
levels of practice among healthcare personnel (Bischoff et al., 2000). Akyol (2007) noted that hand hygiene
compliance by healthcare workers was at a poor level. This is not consistent with the results of the study by
Allah-Bakhshian in which almost all participants (99.1%) had an average practice in relation to infection control
(Allah-Bakhshian et al., 2010). A study in Jamaica showed that 85% of nurses, despite having the knowledge,
did not observe all safety precautions when performing nursing procedures (Figueroa et al., 1997). Mahmoudi
and Hassani (2000) stated that the mere having of knowledge does not lead to good practice so attitudes should
also change and belief structures should be reworked in a rigorous and scientific manner to achieve proper
practice. There was a significant relationship between knowledge and practice in the present study. The study by
Lou also reported a significant relationship between knowledge and practice(Luo et al., 2010). One of the
limitations of this study is that the sample population does not represent all nurses in Iran.
5. Conclusion
According to the results, most nurses do not have a good knowledge and practice about infection control despite
having an average efficacy. Therefore, it is necessary that Iran’s Ministry of Health and Medical Education and
the subsidiary universities do their best to inform the nurses and all the medical personnel about the prevention
of HAIs according to world standards and tailored to each region’s ecology by way of academic courses, posters,
and conferences. It is also necessary to improve the knowledge of standard precautions, develop programs for
HAI control, and hold training courses based on successful educational models.
References
Akyol, A. D. (2007). Hand hygiene among nurses in Turkey: opinions and practices. Journal of clinical nursing,
16, 431-437. http://dx.doi.org/10.1111/j.1365-2702.2005.01543.x
Allah-Bakhshian, A., Moghaddasian, S., Zamanzadeh, V., Parvan, K., & Allah-bakhshian, M. (2010). Knowledge,
attitude, and practice of ICU nurses about nosocomial infections control in teaching hospitals of Tabriz.
Iran Journal of Nursing, 23, 17-28.
Amerioun, A., AA, K. Z., Tavakkoli, R., & Zaboli, R. (2009). Supervisors’ knowledge of hospital infections
control in one of the medical sciences universities related hospitals. Journal Mil Med, 11, 11-12.
Angelillo, I., Mazziotta, A., & Nicotera, G. (1999). Nurses and hospital infection control: knowledge, attitudes
and behaviour of Italian operating room staff. Journal of hospital infection, 42, 105-112.
http://dx.doi.org/10.1053/jhin.1998.057
Arbabisarjou, A. (2012). Practical Management and Leadership in Nursing. Tehran: Nasher-Jameenegar.

196
www.ccsenet.org/gjhs Global Journal of Health Science Vol. 8, No. 3; 2016

Askarian, M., Honarvar, B., Tabatabaee, H.-R., & Assadian, O. (2004). Knowledge, practice and attitude towards
standard isolation precautions in Iranian medical students. Journal of Hospital Infection, 58, 292-296.
http://dx.doi.org/10.1016/j.jhin.2004.07.004
Ayliffe, G., Fraise, A., Geddes, A., & Mitchell, K. (2000). Control of hospital infection: a practical handbook
Arnold. London.
Bischoff, W. E., Reynolds, T. M., Sessler, C. N., Edmond, M. B., & Wenzel, R. P. (2000). Handwashing
compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic.
Archives of internal medicine, 160, 1017-1021. http://dx.doi.org/10.1001/archinte.160.7.1017
Boyce, J., & Pittet, D. (2002). Healthcare Infection Control Practices Advisory Committee. Society for
Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious
Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care
Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Cont Hosp Ep, 23, S3-40.
http://dx.doi.org/10.1086/503164
Cardo, D., Dennehy, P. H., Halverson, P., Fishman, N., Kohn, M., Murphy, C. L., & Whitley, R. J. (2010).
Moving toward elimination of healthcare-associated infections: a call to action. Infection Control, 31,
1101-1105. http://dx.doi.org/10.1016/j.ajic.2010.09.001
Chan, R., Molassiotis, A., Eunice, C., Virene, C., Becky, H., Chit-ying, L., ... Ivy, Y. (2002). Nurses’ knowledge
of and compliance with universal precautions in an acute care hospital. International Journal of Nursing
Studies, 39, 157-163. http://dx.doi.org/10.1016/s0020-7489(01)00021-9
D'alessandro, D., Agodi, A., Auxilia, F., Brusaferro, S., Calligaris, L., Ferrante, M., ... Pasquarella, C. (2014).
Prevention of healthcare associated infections: Medical and nursing students' knowledge in Italy. Nurse
education today, 34, 191-195. http://dx.doi.org/10.1016/j.nedt.2013.05.005
Darawad, M. W., & Al-Hussami, M. (2013). Jordanian nursing students' knowledge of, attitudes towards, and
compliance with infection control precautions. Nurse education today, 33, 580-583.
http://dx.doi.org/10.1016/j.nedt.2012.06.009
Elliott, S., Keeton, A. & Holt, A. (2005). Medical students' knowledge of sharps injuries. Journal of hospital
infection, 60, 374-377. http://dx.doi.org/10.1016/j.jhin.2005.01.033
Figueroa, J. P., Brathwaite, A. R., Wedderburn, M., Ward, E., Lweis-bell, K., Amon, J. J., Williams, Y., &
Williams, E. (1997). Is HIV/STD control in Jamaica making a difference? AIDS (London, England), 12,
S89-98.
Ghadmgahi, F., Zighaimat, F., Ebadi, A., & Houshmand, A. (2011). Knowledge, attitude and self-efficacy of
nursing staffs in hospital infections control. Journal Mil Med, 13, 167-172.
Ghanbari, M., Shamsi, M., Farazi, A., Khorsandi, M., & Eshrati, B. (2013). The survey of knowledge,
self-efficacy and practice of nurses in standard precautions to prevent nosocomial infections in hospitals of
arak university of medical sciences, 2013. Arak University of Medical Sciences Journal, 16.
Gould, D., & Chamberlain, A. (1994). Infection control as a topic for ward‐based nursing education. Journal of
advanced nursing, 20, 275-282. http://dx.doi.org/10.1046/j.1365-2648.1994.20020275.x
Hinkin, J., & Cutter, J. (2014). How do university education and clinical experience influence pre-registration
nursing students' infection control practice? A descriptive, cross sectional survey. Nurse education today, 34,
196-201. http://dx.doi.org/10.1016/j.nedt.2013.09.005
Horan, T. C., Gaynes, R. P., Martone, W. J., Jarvis, W. R., & Emori, T. G. (1992). CDC definitions of nosocomial
surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infection
Control, 13, 606-608. http://dx.doi.org/10.2307/30148464
Luo, Y., He, G.-P., Zhou, J.-W., & Luo, Y. (2010). Factors impacting compliance with standard precautions in
nursing, China. International Journal of Infectious Diseases, 14, e1106-e1114.
http://dx.doi.org/10.1016/j.ijid.2009.03.037
Mac Bride A. (2002).Health Promotion in hospital. The attitudes ،beliefs and practice of hospital nurses. Journal
of Advanced Nursing. 20, 1.

197
www.ccsenet.org/gjhs Global Journal of Health Science Vol. 8, No. 3; 2016

Mahmoudi, G., & Hossani, S. (2000). Knowledge, attitude and practice of barbers about AIDS prevention.
Journal of Gorgan University of Medical Sciences, 2, 26-32.
Nasirudeen, A., Koh, J. W., Lau, A. L. C., Li, W., Lim, L. S., & Ow ,C. Y. X. (2012). Hand hygiene knowledge
and practices of nursing students in Singapore. American journal of infection control, 40,
e241-e243. http://dx.doi.org/10.1016/j.ajic.2012.02.026
Safari, M., & Shojaee, D. (2002). Principles and foundations of health promotion and education, Tehran: Samat.
Saleh Moghadam, R. M. S. (2005). Knowledge and practice of nurses in relation with operating room pollution.
J Knowl Manage., 39, 21-28.
Sodhi, K., Shrivastava, A., Arya, M., & Kumar, M. (2013). Knowledge of infection control practices among
intensive care nurses in a tertiary care hospital. Journal of infection and public health, 6, 269-275.
http://dx.doi.org/10.1016/j.jiph.2013.02.004
Suchitra, J. (2007). Impact of education on knowledge, attitudes and practices among various categories of
health care workers on nosocomial infections. Indian journal of medical microbiology, 25, 181.
http://dx.doi.org/10.4103/0255-0857.34757

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